Summer’s rapid approach often signals the transition to an increase in physical activity for many. The onset of inviting weather can stir individuals to participate in an organized game with a group, or pursue an individual activity, such as running. The arrival of warmer weather sees high school baseball players playing their summer games, tennis players trying to play matches more often, and an increase in people who are out swimming—including triathletes who participate in more events during the summer. With this increased activity, however, comes an increased risk of injuries.
For high school pitchers, the throwing shoulder is the most common site of injury.1 For tennis players, two-thirds of their injuries are repetitive, and the majority of these injuries are to the shoulders, wrists, and elbows.2 The most common complaint among swimmers is shoulder pain.3 As one can see in these sports, shoulder pain is one of the more common complaints for which these athletes will seek care. And, typically, the need for pain relief is what drives them to seek that care.
I believe that pain is the main driver of healthcare and, because of this, pain is sometimes the only thing that is addressed during the healthcare encounter. While pain is what has brought the patient into a facility to seek healthcare services, it is important that as treatment progresses, pain becomes less of the conversation. Goals and function should become the main components of conversations with patients. Even if the nature of the pain is correctly identified, it seems that most of the healthcare system is focused on decreasing the pain, rather than truly identifying the cause of the stress or overload that caused the pain in the first place.
For example, consider the response of a healthcare clinician who is visited by a patient who is a baseball pitcher complaining of shoulder pain. In addition to identifying the nature of the pain, the healthcare clinician should be focused on identifying why there was more stress on the shoulder in the first place, and not simply concerned with reducing the pain in the shoulder through modalities, manual therapy, rest, and some strengthening of the shoulder. The treating therapist needs to also assess the trunk and hips to truly understand what impairments in those areas contribute to the increased stress on the shoulder. If this is not addressed, that patient—who is also a pitcher—will have the same repetitive forces pass through the shoulder, which will cause pain once again.
In terms of management of shoulder pain, one study4 found that only 50% of new episodes of shoulder pain show a complete recovery within 6 months. After 1 year, this number increased to 60%. Another recent study5 shows that for patients with RC tendinopathy, manual therapy may decrease pain but it was unclear whether it can improve function.
Clinicians must ask themselves why these outcomes are substandard. Is the pain not being addressed correctly? Is the true cause of the increased stress to the shoulder not being addressed? In the end, one must truly understand 1) the type of pain and dysfunction with which the weekend warrior presents, 2) why there is increased stress to the system, and 3) what is the best and most effective treatment plan that will enable this patient to return to their sport pain-free for the long term.
Intervention
Typically, when a baseball, softball, swimming, or golf weekend warrior presents themselves to our clinic with complaints of upper body pain, they will have complaints of shoulder or elbow pain. The pain will usually be present in the front of the shoulder or the inside of the elbow. Pain will be worse with their sport and also under increased loading conditions. They will also note that it is painful to reach across their body and/or to reach their back. Mobility of the glenohumeral and scapulothoracic joint will be limited in some regard, and the strength of the glenohumeral and scapular rotators will be about 50% to 60% of what is needed for their sport. Sometimes the patient will also present with upper limb neural tension secondary to improper or excessive loading strategies.
When setting goals for these patients, it is very important to ensure that goal setting is collaborative and that a clear plan with goals and time frames is laid out. Patients need to understand that tissue healing and the necessary adaptations have specific timelines. For example, it is very important for the patient to understand that strengthening usually needs
6 to 8 weeks of consistent loading in order for permanent changes to take place. The first 4 weeks of strengthening are usually a neural adaptation, and any strength change is transient until muscle hypertrophy takes place somewhere in weeks 6 to 8.6 I have heard some physical therapists say very proudly that their patient’s pain was gone in four visits and the patient was discharged. While it is great that the patient’s pain is gone, the permanent change to the tissues to allow the patient to return to the same repetitive forces that caused the injury in the first place have not been addressed fully. This is one of the reasons sometimes accelerated rehabilitation doesn’t have a successful outcome. Proper tissue healing and adaptation has not been allowed to take place.
When treating a weekend warrior, the first thing one needs to do is decrease the pain. Depending on whether the pain is peripheral or central, and then whether it fits into the inflammatory or ischemic pattern, will dictate how to best decrease the pain. Regardless of the pain pattern, it is paramount that the clinician lets the patient know that they will get better and that the treating provider has a clear plan set in place. Most times this will help reduce the patient’s pain at least to a degree, the main reason being that the social anxiety aspect of the pain has been addressed. Most of the modalities I will speak to below can be effective for reducing peripheral pain.
Modalities
Modalities can play a helpful role in reducing the patient’s symptoms and in some cases assisting with healing of the affected tissue. It is important to note that modalities should be an adjunct to treating the weekend warrior. They typically work best when combined with manual therapy and exercise. Below are some common modalities, their general indications, and general dosing.
Transcutaneous Electrical Nerve Stimulation (TENS)
This is commonly used to decrease pain by delivering a pulsed electrical current through the skin. The most common mode is conventional TENS, which means the pulses are of short duration, high frequency, and low to comfortable amplitude.7
Neuromuscular Electrical Nerve Stimulation
For any electrical agent that is used where the goal is to evoke a muscle contraction, the term NMES is used. One of the most common and effective currents is termed “Russian Current.” Research has shown this current to increase strength of a muscle in the short term of healthy subjects.7 The most common dosage is to keep the mA at the lowest setting while ensuring the needed level of muscle contraction, 50 bups (bursts per second), a 10 sec:50 sec work/rest ratio, and a 10/10/50 training protocol (10 contractions per session lasting 10 seconds with a rest period of 50 seconds).
Laser/Light
Low level laser therapy (LLLT) is a fairly new modality compared to the others in this article. It can be used to stimulate tissue healing or decrease pain, though both mechanisms are poorly understood at this point. Based on the Arndt-Schultz law which stipulates a dosage-dependent effect, lower dosages will trigger a wound healing response and higher dosages will trigger a pain management response.7 In general, most LLLT devices can deliver an energy density of 1 to 4 J/cm2, and the time needed to deliver that amount of energy will depend on the power of the probe, the probe beam area, and the total treatment surface area. Research is varied on the effectiveness of LLLT, though some studies have shown LLLT to be effective in the treatment of trigger points and osteoarthritis, and most studies looked at pain as the outcome. This begs the question as to whether most of the studies used the proper dosage to elicit a change in pain, and did they choose the correct patient population based on whether the pain pattern was central or peripheral.
Ultrasound
Therapeutic ultrasound can be used to enhance soft tissue healing, decrease the inflammatory response, and decrease pain. This can be done through a mechanical effect or a thermal effect. The mechanical effect can increase soft tissue healing, decrease inflammation, and decrease pain, while the thermal effect can increase soft tissue healing.7 Dosing can vary greatly depending on the desired effect, but typically the frequency will vary between
85 kHz and 3 MHz and intensities less than 3 W/cm2. The higher the intensity and the more continuous the wave, the greater thermal effect that will take place.
Topicals, Hot/Cold Therapy
In some cases a topical analgesic may be appropriate in providing temporary pain relief to active athletes. Topical treatments are available in a variety of formulas and packaged as creams, gels, or sprays. They can provide an affordable, easy-to-use pain relief option in the clinic or at home. Hot/cold therapy products, too, can be useful in the temporary relief of pain and to reduce swelling. These products often are designed as packs or contoured wraps that can be heated or cooled to provide short-term pain relief. Like topical pain relievers, hot/cold therapy products can be effective when used in the clinic or by patients at home.
Phases of Rehabilitation
While the clinician is working on reducing the pain, it is important to also work on addressing any mobility limitations. Typically, these patients will require mobilizations to their posterior capsule, subscapularis, coracohumeral ligament, or inferior glenohumeral ligament. While it is beyond the scope of this article to discuss what really happens to our patients’ tissues when mobilized, please keep in mind that manual therapy when paired with exercise is more effective than exercise alone.8 Typically, this phase will take 1 to 2 weeks.
Once the clinician has addressed the mobility impairments and has decreased the pain, the clinician should then begin to strengthen the specific muscles and muscle groups that are shown to be deficit. (This can also happen concurrently with the pain/mobility phase, depending on the patient’s needs.) Typically, the infraspinatus, subscapularis, serratus anterior, and trapezius muscle group are deficit. These limitations are then allowing excessive forces through the shoulder and/or elbow with the patient’s activity. This is also where the clinician will need to identify any muscle groups in the trunk or hips that need to be addressed. This phase typically takes 3 to 4 weeks.
Once the mobility and strength of individual muscles are increasing in strength, then the weekend warrior is progressed to working on multijoint/multimuscle exercises that are targeted toward their sport. The clinician will need to 1) keep in mind the planes of motion this athlete needs to control, and what the control mechanisms are, and 2) identify any biomechanical red flags that the patient may present with specific to his or her sport. By addressing the two points, the clinician can help ensure that the patient can return to sport with different loading strategies that help reduce the reoccurrence of the initial injury.
To summarize, in order to return a weekend warrior to their sport pain-free and ensure that there is minimal risk for reoccurrence, the clinician must: 1) properly identify the pain pattern with which the patient presents, 2) correctly identify why excessive force is being applied through the injured tissue, 3) fully assess the impairments that may be contributing to the injury and dysfunction, 4) reduce the pain and address the mobility impairments, 5) increase the strength of the muscles that are deficit, 6) progress exercises toward working on multijoint, multimuscle, and multiplanar movements, and 7) correctly assess and treat any biomechanical red flags specific to that patient’s sport.
By following the above recommendations, the clinician can help ensure that their weekend warriors can reach their potential and have many pain-free summer to come. RM
Donn Dimond, PT, OCS, is co-owner of The KOR Physical Therapy, Portland, Ore. His practice encompasses clients from professional athletes to weekend warriors. Dimond has also worked with various Chinese Olympic Teams to help decrease their incidence of injury. He has authored two books: The Bare Minimum: Baseball, Essential Training for the Baseball Athlete, and The Bare Minimum: Donatelli Shoulder Method. He is a contributing author to Dr. Donatelli’s Sports Specific Rehabilitation, Orthopedic Physical Therapy, and Physical Therapy of the Shoulder, 5th ed. Dimond lectures nationally to other physical therapists about how to assess and treat patients with shoulder injuries.