| A sprain of the rotator cuff or shoulder capsule occurs when there is a forceful injury to the ligaments that stabilize the shoulder joint (glenohumeral joint). The stretching or partial tearing of these ligaments causes the shoulder joint to become loose (lax) and can lead to complete disruption or dislocation.
The glenohumeral joint is the most freely moving joint in the body. Two bones come together at the shoulder: the ball, or humeral head, at the upper end of the arm, and the socket, which is part of the shoulder blade (glenoid of the scapula). Ligaments cross between these two bones and stabilize the glenohumeral joint.
Sprains of the shoulder capsule are classified according to the amount of damage to the ligaments and any resulting laxity of the joint. Mild stretching without tearing of the ligaments is a grade I or first-degree sprain. There may be some minimal instability of the joint at this point. In a grade II or second-degree sprain, some fibers of the capsule tear causing the head of the humerus to slip and almost dislocate (subluxation), creating a feeling of instability.
Grade III, or third degree sprains, result in complete disruption of the joint capsule and displacement of the humeral head out beyond the joint (shoulder dislocation). The dislocation can be downward, upward, frontward, or backward (inferior, superior, anterior, or posterior) or result in multidirectional instability, which means the humeral head moves too far in many directions. The most common direction for shoulder dislocation is anterior, followed by posterior, and infrequently is multidirectional. The grading of rotator cuff sprains is not an exact science but based on clinical assessment and experience related to signs, symptoms or imaging studies.
Sprains with movement of the humeral head toward the front (anterior) are the result of trauma and usually are caused by forced external rotation with the elbow away from the body. This movement is similar to throwing. Acute posterior sprains and dislocations are rare and most often result from a direct blow to the shoulder or outstretched arm. Chronic sprains result when supporting ligaments stretched from repeated injuries do not heal; they also result from changes in the glenoid lip and humeral head when the bones slip out of position.
Acute shoulder dislocations are a true emergency because of the possibility of nerve damage while the bones are out of position. They require immediate attention, either in a physician's office with x-ray capability, urgent care units, or an emergency room.Risk: Athletes, especially those who participate in contact sports such as rugby, football, lacrosse, and ice hockey, are among those most likely to sustain a shoulder sprain. Individuals who perform heavy overhead work or heavy lifting are also more likely to experience one. Incidence and Prevalence: Estimate suggest 3.7 million individuals in the US visit their physicians each year for upper arm and shoulder sprains and strains ("Common Shoulder Injuries"). |
Source: Medical Disability Advisor
| History: Individuals may report a wide variety of symptoms and prior activities. Most individuals will report a traumatic event such as a fall, having their arm jerked backward, or trying to catch something heavy that was slipping. The amount of pain experienced is relative to the grade of sprain. In grade I sprains, individuals may complain of some pain with motion. In grade II sprains, immediate pain will have subsided if the arm bone (humeral head) has returned to its normal position (reduced) and only shoulder motion is painful. Grade III injuries most often present with the individual carrying his or her arm with the elbow bent and away from his body. Individuals may report a feeling of slipping or tearing in the joint. Pain is immediate and does not subside until the shoulder is reduced. If this is a second episode of a grade III sprain or dislocation, the individual may have attempted a self-manipulation or reduction. Physical exam: A sunken area may be obvious just below the tip of the shoulder (sulcus sign) created by the arm bone being out of position. One diagnostic test is to attempt to move the arm through the throwing motion, checking not only the shoulder function, but also the individual's level of anxiety (apprehension sign). Changes in color, temperature, sensation, and strength may be evident in the arm and hand. Reflexes may be either decreased or accentuated. Tests: Plain shoulder x-rays (anterior-posterior [AP], lateral, and glenoid views) will demonstrate the position of the humeral head, which defines the direction of any subluxation or dislocation. X-ray examination will also determine the presence of fractures of the shoulder (glenoid fossa, humeral head, clavicle, or acromion). An MRI is indicated if a tear of the rotator cuff is suspected in association with a sprain, or if the sprain resulted from significant trauma. Diagnostic ultrasound may also be performed to help diagnose this condition. |
Source: Medical Disability Advisor
| The inflammation and pain caused by ligaments stretching and tearing decreases with rest. If bleeding has occurred, scar tissue will form around the ligaments, adding stability and some strength to the joint. Ligaments that are torn away from a bone (avulsed) may reattach themselves if allowed to rest during the healing phase. The term "rest" is relative; motion is often allowed, but not the stress of lifting the arm. Treatment is aimed at reducing further trauma to the joint, regaining motion of the joint, and rehabilitating supporting muscle groups for added stability.
Grade I sprains are treated with relative rest, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs) as needed. Strengthening of the shoulder muscles can begin when active range of motion is achieved. A sling with waist strap is worn initially to rest the shoulder, but wrist motion and gripping exercises are encouraged.
Grade II sprains are treated in a similar manner, with relative rest lasting about 2 weeks, allowing scar tissue to form around the ligaments. Strengthening exercises focus on the muscles stabilizing the shoulder to help prevent further subluxations. A sling with waist strap is used initially full-time, even in bed, and then for activities that put the shoulder at risk.
In grade III sprains, the need for shoulder reduction is urgent, but care must be taken to prevent possible nerve and vessel damage from improper manipulation. Most often, no attempt to reduce a first episode dislocation is made without an x-ray examination. Closed relocation or the bones to their anatomically normal position (closed reduction) is possible only when the muscles around the shoulder are relaxed. Medication for relief of pain and muscle relaxation usually is necessary. Pain relief is immediate and often quite dramatic with reduction. A sling or sling with waist strap (sling and swath) is worn for up to 6 weeks, and medication for pain and muscle relaxation is often prescribed. Physical therapy begins after about the first week with a focus on joint mobility and strengthening.
Reconstructive surgery (shoulder capsulorrhaphy) is indicated in younger individuals who have a higher chance of injury recurrence. It usually is indicated after the third dislocation, although some individuals choose to change their lifestyle, reducing the risk of repeated dislocations, instead of undergoing surgery. |
Source: Medical Disability Advisor
| Relief of pain and regaining a feeling of stability may come as early as 1 to 2 weeks as the capsule ligaments heal by scarring and inflammation of the tissues decreases. This is deceptive, especially in grade II and III injuries. The stretched joint capsule takes about 6 weeks to heal, and the shoulder muscles need about 4 weeks of strengthening to maintain stability. Recovery may then take up to 10 weeks.
In grade III sprains or dislocations, adequate reduction is common, but repeated dislocation is frequent without surgical repair. Fractures associated with a grade III sprain or dislocation may indicate a less optimum recovery because of increased instability of the joint. Individuals may continue to experience apprehension when the arm is placed in a vulnerable position.
Individuals who have recurring episodes of dislocation will have a shorter recovery time after each episode but may not be able to return to overhead activities. They are also at greater risk for degenerative arthritis. |
Source: Medical Disability Advisor
| Note on research and authorship The initial goals of rehabilitation following shoulder capsule sprain are to decrease pain and inflammation associated with the injury and to prevent stiffness and weakness (Cleeman).
The specific rehabilitation program depends greatly on the severity of the injury. After an acute injury, all individuals are prescribed some degree of rest. Individuals with a grade I sprain may need a few days of rest, whereas individuals with complete dislocation (grade III) nearly always are immobilized, usually up to 4 weeks. During this time, cold therapy may be used to reduce inflammation. Individuals will be instructed in range of motion exercises for the hand, wrist, and elbow. The individual may be allowed some limited range of motion at the shoulder under therapist supervision (Bottoni). The individual may be taught isometric strengthening exercises (Cleeman).
Once adequate healing has occurred, therapy helps the individual regain range of motion and improve strength (Hayes). To achieve these goals, the individual performs a progressive range of motion and strengthening program for the shoulder (Liu). The specific timing of these exercises will vary with the severity of injury. Generally, individuals with a grade I sprain will be able to begin range of motion and strengthening immediately after the acute phase. However, for individuals with dislocations, only progressive range of motion exercises and isometrics are performed for the 4 weeks following the immobilization period (Bottoni). All exercises and daily activities will need to be limited to a pain-free range of motion, so as to not impede the continued healing of the injured capsule.
In a grade III sprain, the individual must wait until about 12 weeks after injury to begin strengthening exercises that involve joint movements (Bottoni). At this stage, strength training may include weight equipment/machines, elastic bands, or manual resistance from the therapist. The strengthening program will focus on shoulder girdle, upper trunk, and upper arm musculature (Cleeman; Liu). Strengthening exercises intensify as the individual's pain decreases and strength increases. Individuals should be instructed in a home program that reflects the exercise regime prescribed during rehabilitation.
An individual with full range of motion and strength may still be at risk of re-injury, so the final component of rehabilitation should include exercises to stabilize the shoulder joint. By 4 months, an individual whose case is uncomplicated should be able to return to contact sport or other highly aggressive activities (Bottoni).
In grade I and II injuries, conservative management is usually effective. In a grade III injury, complete dislocation of the glenohumeral joint can occur, and surgical intervention may be needed. See Dislocation, Glenohumeral. |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical ‡ | |
| Physical or Occupational Therapist | | Up to 20 visits within 12 weeks | |
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| ‡ Note on Nonsurgical Guidelines: Degree of injury will determine when rehab can be started. |
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Each time the shoulder capsule is injured, more damage is done to the supporting ligaments, and the laxity of the joint is increased. Increasing laxity, in turn, increases the chance of repeated sprains and the onset of impingement syndrome.
Tears of the rotator cuff and a pulling away of its attachment to the arm (avulsion of the greater tuberosity) may occur during a severe sprain. These tears may require early surgical repair.
Any fractures that occur during a grade III sprain (dislocation) change the anatomy of the shoulder and the mechanical action of the joint. Especially troublesome are fractures of the upper arm bone (humeral head) or shoulder blade (scapula, glenoid). These fractures may require surgical correction to restore normal anatomy, allowing the shoulder to be stable. Stability of the shoulder is critical in preventing recurring sprains of the shoulder capsule.
Nerve or blood vessel injury from the dislocation will need attention immediately. |
Source: Medical Disability Advisor
| Access to ice for control of pain and swelling will allow earlier return to work after injuries involving the nondominant arm.
Use of a sling, or a sling and swathe, is recommended for grade I and II sprains and is mandatory for first-time dislocations (grade III injuries). Use of a sling limits manual dexterity and may prove hazardous to the individual or those around him or her.
Lifting, carrying, and overhead work will be restricted from several weeks or permanently; the individual may need temporary or permanent job reassignment.
Individuals whose work environment places them at risk for recurrent episodes may be asked to wear a protective harness, the use of which may become permanent. Overhead use of the arm is restricted with this device.
Older individuals may not be able to regain adequate strength and stability to resume strenuous activities that stress the shoulder.
Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Was the sprain classified as grade I, II, or III?
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What was the mechanism of injury?
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Was a deformity noted on exam?
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Was this a first-time sprain or a repeat sprain?
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If a repeat or chronic sprain, is it related to job requirements such as overhead work?
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What level of pain did individual have?
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Was individual able to move the arm? What was the level of anxiety?
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Were individual's reflexes decreased or accentuated?
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Did individual have plain x-rays? MRI or other imaging tests?
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Were there any signs of nerve or vascular damage or associated fractures?
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Have conditions with similar symptoms been ruled out?
Regarding treatment:
- Is individual giving the affected joint and arm appropriate rest using a sling?
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Is individual using ice and NSAIDs?
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Is individual continuing to use the wrist? Doing gripping exercises?
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Was the acute sprain reduced on an emergency basis?
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Was a closed reduction done?
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Was surgery necessary?
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Have medication for pain and muscle relaxation been prescribed?
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Was physical therapy started at the appropriate time? Is physical therapy continuing?
Regarding prognosis:
- Is individual active in physical therapy? Is individual doing exercises at home?
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Is the injury on the dominant or nondominant side?
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If necessary, does individual wear a protective harness?
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Does individual have any conditions that may affect ability to recover?
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Has individual developed degenerative arthritis?
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Has individual had other complications such as repeated strains or impingement syndrome?
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Would individual benefit from additional physical therapy?
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Is individual's employer able to accommodate any necessary restrictions?
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Source: Medical Disability Advisor
| Bottoni, C. R., et al. "A Prospective Randomized Evaluation of Arthroscopic Stabilization Versus Nonoperative Treatment in Patients with Acute, Traumatic, First-Time Shoulder Dislocations." American Journal of Sports Medicine 30 4 (2002): 576-580. National Center for Biotechnology Information. National Library of Medicine. 1 Oct. 2008 <PMID: 12130413>.Cleeman, E., and E. L. Flatow. "Shoulder Dislocations in the Young Patient." Orthopedic Clinics of North America 31 2 (2000): 217-229. National Center for Biotechnology Information. National Library of Medicine. 1 Oct. 2008 <PMID: 10736391>. "Common Shoulder Injuries." American Academy of Orthopaedic Surgeons. Aug. 2007. American Association of Orthopaedic Surgeons. 23 Mar. 2009 <http://orthoinfo.aaos.org/topic.cfm?topic=A00327>. Hayes, K., et al. "Shoulder Instability: Management and Rehabilitation." Orthopedic and Sports Physical Therapy 32 10 (2002): 497-509. National Center for Biotechnology Information. National Library of Medicine. 1 Oct. 2008 <PMID: 12403201>. Liu, S. H., and M. H. Henry. "Anterior Shoulder Instability. Current Review." Clinical Orthopaedics and Related Research 323 (1996): 327-373. National Center for Biotechnology Information. National Library of Medicine. 17 Dec. 2004 <PMID: 8625601>. |
Source: Medical Disability Advisor
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