Shoulder Injuries: Understanding Sports Injuries, Degeneration and the Importance of Mobility

Shoulder pain is one of the most common problems seen in orthopaedic practice. It can affect a young athlete, a regular gym-goer, a person who works at a desk all day, or an older adult simply trying to reach a cupboard.

The shoulder is a highly mobile and complex joint, and the problems affecting it can be very different depending on a person’s age, activity level, previous injuries, occupation, posture and lifestyle.

A young athlete with shoulder pain may have an instability or labral injury, while an older person may have degenerative rotator cuff disease or arthritis. Someone else may have a frozen shoulder, biceps tendinitis or calcific tendinitis.

Understanding this difference is the first step towards appropriate treatment.

Why is the shoulder so vulnerable?

The shoulder allows an enormous range of movement. Unlike the hip, which is a deep and inherently stable ball-and-socket joint, the shoulder sacrifices some stability to achieve greater mobility.

The stability of the shoulder therefore depends heavily on:

• The rotator cuff muscles
• The labrum
• The joint capsule and ligaments
• The biceps tendon
• The shoulder blade and surrounding muscles
• The thoracic spine and chest mobility

When any of these components stops functioning properly, shoulder mechanics can change.

The active shoulder: injuries caused by demand and repetition

Highly active individuals — including athletes, gym-goers, swimmers, throwers, racquet-sport players and people involved in repetitive overhead work — place considerable demands on their shoulders.

In these individuals, we commonly encounter overuse injuries, instability, labral injuries and acute tendon injuries. The shoulder may be perfectly healthy at baseline, but repetitive loading can eventually exceed the capacity of the tissues to recover.

SLAP tears

A SLAP tear is an injury to the upper part of the shoulder’s labrum. It can occur following trauma, but repetitive overhead activity — particularly throwing — can also contribute.

Patients may experience:

• Deep shoulder pain
• Clicking or catching
• Pain during overhead activity
• Reduced throwing or lifting performance
• A sensation of instability

Importantly, finding a SLAP lesion on an MRI does not automatically mean that surgery is required. The MRI finding needs to be interpreted alongside the patient’s age, symptoms, activity level and clinical examination.

Rotator cuff tears: injury versus degeneration

The rotator cuff consists of four muscles and their tendons that help move and stabilise the shoulder. A rotator cuff tear can occur in two very different settings:

1. In younger and highly active individuals

A significant fall, sports injury or sudden force can cause an acute tear in an otherwise relatively healthy tendon. These injuries may require a different approach, particularly in athletes or patients with significant functional demands.

2. In older adults

Rotator cuff tears are often associated with age-related tendon degeneration. The tendon may gradually weaken over years before eventually developing a partial or full-thickness tear.

This distinction matters. A 30-year-old athlete and a 70-year-old patient can both have a “rotator cuff tear” on MRI, but the significance of that finding and the appropriate treatment may be very different.

Rotator cuff tear arthropathy

When a large rotator cuff tear remains untreated for a long period, particularly in an older shoulder, progressive changes can occur within the joint. This can eventually result in rotator cuff tear arthropathy.

Patients may develop chronic pain, significant weakness, difficulty raising the arm, loss of shoulder function, and progressive arthritis. In advanced cases, reverse shoulder arthroplasty can restore useful shoulder function by changing the mechanics of the joint and allowing the deltoid muscle to play a greater role in elevation.

Frozen shoulder: when movement gradually disappears

Frozen shoulder, or adhesive capsulitis, is characterized by a progressive loss of movement. Patients may notice difficulty putting on a shirt, reaching behind their back, combing hair, or sleeping on the affected side.

One important principle is that more exercise is not always better. During a highly painful phase, aggressive stretching may actually aggravate symptoms. Rehabilitation should therefore be guided by the clinical stage and individual tolerance.

Biceps tendinitis & Calcific tendinitis

Biceps Tendinitis: Long head biceps tendon pain commonly presents at the front of the shoulder, often coexisting with rotator cuff issues.

Calcific Tendinitis: Occurs when calcium deposits develop within a rotator cuff tendon, causing sudden, severe pain without prior injury. The size of the deposit on an X-ray does not always correspond to symptom intensity.

The forgotten component: chest and upper back mobility

One of the most overlooked aspects of shoulder rehabilitation is thoracic and chest mobility. The shoulder blade glides over the rib cage and works together with the thoracic spine.

Tightness in the Pectoralis minor (pec minor) pulls the shoulder blade forward, leading to altered shoulder mechanics. Improving chest and thoracic mobility is often a crucial component of recovery.

Comprehensive Shoulder Rehabilitation

Effective rehabilitation goes beyond simple rotator cuff band exercises. It includes:

1. Restoring mobility: Ensuring proper range of motion in the shoulder, thoracic spine, and chest.
2. Improving scapular control: Correcting how the shoulder blade moves with the arm.
3. Strengthening the rotator cuff & surrounding muscles: Targeting deltoids, serratus anterior, trapezius, and rhomboids.
4. Movement pattern correction & gradual return: Progressive reloading tailored to sports or desktop ergonomics.

When should you see an orthopaedic surgeon?

• Persistent shoulder pain or night pain
• Pain returning repeatedly during exercise
• Significant weakness or inability to raise the arm
• Recurrent dislocation, instability, clicking, or catching
• Pain following a fall or sports injury