The shoulder complex is made up of the clavicle, scapula, and humerus. This area has four joints, the glenohumeral (GH) joint, the Sternoclavicular (SC) joint, the acromioclavicular (AC) joint, and the Scapulothoracic (ST) joint, which is also sometimes known as the floating joint. All four work together to allow the shoulder to move and function properly and numerous ways.
All four joints work together to create normal shoulder girdle movements. The shoulder complex works with the muscles, ligaments, and bony articulations to create the proper movement of this area. It is a complex relationship that requires very specific functions to happen. The GH joint, specifically, is designed to support mobility. It allows a person to move and position their hand in a wide range of ways. The GH joint provides the largest range of motion of any joint in the body.
Why Problems Develop
That significant amount of movement and reach is important to everyday life. Yet, with all that range of motion and freedom of movement comes the higher risk of instability. This is called the mobility stability trade off. The intricate structural and functional elements of this joint and the need for ample mobility led to a higher risk of injury. The shoulder complex is at a higher risk than other joints for dysfunction and instability overall.
Dynamic stabilization is present here. In short, this describes the reliance of the shoulder joint on active forces and muscular control to help maintain its proper position. The muscle forces help ensure the shoulder girdle remains in place to the thorax with the shoulder complex. These muscles also help with the support of the upper extremity movement.
A wide range of injuries can occur to this area of the body. It is not uncommon for an injury to be sustained in day-to-day activities.
Consider the Tennis Movements
One of the best ways to understand pathological shoulder complex is to consider what occurs while a person is playing tennis and the movements of the shoulders as a result.
Consider the serve motion. This motion produces high forces, and it requires large movements that place a significant amount of demand on the shoulder to function properly. This is particularly significant during the late cocking phase and at the point of early acceleration. This is when the most harmful position for the shoulder is present.
These intense demands often lead to changes in the dominant shoulder. The body compensates for the demand that is being placed on the shoulder, especially in elite or constant players. As a result of this, there is often a reduced level of internal shoulder rotation. In addition, there is increased external shoulder rotation and total arc motion.
Dr. Brian Cable, MD, offers some insight into pathological shoulder complex. He states, “Injuries to the shoulder account for 35 percent to 50 percent of all upper extremity injuries. They are often overused in nature and are predominantly caused by overhead movements, such as the serve and the smash, which is an overhead serve-like flat, straight shot hit with minimal spin, and have been associated with reduced isometric external rotation strength, imbalanced external/internal shoulder rotation ratio, and glenohumeral internal rotation deficits when compared with the nondominant shoulder.”
This can lead to numerous concerns. When it comes to external rotation, strength is an important component for decelerating the shoulder during the follow through. It also helps to provide stability. Imbalances of the soft tissues in this area can sometimes result in impingement and rotator cuff pathology. It can also cause labral tears. Each of these can occur on their own or as a part of pathological shoulder complex.
Most of the time, tennis players who engage in this type of motion are most likely to report pain in the posterior of the shoulder. This usually happens in the late clocking and early acceleration phases. In some people, anterior shoulder pain can also happen. Some people may also have mechanical symptoms, including a clicking feeling or sound and instability overall.
Pain is often a component of this. If a person feels pain while serving and smashing, with loss of maximum power and later groundstrokes, this may also be an indication of this condition. While pain and limitations of maximum power may be evident, it is also important to know that many people do not experience a significant drop in performance.
Treating Pathological Shoulder Complex
There are various ways to treat this condition. The cornerstone to treating the pathological shoulder complex should begin with conservation management, focusing on correcting the internal impingement potentiating factors. Scapular stabilization strengthening and stretching rehabilitation and injury prevention programs should focus on improving internal shoulder rotation range of motion, external shoulder rotation strength, and restoring the external/internal shoulder rotation ratio, where external rotation strength is at least two thirds the strength of internal rotation.
In addition to this, it is very important to reduce the scapular protraction. It may also be necessary to reduce or even remove serve loads, including the kick serve, which may also provide some relief to patients. It may also require a slow getting back to it with the slice serve, which has a lower force level. If this type of treatment does not help, it may be necessary to consider arthroscopic surgery. With proper treatment, it is possible to see improvement of the pathological shoulder complex, and that could improve overall function and comfort even in the game of tennis.
