The recent enthusiasm for pickleball has made it one of the fastest growing sports in America. According the USA Pickleball Association (USAPA), the last six years have seen an increase of 650% in participants. Initially embraced by the over 60 crowd, it is now seeing tremendous growth in younger athletes. It is social and friendly but can also be quite competitive.
Frequent stress is applied to the shoulder in racquet sports such as: tennis, pickleball, squash, racquetball, and badminton. While professional athletes spend hours daily training and preparing for their sport, the rest of us “Sunday athletes” jump right in with little conditioning or preparation. Hence the common shoulder problems discussed around the court. Fortunately, the vast majority of issues can be easily resolved without surgery.
The shoulder is a unique ball and socket joint that allow a tremendous range of motion necessary in racquet sports. The ball is part of the humerus bone. The shoulder joint has a very shallow socket to allow all of this movement. Muscles then form tendons that attach to the humerus to activate this motion. The tendons that merge and move the ball in the socket are called the rotator cuff.
The most common source of pain is called “impingement”. Other, frequently used terms may include bursitis, tendonitis or rotator cuff type pain. Anatomically, the acromion bone from the scapula, forms a “roof” over the rotator cuff tendons (see figure 1). The undersurface of this bony roof starts out as flat, providing plenty of space for the rotator cuff tendons.
As one raises their arm, impingement is the process when the ball (humerus and rotator cuff tendons) rides upward and rubs or “impinges” on the undersurface of the acromion bone (see Figure 2). This can happen because the rotator cuff muscles are weak and allow this upward motion, or because the bone begins to form a spur or hook downward towards the tendon. This rubbing causes the cuff and its overlying tissue (the bursae) to become inflamed and painful.
Many people notice it most when it begins to disturb their sleep. Rolling onto the affected shoulder often causes one to wake up or shift to another position. Other common symptoms include weakness or lack of pain-free motion. Overhead motion can be particularly painful. It often progresses over time. If neglected, it can progress to damage the rotator cuff tendons. Sometimes, continued impingement or trauma can lead to a complete tear of the rotator cuff tendons. The repair of a complete rotator cuff tear is a topic that be will covered in another article.
It is ill advised to “play through the pain.” Although anti-inflammatories can control some inflammation and discomfort, the efficacy typically wears off. We would suggest an evaluation by an orthopedic surgeon with expertise in Sports Medicine. Virtual medicine can be quite effective in the days of Covid-19 for some conditions, but a doctor’s visit with a physical exam is the most valid form of diagnosis. This typically involves a history of the problem, an x-ray and thorough exam of the shoulder. Sometimes, in more advanced or traumatic cases, an MRI test is necessary. However, a MRI exam is not a good substitute for a skilled physician history and exam. MRI tests done without the proper skills of a sports medicine orthopedist can be quite misleading. We frequently will use an MRI to gather information; we have unfortunately encountered many cases of missed or incorrect treatment plans based upon MRI report alone.
Once diagnosed, it is time to formulate a treatment plan. Physical therapy with specific rotator cuff exercises may be the most effective choice for most patients. This includes exercises to isolate and strengthen the rotator cuff muscles that bring the ball downward and recenter it in the socket to prevent it from impinging. Overall, therapeutic exercises are effective in up to 75% of patients with impingement, without resorting to more invasive treatment options. We typically begin with visits to an outpatient physical therapy center. Muscles of the rotator cuff respond gradually. Soon thereafter, a patient can master the exercises and be promoted to a self-directed home program with a gradual return to their sport while maintaining their strength. The results can be achieved within six weeks in many cases.
If this fails, other options do exist. Injections can be considered, but we do so with caution. Injection without therapeutic strengthening will not address the underlying cause. Some types of injections may accelerate tissue breakdown. “Biologic agents” have been used for injections, but valid scientific evidence supporting PRP or “stem cell” injections is currently lacking. Many respected orthopedic surgeons do not want to mislead the public without full disclosure of our knowledge on this subject.
In cases unresolved with conservative treatment for impingement, surgery can offer relief. If surgery is considered, then we typically will obtain an MRI to better evaluate the rotator cuff tendons as well as associated shoulder structures. If the rotator cuff tendons are relatively healthy, then a procedure called an arthroscopic acromioplasty may be indicated. If however, the rotator cuff has a significant tear, then a rotator cuff repair would be performed. A repair is more involved with a longer rehabilitation. We will cover cuff repair details in another posting.
Shoulder arthroscopy is a procedure that allows the surgeon to use small instruments, colloquially termed a “scope” to perform detailed evaluation of the shoulder. The instrument has a lens equipped with a light and a camera. A skilled surgeon can evaluate the entire shoulder and often gather more information than an MRI. This includes inside the joint and above the joint. It is above the joint, called the subacromial space, that the impingement of the rotator cuff upon the undersurface of the acromion bone occurs. The surgeon may then remove the downward sloping portion of the acromion bone with the arthroscopic instruments (figure 3). The arthroscopic burr smooths the undersurface of bone while the surgeon views the procedure with arthroscopic lens attached to a light and camera system.
The procedure is outpatient. Additional shoulder pathology can be addressed by the surgeon arthroscopically.
Dr. Caldwell has developed an anesthetic block for the shoulder that minimizes postoperative pain and most patients can recover with no narcotic use (see figure 4). This is an important consideration.
The sling is used for just a few days and recovery is relatively quick for most patients. Physical therapy is used to help restore the motion and strength. The prognosis for return to sports is very good.