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THE SHOULDER

Structure
In dancers, injuries to the shoulder and arm are not as common as lower
extremity injuries. However, acute and overuse injuries from repeated spins,
lifting, and drops can lead to injury. Also, choreography that involves weight
bearing on the shoulder and/or arm can produce atypical stresses to the
shoulder joint and can also lead to injury.
The shoulder is comprised of three bones: the scapula in the back
(shoulder blade), the clavicle across the front (collar bone), and the humerus
(upper arm bone). These three structures rely heavily on dynamic stability
from the rotator cuff muscles around the joint. There is also a joint capsule
and labrum (cartilage) which provide further stability to the joint.

Common Injuries

Shoulder Dislocation
“My shoulder popped out of joint.”
The shoulder joint is the body’s most mobile joint. While this provides
tremendous functional benefit, this also makes the shoulder easy to
dislocate. A partial dislocation (subluxation) means the head of the upper
arm bone (humerus) is partially out of the socket (glenoid). A complete
dislocation means it’s popped all the way out.

Causes
Falling is the most common cause of a new shoulder dislocation. However,
a dislocation can also occur when the arm is forcibly moved into an awkward
position, usually while extended away from the body. Both partial and
complete dislocations cause pain and unsteadiness in the shoulder. The
muscles may have spasms from the disruption, and this can make it hurt
more. Repeated shoulder dislocations will lead to instability of the joint.
Dancers with this injury may notice it becomes easier to sublux or dislocate
the joint again and again.

Treatment
Shoulder subluxations will usually relocate without much assistance.
Dislocations, particularly first time dislocations, may need the assistance of
a physician to relocate the joint. The physician may also wish to x-ray the
joint to rule out any fractures. Following relocation, a sling and activity
restriction is advised for several weeks. Ice and anti-inflammatory
medication can be helpful to help reduce acute inflammation in the joint. A
supervised physical therapy program is crucial to help prevent repeated
dislocations. The therapy is directed at strengthening the muscles around
the shoulder and upper back that help stabilize the shoulder in its socket.
Technical Tip:
Maintaining excellent strength and stability of the shoulder and upper back
muscles may help prevent shoulder dislocations. However, as most
dislocations occur accidentally, safety in the studio or rehearsal space
should be of top importance. Avoid repeating lifts or difficult movements too
many times, as when the muscles fatigue accidents become more likely.

Shoulder impingement
“My shoulder hurts when I reach overhead.”
Shoulder impingement syndrome is primarily due to a narrowing of the
space underneath a bony process (the acromion) in the shoulder. The
supraspinatus muscle (one of the rotator cuff muscles) passes through this
space and can become inflamed and painful if compressed. In some cases,
the supraspinatus bursa also becomes compressed and inflamed; or
calcium deposits may form within the tendon of the supraspinatus.

Causes
Shoulder impingement syndrome can be due to a number of factors,
including:
• Repetitive arm movements, especially with overhead activities.
• Frequent extension of the arm at high speed under high load, such as with
baseball pitching.
• An increase in upper extremity training by a dancer whose rotator cuff
muscles are not in good condition.

Symptoms
It is common for individuals with shoulder impingement syndrome to ignore
the first signs of symptoms. There is usually no single episode of the
shoulder giving way and, at first a person may notice only minor pain and a
slight loss of strength. The injury will generally progress over time. Dancers
typically seek medical attention once they notice regular pain with overhead
motions or lifting objects.

Treatment
Initial treatment for shoulder impingement involves ice, rest, and the use of
anti-inflammatory medications to reduce acute swelling in the joint. For
chronic cases, a physician may recommend a corticosteroid injection to
assist with decreasing the inflammation in the joint. Physical therapy or
athletic training consultation is advised to evaluate the shoulder function and
improve rotator cuff strength. Dancers with chronic, unresolved impingement
conditions may be candidates for a surgical technique to decompress the
acromioclavicular joint.

Rotator cuff tears
“I can’t raise my arm overhead.”
The rotator cuff muscles are attached to the upper arm bone (humerus) by
tendons. Rotator cuff tears occur when one or more of these rotator cuff
tendons are torn partly or completely.

Causes
Rotator cuff tears are most often the result of a forceful injury, such as falling
with an extended arm. Tears can also result from repeated, abnormal
stresses placed on the arm, such as with a throwing mechanism. A tear or
complete rupture of the rotator cuff tendons is usually quite painful and
disabling. The dancer will notice significant difficulty or inability to raise the
arm overhead. There is usually no pain with passive movement of the
shoulder. Along with X-rays, the physician will often request an MRI to
confirm the diagnosis of a rotator cuff tear.

Treatment
As with most soft tissue injuries, the initial treatment for a rotator cuff tear is
a combination of rest and ice. Anti-inflammatory medications can be helpful
in reducing acute pain. Dancers with a partial rotator cuff tear may be able to
strengthen the shoulder with a rehabilitation program to regain full function.
Complete tears will most likely require surgery to repair the injured tendon.
Surgery is followed by 2-3 months of additional rehabilitation before full
function to the shoulder can be restored.
Technical Tip:
The key to preventing a rotator cuff tear is to maintain a healthy rotator cuff.
Dancers should address any discomfort or weakness in the rotator cuff
immediately. If the shoulder is painful with activity or with overhead motions,
the dancer should avoid activities such as lifting or throwing a partner until a
proper diagnosis can be obtained.

Acromioclavicular Joint sprain
“I fell on the top of my shoulder.”

Causes
The acromioclavicular joint (AC joint) joins the shoulder blade (scapula) in
the back to the collar bone (clavicle) in the front. Injuries to this joint are
usually the result of a direct force to the tip of the shoulder, or by falling onto
the shoulder. The ligament between the acromion and the clavicle will be
torn, either partially or completely. With a complete tear, there is often a
“bump” that develops on top of the shoulder. This area will be swollen and
painful to touch, and the shoulder is usually painful with all movements.

Treatment
Initial care of AC joint sprains will include ice and rest. Once the diagnosis is
confirmed, the physician may issue a sling or a clavicle brace to help
stabilize the joint. Tissue healing for partial AC joint sprains will take about 6-
8 weeks. During this time, athletic training or physical therapy treatments
can be helpful to strengthen the shoulder and restore proper movement
mechanics. Though not common, complete AC joint tears may require
surgery to repair the injured ligament and restore joint integrity.

Prevention / Tips for
dancers:

1. Overuse injuries
require attention.
Dancers should not try to
"work through the pain."
When a shoulder injury is
ignored, it can become
the source of chronic
problems.

2. If your shoulder is sore
after you use it actively,
especially at the limits of
your reach, try giving it
some rest. If the pain
persists or worsens,
consult your physician.

3. When strengthening
the shoulder girdle,
dancers should focus on
developing the posterior
shoulder muscles as well
as the intrinsic rotator
cuff muscles. This will
provide the greatest
potential for shoulder
stabilization possible.