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Treatment

Treatment is multi-disciplinary, involving player, physiotherapists, coaches, doctors and family unit.  As with all branches of medicine patient compliance is vital; and in the case of musculoskeletal injuries is the largest factor affecting the success or failure of treatment.  Initial management of shoulder pain in the athlete ought to be conservative[9]. 

The following practice is recommended [3]:

1) Avoid all painful activities
2) 2 week course of Non-steroidal anti-inflammatories & ice (this has the dual affect of decreasing nerve fibre transmission so decreasing pain and by also decreasing chemical activity and so decreasing inflammation).
3) decreased anterior capsule stretching & increased posterior capsule stretching
4) Increased rotator cuff exercises with emphasis on external rotators
5) Scapular positioning musculature exercises & increased body roll.

Physiotherapy is widely used with emphasis on loosening the musculature in a tight shoulder, via sports massage, ultrasound, interferential or diathermy heat treatments. 
Physiotherapists also use strengthening exercises for the muscles of the shoulder girdle, care should be taken not to neglect the scapular musculature, dysfunction and weakness of which can lead to altered biomechanics of the shoulder girdle [21].  Hence a knowledge and understanding of how the scapular musculature influences shoulder function is vital information for the clinician attempting to treat the painful athletic shoulder.  Patient education is important, and can lead to modification of activities to increase stability [4].  In the presence of instability bracing and taping are employed to decrease load and weight bearing but this is not always appropriate in contact sports as further injury/ risk of injury to other players may be present.

Treatment depends on the healing process of the involved tissues.  In tendon damage there is an initial 48 hour inflammatory process involving swelling in the adjacent tissues as increased tissue permeability also happens.  During this period ice is indicated (see earlier).  In the subsequent weeks there is a proliferative phase where new collagen is laid down and mature cross-links are made.  The following formative phase involving tissue remodelling can last for up to a year; during this time there is little inflammatory reaction but the process is more one of degeneration.  The underlying causes of this degeneration include inadequate oxygenation, decreased nutrition, hormonal changes, and the effects of chronic inflammation as well as ageing.  The degeneration that takes place is closely linked to the rate of and success of injury recovery.  Tendon function is not just reliant upon the number and size of the collagen fibres reproduced but also on their orientation in fibres the tendon needs to be placed under tension and motion.  Therefore immobilisation is contraindicated with a push to protected mobilisation as soon as possible following injury is seen.  At the very latest movement ought to be achieved by the 3rd week after injury [13].  If met with resistance to therapy an early referral for surgical evaluation is appropriate.  Following the initial 48-hour phase, heat therapy is widely used as it decreases joint stiffness, increases the extensibility of collagen and affords pain relief.  Many methods for delivering this heat can be used; heat retainers, neoprene sleeves, high voltage galvanic stimulation, infrared lamps, ultrasound and whirlpools – care must be taken against burns.

Corticosteroid injections are commonly used, but decrease metabolic activity locally and there is a risk of necrosis.  Clinicians suggest no more than 3 corticosteroid injections to any given joint in a year.  Corticosteroid injections into the subacromial bursa have good results but note the underlying cause is not resolved and their role is one of short term pain relief only [17].

  Tissue shrinkage has been used to decrease laxity in the joint, this is achieved through thermal energy imparted via a thermal probe. This treatment has been shown to give a high return to previous levels of competition [10].  Much research is being undertaken into the analysis of rehabilitation exercises, suggests that the future of the treatment of these injuries will become increasingly evidence-based [22].  Whilst there is an ever increasing push towards managing these injuries non-operatively, it has been shown that less than 50% of subjects with multidirectional hyperlaxity and instability of the shoulder resolve with rehabilitation alone [23].  In fact it is suggested that in cases where instability is the main symptom surgical management with physiotherapy ought to be the initial treatment [23]. 

Surgical treatment aims to decrease anterior capsular laxity and can also be used to remove chronic inflammatory and scar tissue posteriorly  [4, 23]. Lesions, such as SLAP tears, labral tears and impingement can also be dealt with.

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