Focus On: Shoulder & Knee Injuries

Common Injuries of the Shoulder, Elbow and KneeWith Andrew Judelson, M.D.

Staff physiatrist Andrew L. Judelson, M.D., is an expert on a wide range of medical issues - musculoskeletal injuries, cardiac rehabilitation and wound management, among others. He's also a sports and exercise hound.

"I like to challenge myself," Dr. Judelson says. "I love running and cycling." In fact, he's ridden in the Last Gasp Bike, Boat 'n Bake charity bicycle ride and run in the Falmouth Road Race.  Here, he discusses common shoulder, elbow and knee injuries.

Q: What are the most common shoulder and elbow injuries?
A: Common shoulder injuries include:

• Contusion or bruise
• Biceps tendonitis
• Rotator cuff tendonitis from repetitive lifting or overhead motion.  The rotator cuff is a group of tendons and muscles in your shoulder that allows you to raise and twist your arm.
• Shoulder instability or shoulder impingement.  Impingement occurs when there is a pinching of tendons or muscles during overhead activity.  Usually this is due to arthritic changes to the shoulder joint.

More serious injuries include:

• Dislocation (traumatic)
• Separation of the AC joint (Acromio-clavicular joint), where the collarbone joins the shoulder
• "Stinger"/"burner":  a nerve injury caused by traction or pulling of the nerves in the neck and shoulder
• Fracture of the scapula (shoulder blade) or clavicle (collarbone)
• Biceps tendon tear (more typical in older patients)

Common injuries of the elbow include:

• Tendonitis of the biceps or triceps
• Epicondylitis, also known as "tennis elbow" or "golfer's elbow
• Bursitis
• Nerve impingement
• Strain of the capsule, the tissue that surrounds and holds the joint in place

Q. What causes rotator cuff and elbow problems?
A: Believe it or not, regular wear and tear can slowly damage your rotator cuff. Overuse is a big problem as well by causing small tears and tendonitis.   Activities where you repeatedly use your arms above your head - anything from painting to swimming - can lead to problems over time.

Tennis or golf elbow is also caused by repetitive movement - this time of the arm, wrist and elbow.  As you'd expect, playing golf or tennis can strain the muscles and tendons around the elbow, but so can activities like gardening and cleaning the house if you're using the same muscles over and over.

Q.What are the most common knee injuries?
A: Traumatic injuries of the knee are fairly common.  These include:

• Ligament strains or  tears, specifically, injuries to the anterior cruciate ligament (ACL) and the medial collateral ligament ( MCL).  The ACL helps stabilize the knee joint. When you injure your ACL, your knee becomes unstable, and it will be difficult to make pivoting movements. ACL injuries can strike anyone, but individuals who play sports requiring sudden turns, cutting or pivoting are most at risk.  The MCL helps keep the knee in a straight alignment.
• Meniscal tear
• Fracture
• Dislocation

Other knee problems include:

• Injury of the kneecap (patella), either from direct trauma or overuse from running, jumping, cycling, walking.  This is called the patella femoral syndrome.  In some people there  is a physical pre-disposition to this type of injury.
• Bursitis

Q: What is bursitis and what causes it?
A: The bursa is a sac filled with lubricating fluid which is located between tissues.  The role of the fluid is to decrease friction between structures. 

Bursitis occurs when you inflame or irritate the bursa, through work or play, trauma, overuse, infection (which is rare) and inflammation (such as occurs with gout and rheumatoid arthritis).  Bursitis can affect your shoulder, knee, hip, elbow - anywhere there is a bursa.

Q: What basic first aid techniques should be applied right after an injury?
A: The acronym PRICES will help you remember what steps to take.
P = P rotection.  First apply a bandage, sling or splint to protect the injured area.
R = R est.  Rest the injury.
I = I ce.  Apply ice to reduce pain and swelling.
C = C ompression.  Wrap the injured area with an ace bandage or other form of compression to reduce swelling.
E = E levation.  Elevate the affected limb above the level of your heart.   This also lessens swelling.
S = S upport.  If indicated, use a splint or brace to support the injured area during the healing process.

Taking a non-steroidal, anti-inflammatory drug (NSAID) such as ibuprofen can help reduce the pain and swelling.   Check with your doctor to see if using an NSAID is appropriate for the injury and okay for you to use.

Q: When should you consider seeing a doctor?
A: Common sense and the nature of the injury are key factors. Generally you'll know if you need to see a doctor depending on how you got hurt and what your pain level is.

If your knee suddenly gives out while you're playing basketball, you should seek care.  If your shoulder is sore after swimming or throwing around a softball, you probably don't need to see a doctor. You can take some basic measures and see if they help the problem.  Generally, if symptoms persist more than two weeks, you should see your doctor. 

Q:  If you do have a moderately serious injury, what is the treatment?
A: First, there's a spectrum of treatment options and a range of possibilities to try.  These include NSAIDS, injections, physical or occupational therapy, exercise and the use of a device or brace to provide support.  Physical therapists can offer many modalities of treatment, including ultrasound and electrical stimulation.

Second, every injury is different, and each patient has different goals, abilities, and circumstances.  The best approach is to work with a physician and/or therapist who will develop an individualized treatment plan that addresses your needs.

Q. What about surgery?
A.  Surgery may be the answer with some severe injuries, but usually surgery is the last resort.  Often more conservative approaches, such as physical therapy, will resolve the problem.

Q.  What role does exercise play?
A: I'm a big advocate of a general exercise program that involves stretching and flexibility.   Flexibility exercises, cardiovascular conditioning and strength training form the core of any well-rounded exercise program.

I know it's easy to say and harder to do, but 30 minutes of exercise a day can help prevent a range of injuries. You don't have to go to a gym and pump iron. You don't have to exercise all at once - you can break it down into three, 10-minute segments if you want

Q. How important is exercise for the older athlete?
A.  In my view, it's very important.  Our bodies go through many physiologic changes associated with aging.   These can increase our risk of injury due to decreases in flexibility and nerve conduction and loss of muscle mass.  Problems with hearing, vision and gait can also increase the risk of injury.  Plus degenerative joint disease, rheumatoid arthritis, osteoporosis and other diseases can negatively impact our mobility, balance, activity levels and general quality of life.

Exercise can be both therapeutic and preventive.  If someone has not been exercising, however, it's important to get medical clearance before starting an exercise program.  Your doctor will want to review your musculoskeletal and cardiovascular systems, as well as your medications, before you begin.

Q: You're a physiatrist.  What is a physiatrist, and what expertise can a physiatrist bring to treating knee and shoulder injuries?
A: A physiatrist is a doctor who focuses on rehabilitation and function. In our training, we have exposure to orthopedics, neurology, pain management and anatomy/physiology.   We learn to think about treating the patient as a whole, so our approach is holistic.  We look at not only the physical, but also the emotional, mental and social aspects of treatment and recovery. We tend to take a broader view of the mind-body relationship, and I think we tend to be more liberal about alternative treatments and medications.

For office locations, appointment information for Dr. Judelson, click here.