Shoulder Injuries-Overuse to Trauma: Part 1

The National Ambulatory Medical Care Survey found that over the course of a year up to 50% of the general population will experience shoulder pain, with half of them consulting a physician. In most cases, this discomfort is related to trauma, although there are many other causes for shoulder pain.

The shoulder is made up of three bones: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). The head of the humerus fits into a curved socket, called the glenoid, which is part of the shoulder blade. A group of muscles and tendons, known collectively as the rotator cuff, keep the arm bone centered in the shoulder socket and allow for movement in many different directions. This mobility, however, comes at a price, since the shoulder joint is less stable than most joints in the body. This increases its susceptibility to a number of problems.

Overuse Conditions Affecting the Shoulder. Overuse conditions, also known repetitive strain injury (RSI), are conditions characterized by chronic inflammation brought on by excessive use of a particular body part. Overuse conditions in adults are most often occupationally-related, whereas in younger individuals they are often a result of a sports-related repetitive activity. Some of the most common overuse conditions affecting the shoulder are:

• Bursitis--- A bursa is a fluid-filled sac that acts as a cushion between muscles, tendons, and joints. There are a number of bursae around the shoulder joint. The one most commonly affected in the shoulder is located between the rotator cuff and a portion of the shoulder blade known as the acromion. Excessive use of the shoulder, such as repeated raising and lowering of the arm, can cause this bursa to become inflamed, a condition known as subacromial bursitis. Subacromial bursitis can have an impact on many activities of daily living as well as affecting job performance with certain occupations.
   
• Tendinitis---A tendon is specialized type of connective tissue that connects muscles to bone. Tendonitis, or inflammation of the tendon, can develop suddenly from overuse (acute tendonitis) or more gradually, due to aging and “wear and tear” (chronic tendonitis). Examples of activities that can cause shoulder tendonitis include playing sports that require the arm to be moved over the head repeatedly, as in tennis, and working with the arm overhead for prolonged periods, as when painting. The most commonly affected tendons in the shoulder are the rotator cuff tendons and the tendon that connects to the biceps muscle.
   
• Impingement---This common shoulder condition is named for its mechanical cause, rather than for an affected structure. In shoulder impingement, a portion of the shoulder blade known as the acromion rubs against the underlying soft tissues (bursa, tendons, muscles) when the arm if lifted overhead. This repeated rubbing or “impingement” causes these tissues to become inflamed with the development of bursitis or tendonitis. Symptoms of impingement are similar to that of shoulder bursitis/tendonitis and include shoulder pain with lifting, reaching behind the back, or with overhead movements. Commonly, impingement-related pain will be felt on the outside (lateral aspect) of the shoulder or become particularly noticeable at night.
    

Treatment of Overuse Conditions of the Shoulder: Almost always, initial treatment of overuse conditions of the shoulder is nonsurgical. Resolution of symptoms, however, may take several weeks or months with very gradual improvement and return to function. The first step is to modify activity so that painful motions, such as overhead lifting, are avoided. Typically, a course of non-steroidal anti-inflammatory medicines (ibuprofen, Aleve, others) are given to help reduce pain and swelling. Once the pain has begun to resolve, physical therapy, either self-directed or formal, is employed to help restore strength and regain any range of motion that had been lost. This program usually involves some combination of stretching, strengthening and range of motion exercises. In some instances, an injection of a corticosteroid into the region of the inflamed bursa or tendon may also be helpful if the measures mentioned above are not completely successful.

About ALS (Lou Gehrig's Disease)

ALS is an abbreviation for the disease, Amyotrophic Lateral Sclerosis. Also known as “Lou Gehrig’s Disease”, ALS is a progressive degenerative disease that affects the nerves that control voluntary movements and muscle power. The specific types of nerves affected are the “motor neurons”, located in the brain and spinal cord. These are the nerves that serve as a communication link between the brain and the muscles that they control. With degeneration and eventual death of the motor neurons, muscles weaken, waste away (atrophy), and ultimately cease working. At this time, there is no known cure for ALS with most people living only 3 to 5 years following its diagnosis.

What are the symptoms of ALS? The onset of ALS is typically very gradual with initial symptoms being so subtle that the diagnosis may be overlooked. Early symptoms include fine muscle twitches called fasiculations, muscle weakness affecting the hand, arm or leg, and slurred speech. Over time, the muscle weakness may become more profound with disturbance of normal walking gait, difficulty with performing fine motor activities, such as buttoning a shirt, or excessive fatigue of the arms or legs with minimal exertion. Eventually, the muscles that control the important functions of chewing, swallowing, and breathing are affected by the nerve degeneration.

What causes ALS? There is no known cause for ALS, although environmental and genetic factors have been suspected. Some of the environmental exposures suspected (but not confirmed) of causing ALS include heavy metals (e.g., lead and mercury), solvents, radiation, and agricultural chemicals. Military veterans who were deployed to the Gulf region during the 1991 war have been approximately twice as likely to develop ALS as compared to military personnel who were not in the region, although the reason for this has not been determined. About 5-10% of ALS cases occurs within families and is related to a genetic mutation. This is called “familial ALS” and can be passed down through generations. Genetic testing is sometimes done to look for the possibility that ALS is related to a gene mutation, but in general, this is only done when someone has symptoms of ALS in addition to having a family history of ALS. A more thorough discussion of genetic testing for ALS and when it is most appropriately employed can be found on the ALS Association website. The great majority of ALS cases occur sporadically, with no family history of the disease. Most people who develop ALS are between the ages of 40 and 70, with an average age of 55 at the time of diagnosis.

How is ALS diagnosed? Typically, ALS is confirmed by a neurologist after reviewing the person’s symptoms and physical signs, and performing certain tests and procedures. Tests could include magnetic resonance imaging (MRI) of the brain, muscle biopsy, electrodiagnostic testing (nerve conduction velocity and electromyography), and spinal tap.

Is there a treatment for ALS? Motor neurons send signals to one another via chemical substances known as neurotransmitters. In ALS, an excess of one these neurotransmitters, an amino acid called glutamate, has been found to be present in the brain and spinal cord. Too much glutamate is thought to lead to excessive nerve stimulation and damage to the nerve cells. This knowledge has led to the development of riluzole, the only currently available medication used to treat the symptoms of ALS. Its major function appears to be a reduction in the release of glutamate by the nerve cell. Current research indicates that riluzole prolongs the life of persons with ALS by only a few months. Other than riluzole, treatment of ALS is directed primarily at its symptoms. This can include medications to help with muscle cramps or spasticity, physical therapy, nutritional support, and speech therapy. Antidepressants may be used for accompanying pain or depression. When the muscles controlling breathing are no longer able to function, mechanical support with a ventilator becomes necessary for survival.

ALS is a relatively uncommon disease in the U.S. with approximately 5,600 new cases being diagnosed each year. With up to 30,000 Americans living with the disease, however, it is one that many people have familiarity with through friends or family members. Hopefully, future research will shed additional light on its underlying cause as well as producing an effective treatment.

What is the DASH Eating Plan?

Recently, U.S. News and World Report released its ranking of the best diets for 2014.  This list was compiled by a panel of health experts including nutritionists and physicians specializing in diabetes, heart disease, and weight loss. In this ranking, the DASH eating plan topped the list, beating out better known diets, such as the Mediterranean, Jenny Craig, and Mayo Clinic. How could a diet with an acronym that stands for “Dietary Approaches to Stop Hypertension” have received the highest overall ranking? 
While the DASH diet was originally designed to help lower high blood pressure, its nutritional components have stood the test of time in the ever changing world of nutrition.  The basic principles of the DASH Eating Plan are that it:

• Emphasizes eating a variety of foods available in most grocery stores
  
• Is low in saturated fat, cholesterol, and total fat
  
• Focuses on fruits, vegetables, and fat-free or low-fat dairy products
  
• Is rich in whole grains, fish, poultry, beans, seeds, and nuts
  
• Contains fewer sweets, added sugars and sugary beverages, and red meats than the typical American diet
  
• Is lower in sodium (salt) than the typical American diet.

By following the DASH diet, many people with hypertension have been able to lower their blood pressure readings by several points. But in addition to helping with blood pressure control, the DASH diet is consistent with the current dietary recommendations for osteoporosis, heart disease, diabetes, and cancer prevention.
The DASH plan includes daily servings from the following food groups:

• Grains---bread, cereal, rice and pasta. Whole grains are encouraged since they have more nutrients and fiber than refined grains.  Examples include brown rice, whole-wheat pasta, and whole-grain bread.
  
• Fruits---apples, apricots, bananas, dates, grapes, oranges, melons, peaches, pineapples, raisins, strawberries.  Canned fruits or fruit juices are thought to be OK as long as no sugar has been added. It should be noted that certain fruits, such as avocado and coconut are fairly high in fat (and calories) than most others.
  
• Vegetables---broccoli, carrots, green beans, green peas, kale, lima beans, potatoes, spinach, squash, sweet potatoes, tomatoes. Like fruits, vegetables are important sources of potassium, magnesium, and fiber. Fresh, frozen or canned are all acceptable choices although the sodium (salt) content of canned foods should be taken into consideration.
  
• Dairy---milk, yogurt, cheese.  These are major sources of calcium, vitamin D and protein. In general, low-fat or fat-free should be chosen. Many fat-free cheeses, however, can be high in sodium which should be avoided.
  
• Lean meat, poultry and fish. Lean cuts of meat with the fat trimmed away are recommended. Skin should be removed from chicken.  Eating fish that are high in omega-3 fatty acids (e.g. salmon, herring and tuna) is encouraged.  Broiling, roasting or poaching rather than frying is encouraged.
  
• Nuts, seeds and legumes---Almonds, peanuts, walnuts, sunflower seeds, peanut butter, kidney beans, lentils, soybeans, split peas.  These are rich sources of magnesium, protein, and fiber.  Meals centered on beans, lentils or soybean products are encouraged as a substitute to meat-based meals. Since nuts are fairly high in fat, they should be eaten in moderation.
  
• Fats and oils--- The DASH diet limits fats to 27% or less of daily calories including fat in foods and added fats or oils. Mono- and polyunsaturated fats are recommended over saturated fats. Common sources of these healthier fats are vegetable oils (canola, corn, olive, and safflower), low-fat mayonnaise, and light salad dressing. Saturated fats from meat, butter, cheese, whole milk, lard, and “tropical oils” (palm and coconut) are limited to less than 6% of total calories. Trans fat, a major cause of elevated blood cholesterol should be avoided.
  
• Sweets---Unlike many diets, the DASH plan allows for eating sweets. The key is moderation and portion control. Artificial sweeteners (NutraSweet, Equal, Splenda) are recommended sparingly.

Serving sizes of each of these vary depending on the specific group.  One “serving” of meat is considered to be one ounce.  A “serving” of sweets could be 1 tablespoon jam, ½ cup sorbet, or 1 cup lemonade. The number of servings from each group depends on the daily caloric requirement which is based on age, gender, and activity level.   As an example, a young woman who is moderately active would be allowed to eat up to 2,200 calories per day. This could include up to 8 servings of grains, 5 servings of fruits, 5 servings of vegetables, 3 servings of dairy, 3 servings of fat and oils,  6 servings (approximately 6 ounces) of meat, 5 servings (per week)  of nuts, seeds and legumes, and 5 servings (per week) of sweets.
While not developed as a weight-loss diet, the DASH food plan can be effective as part of a weight-loss strategy by slightly reducing the number of base calories and the addition of regular exercise. You can learn more about the DASH Eating Plan from the National Institute of Health.  Additionally, a DASH meal guide is available at: www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf