Trott Any number of things can cause shoulder problems, from lifting something too heavy, to falling, to over-use, to poor posture.

Physiotherapists Mary McCabe and Jill Bewsher know all too well the complexities of shoulder injuries. They help patients through rehab following surgery by Dr. Colin Couper and Dr. Joseph Froncioni.

"The shoulder joint is a very mobile joint but not a very stable joint,'' Miss Bewsher revealed.

"It has a lot of muscles, nerves and tendons to help hold it in place and because of its relationship with the spine, collarbone and shoulder blade you can have pain in any one of those. So if somebody has shoulder pain it doesn't necessarily mean that it is always from the shoulder.'' It is the early pain which often brings a patient in to see their doctor or a physio, but there are other early signs.

"First sign is pain,'' said Mrs. McCabe who also serves as president of the Bermuda Physiotherapy Association.

"A lot of people are under the impression that with pain you can work through it or try to do more exercises to work it out, but it might be an inappropriate exercise that they are doing.

"You can classify pain when you use the arm and sometimes shoulder patients will only get pain when they do particular movements. The rest of the time they are okay. You can get pain with every movement and even get pain when you are not moving it at all.'' Added Mrs. McCabe: "Second is stiffness, loss of range of motion and inability to lie on the shoulder at night or even to lie on their back.

"Third is weakness, where a patient feels they can only do so much with the arm before it starts to feel tired and heavy. With shoulder pain it very often refers, so the patient comes in and says they have pain in their elbow but they have something going on in their shoulder which very often refers down to the elbow and sometimes right down to the wrist.

"With shoulder pain we would always check the neck as well because very often you can get pain referring into the shoulder area but it's coming from the neck. With stiffness sometimes it's a noticeable stiffness and sometimes it's only a loss of range of motion that the physiotherapist picks up, like using their arm in a smaller range of motion.'' A seemingly harmless chore around the house on the weekend can result in a stiff and sore shoulder a couple of days later.

"Like somebody who has painted their ceiling on the weekend,'' explained Miss Bewsher, who is also an executive member of the Bermuda Physiotherapy Association.

"They would have been doing an exercise or movement they are unaccustomed to for a prolonged period of time.'' Mrs. McCabe added: "We can get shoulder pain because of traumatic injury which would be if somebody has fallen over or overstretched their arm or as a result of an old broken bone.

"That would be a classification of a traumatic injury. Or you can get injuries from overuse and those are pretty common. That would be some sports, like racquet sports.'' Are the injuries more common amongst athletes? "Not necessarily,'' says Mrs. McCabe.

"It can hit a lady doing her housework. If they have done a lot of hard work and have overdone it and have ignored the early signs of injury and have worked through it.

"From a children's point of view it tends to be more sporting, overhead type of movements like throwing, serving in tennis, volleyball, basketball, freestyle and butterfly swimmers. With neck pain the two are very closely related.'' Taking the warning signs seriously are important to treating shoulder injuries.

"In the early stage of an injury ice is one of the best things you can do in acute injuries,'' Mrs. McCabe assures.

"The best way to ice it is to get crushed ice in a ziplock bag with a little bit of water in the bag as well. Put a wet face cloth on top of the skin, put the ice pack over the top and wrap the whole lot in a dry towel and leave for 20 minutes to 30 minutes.

"With a traumatic injury, if you think there is any chance that you've broken anything, go straight to the hospital or doctor. We don't want people icing broken arms, but if it's just a pull or an overuse injury then ice is going to be very helpful in the early stages.'' Miss Bewsher warned: "But if the pain hasn't changed or gets worst over the next two days than they need to seek professional help.'' And while many of the shoulder injuries come from head-above-the-head movements, McCabe said that pain can come from seemingly harmless movements like reaching into the back seat of the car for something.

"A lot of injuries we see come from rotator cuff injuries,'' said Mrs.

McCabe.

"The rotator cuff is a cuff of four muscles which help keep the ball in the socket. The rotator cuff isn't designed very well because one of the groups of muscles, the external rotators, is usually weak even in active people. So then you get a muscle in-balance, with strong internal rotators and weak external rotators which can lead to rotator cuff tendinitis.'' Improper exercises can lead to further problems, Miss Bewsher says. Physios devise a series of exercises for the patient to do at home.

"Sometimes as far as treatment goes, you are helping to settle down the tendinitis, but once the pain is gone unless you re-educate the muscles to get the right pull on the bone and hold it in the right position then it can be something that reoccurs,'' Miss Bewsher said.

"From the treatment point of view they are doing the ice initially to help settle the initial inflammation from the injury, with relative rest so they are not using the aggravating movements.

"Once that settles down with very little pain they can start doing stretches so they are getting a full range of movement back in their arm. Then it's important once they are pain free that they do a gradual buildup of the exercises to make sure they have full strength back in their shoulder but in a balanced way within the muscles.'' When a patient goes in to see a physiotherapist a full assessment of the injury will be done to diagnose what type of injury it is.

"Then from that assessment we'll work out a treatment plan,'' said Mrs.

McCabe. Treatment could involve electrical modalitis, ultrasound, laser, interferential and shortwave diathermy.

The home exercises are designed to help the patient to maintain or increase their range of motion.

"Which is done in a very graded way so that you build up the muscles in such a way as not to inflame the joint again,'' said Miss Bewsher.

Sitting for long hours at a computer can lead to stiffness in the shoulders, but simple stretching exercises can help tremendously. Those simple exercises could include stretching the arms, flexing the shoulders and moving the head from side to side and in circular motions.

"To relieve shoulder tension you don't necessarily have to stand up,'' Mrs.

McCabe stressed.

"The shoulder can be complex, it's a multi-axial joint so therefore very difficult to immobolize whereas the knee is a hinge joint and basically only has forward and backward movements.

"The other joint you have to consider when looking at shoulder joint injuries is the joint at the top of the shoulder called the AC (acromio-clavicular) joint and that presents different symptoms than shoulder joint problems. It's where the collar bone joins onto the shoulder blade.

Usually there is pain on the top of the shoulder and the patient has difficult in raising their arm and also moving it to the front of their body.'' On Tuesday: Top swimmer Chris Flook talks about the shoulder injury that ended his career.