If you are like many golfers, sometimes you will continue to play golf with shoulder pain and finally seek medical attention when a) they can no longer play without pain, or b) when they can no longer drive through the ball at a velocity that they are accustomed to and the frustration of added strokes has made the game miserable for them.
Now how did that shoulder get painful? For most golfers it is a matter of overuse or poor technique, such as killing the ball. Sometimes a golfer will hit the ground too hard and cause an acute impact injury. Golfers are prone to the same shoulder injuries as other sports. The list includes:
- Rotator cuff tears,
- Shoulder impingement or Subacromial impingement, degenerative joint disease and shoulder joint instability.
- SLAP tear
- Shoulder subluxation or chronic dislocation
- AC joint pain
A painful shoulder decreases club head velocity
A German study (1) suggested what you already knew, a painful shoulder decreases club head velocity. Of course they came to this conclusion after examining many golfers using various testing methods. Here is what the study said: “Joint structure damages due to overstrain often occur even in commonly not injury-prone golfing. Triggered by the golf swing’s repetitive movement pattern and technique deficits of the player these structural damages are most likely to affect the lumbar spine as well as shoulder and elbow joint. As a synonym for shoulder impingement symptoms in golfers the term golf shoulder has been established in medical terminology.”
The authors of this study suggest wear and tear strain and poor technique can impact not only the low back and elbow but cause shoulder impingement syndrome, further they state: “a persisting shoulder impingement syndrome can have a negative effect on club head velocity.” Reduced club head velocity adds strokes.
Although “impingement” refers specifically to pressure on the tendons and bursa in the shoulder, it is a generalized term often used to refer to shoulder pain of unknown origin. Other terms used to describe pain that cannot be pinpointed are tendinitis, tendinosis, and bursitis.
Shoulder Impingement Treatment
I see many people who play golf with shoulder pain, sometimes a severe shoulder pain. They complain about pain at the top of their shoulder, the side of their shoulder and when they extended their hands over their head during the swing. After playing a few rounds, they have a problem sleeping at night because of their shoulder pain.
If you have chronic shoulder pain affecting your game you have probably tried remedies and exercises including RICE (rest, ice, compression, and elevation) and self-medicating with anti-inflammatory medications that may have helped short-term, but did not help you play long-term.
When you got to the point where you may have to stop playing, this is when you decided to get medical care. Medical care may not have been to your likening. You may have not liked the suggest your doctor gave you to stop playing for a while to see if your shoulder heals on its own. You may have liked it worse when after a long bout of rest, you picked up a club, went through a swing and the same pain remained.
When you returned to your doctor after the rest period and want to try something else to help accelerate your healing you may have been told to go to physical therapy to see if that works. You can also try a cortisone injection.
Injections for shoulder pain
If you have increased shoulder pain and you are seeking medical care, you will usually be offered the typical medical care of oral anti-inflammatory and painkiller medications. If these do not work, then injections may be offered.
The “go to” injection choice is corticosteroid or more commonly a cortisone shot. Many people will not get the cortisone injection alone, it will be coupled with a physical therapy program. The reasoning being that research shows cortisone and physical therapy work better than physical therapy alone. An August 2021 study (2) suggested “(a) combination of corticosteroid injection and physiotherapy is more effective than the physiotherapy alone in resolving the shoulder pain and disability of shoulder.”
As I mentioned above, once the pain is determined to come from the subacromial space of the shoulder, that is the area of the rotator cuff tendons and the subacromial bursa, then rotator cuff tendinopathy, (shoulder impingement) is often diagnosed. The impingement occurs when the Acromion’s underside, presses against the rotator cuff tendons, wear and tearing at them. When a patient comes into our office we will perform a detailed physical examination of the shoulder looking for pain generators. Spots on the shoulder that elicit a pain response when pressed. Typically these are the spots of damage.
Cortisone does come with its side-effects
Like all injections side effects can include infection at the injection site. Cortisone however does have its own history of documented concerns and side-effects.
Another December 2019 study (3) suggests that a steroid injection in the shoulder prior to rotator cuff surgery, puts you at a greater risk for post-surgical shoulder complications and possibly the need for a secondary or revision shoulder surgery.
A January 2019 study (4) examined the effects of one or multiple corticosteroid injections a patient received for shoulder pain prior to having rotator cuff surgery. The research team found administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery.”
An October 2020 study (5) compared one PRP injection to one corticosteroid injection for pain relief and improved function in patients with rotator cuff tendinopathy and partial thickness rotator cuff tears. After the one injection, patients were followed and results recorded at six weeks, three and twelve months post-injection. The researchers observed that patients with partial rotator cuff tears or tendinopathy experienced improvement in pain after both ultrasound-guided corticosteroid and PRP injections. However the patients who received PRP had superior improvement in pain and function at short-term follow up (3 months). One injection of PRP is not the way we offer the treatment.
Bone Marrow aspirated stem cells injected into the shoulder
Bone marrow aspirate concentrate stem cell injections
For many patients, not all, stem cell therapy or bone marrow aspirate concentrate may be effective. The treatment in demonstrated in the above video. In our research which appears in the peer-reviewed journal Cogent Medicine found here in its entirety: Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections with a June 20, 2019 publication date, we were able to demonstrate:
- Selected patients with rotator cuff tendinopathy and degenerative shoulder disease would benefit from either one and two stem cell treatments. Patients reported significant improvements in resting pain, active pain, and functionality score when compared to baseline.
- These groups also experienced a 42.25% and 50.17% overall improvement respectively.
- The group that received two treatments experienced statistically significant improvements in active pain when compared to the group that received one injection.
- There were no significant outcome differences between rotator cuff tear and osteoarthritis patients.
Conclusions: Our study demonstrated that patients diagnosed with shoulder osteoarthritis or rotator cuff tears experienced symptomatic improvements in pain and functionality when injected with bone marrow concentrate (BMC) or whole bone marrow (WBM). Further randomized control studies are needed to validate these findings.
References
1 Ostreicher M, Schwarz M. Relation between shoulder impingement syndrome and club head velocity in high-performance amateur golfers. Sportverletzung Sportschaden: Organ der Gesellschaft fur Orthopadisch-traumatologische Sportmedizin. 2013 May 27;27(2):108-11.
2 Khan RD, Shahzad K, Khan S, Israr M, Zahid FM. Comparison of physiotherapy with and without intra-articular corticosteroid injection for treatment of frozen shoulder: A comparative study. JPMA. The Journal of the Pakistan Medical Association. 2021 Aug;71(8):S17-21.
3 Puzzitiello RN, Patel BH, Nwachukwu BU, Allen AA, Forsythe B, Salzler MJ. Adverse impact of corticosteroid injection on rotator cuff tendon health and repair: A systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019 Dec 17.
4 Desai VS, Camp CL, Boddapati V, Dines JS, Brockmeier SF, Werner BC. Increasing numbers of shoulder corticosteroid injections within a year preoperatively may be associated with a higher rate of subsequent revision rotator cuff surgery. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019 Jan 1;35(1):45-50.
5 Kwong CA, Woodmass JM, Gusnowski EM, Bois AJ, Leblanc J, More KD, Lo IKY. Platelet Rich Plasma in Patients with Partial Thickness Rotator Cuff Tears or Tendinopathy Leads to Significantly Improved Short-Term Pain Relief and Function Compared to Corticosteroid Injection: A Double-blind Randomized Controlled Trial. Arthroscopy. 2020 Oct 27:S0749-8063(20)30893-8. doi: 10.1016/j.arthro.2020.10.037.