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    Default General guide to arm and shoulder injury

    Since badminton involves a lot of repetive overhead injuries, badminton players are espically vulnerable to shoulder injuries much like basball pitchers. The shoulder is easily injured due to the lack of blood supply there, and hence its inability to quickly heal. Thus, continuous use of the shoulder, espcially in clears and smashes, can cause wear and tear faster than the body can fix it. When other actvities that stress the shoulder are factored in, such as heavy lifting, injury seems invetiable.

    Treatment of shoulder injuries, pretty much regardless of what it is, is rather straight forward. Conservative treatment is compsed of rest. When the pain becomes minimal, or when it is just starting, rotator cuff stregnthening exercises should be added to reduce future risk of injury. If the fails, sugery is the only other option.

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    Detailed look at impinged nervers. This is the first step in shoulder injury, and usually comes before others.



    What is Impingement Syndrome?
    If you experience impingement syndrome in your shoulder, the bones and tissue in your upper arm are improperly aligned – narrowing the space between the acromion and the rotator cuff. It is often a precondition for many common shoulder ailments, including bursitis, tendinitis, arthritis, as well as injuries to the rotator cuff tendons. One of the common signs of impingement syndrome is discomfort when you raise your arm above your head.

    The normal shoulder joint is a very elegant, complex machine – it has the most mobility of any joint in the body. The ball and socket design of the shoulder allows the arm to rotate, enabling us to reach and swing our arms, hit or pitch a baseball, use a tennis racket, wash our hair, and lift and carry a child. It is because of this flexible design that we are able to use our hands and arms in many so different positions.

    The design of the shoulder joint gives it great range of motion but limited stability. It is prone to injury as we age. As long as the parts of this elegant machine are in good working order, the shoulder can move painlessly and easily. When injury or conditions such as impingement syndrome, tendinitis, or bursitis affect the shoulder joint, pain and the loss of mobility result. Because we depend on flexible arm movement for so many of the activities that are important and pleasurable to us, injuries to the shoulder joint can be very disruptive.

    To understand impingement syndrome, it is important to know something about the anatomy of the shoulder. Anatomically, the shoulder is like a cup and saucer. The cup is the head of the humerus (arm bone), and the saucer is the glenoid socket of the scapula, or shoulder blade. The tendons of four muscles form the rotator cuff, blending together to help stabilize the shoulder. The fibers of the rotator cuff bend as the shoulder changes position.

    Tendons attach muscles to bone and are the mechanism enabling muscles to move bones. It is because of the rotator cuff tendons, which connect the long bone of the arm (the humerus) to the scapula (the shoulder blade) that we can raise and rotate our arms. The rotator cuff also keeps the humerus tightly in the socket (glenoid) when the arm is raised. For normal function, each muscle must be healthy, securely attached, coordinated, and conditioned.

    Another important structure within the shoulder joint is the bursa, or lubricated sac of synovial fluid that protects the muscles and tendons as they move against each other. There is a bursa between the part of the scapula that makes up the roof of the shoulder (known as the acromion) and the rotator cuff tendons. The bursa simply allows the moving parts to slide against one another without too much friction.

    Causes of Impingement Syndrome?
    People who continuously work with arms raised overhead, or who engage in repetitious throwing activities, are especially vulnerable to this condition. Activities requiring overhead reaching put particular pressure on the rotator cuff tendons, and any form of repetitive movement, chronic misuse, or recurring stress may result in impingement.

    When the space between the humerus and the acromion above it is narrowed, the four rotator cuff tendons, the cartilage on the ends of the bone, and the bursa are all impinged upon, or squeezed. This results in one or more forms of inflammation of the joint. Bursitis, tendinitis, and arthritis, are all inflammatory conditions closely related to impingement syndrome, often occurring in combination with it. Impingement syndrome also contributes to the tearing of rotator cuff tendons, as it weakens the rotator cuff and makes it more susceptible to injury.

    Another problem that may contribute to impingement is the development of bone spurs. Bone spurs can further reduce the space available for the rotator cuff and cause wear and tear of the acromioclavicular (AC) joint between the collarbone and the shoulder blade. This joint sits directly above the bursa, and any bone spurs developing beneath it irritate the bursa, making impingement worse.

    Symptoms of Impingement Syndrome?
    To some degree, impingement occurs in everyone’s shoulder as the result of daily activities we do that use the arm above shoulder level. But people who continuously work with arms raised overhead, or who engage in repetitious throwing activities, are more vulnerable to this condition. They may become aware of a generalized aching sensation in the shoulder, or pain when raising the arm out from the side or in front of the body.

    Most people with impingement syndrome complain of difficulty sleeping when they roll over onto the affected arm. A sharp pain when trying to reach into a back pocket is also a very reliable indication of impingement. As time goes on, discomfort increases and the joint may become stiffer. There may be a “catching sensation” when the arm is lowered. If the arm is so weak that you are unable to lift it on your own, the rotator cuff tendons have probably been torn.

    Impingement syndrome usually results in the slow onset of pain and discomfort in the upper shoulder, especially when the arm is raised. If tendinitis or bursitis develop, there may also be pain when the arm is lifted away from the body. Sometimes tendinitis develops in the biceps tendon, the tendon located in the front of the shoulder that helps bend the elbow and turn the forearm. If so, pain may travel to the front of the arm and down the forearm.

    Treatment of Impingement Syndrome?
    In diagnosing impingement syndrome, your doctor will ask about your medical history and any other previous or persistent conditions of the arm and shoulder. He or she will inquire about your activities and occupation, as they usually play a major role in the onset of impingement. A complete and competent exam involves considering the possibility of associated injuries or conditions such as tendinitis, bursitis, arthritis, and rotator cuff tears.

    X-rays may be taken to examine the site for bony abnormalities or evidence of arthritis. Some people have an unusual anatomy of the acromion, in which the bone tilts too far down and reduces the space between it and the rotator cuff. X-rays will indicate this, and will also reveal any bone spurs in the acromioclavicular (AC) joint. If the shoulder is noticeably swollen, your doctor may aspirate the joint, testing the withdrawn fluid for infection.

    A test called an arthogram may be used if your physician suspects a tear of the rotator cuff tendons. For this test, dye is injected into the shoulder joint before x-rays are taken. If dye leaks out of the place where it was injected into the joint, there is likely to be a rotator cuff tear at that location. An MRI scan is another special test, involving the use of magnetic waves to create pictures that look like slices of the shoulder. The MRI scan can also show whether there has been a tear in the tendons. Sometimes ultrasound is used to examine the shoulder joint.

    Another common test for impingement involves the injection of a small amount of local anesthetic (such as novocaine or lidocaine hydrochloride) into the space under the acromion. This test helps eliminate the possibility that the pain results from a problem in the neck. If pain subsides immediately after injection, impingement syndrome is likely to be the cause of discomfort.

    The first step in treating impingement syndrome and its related conditions is to reduce pain and inflammation. The commonly preferred treatment protocol involves rest, ice, and over-the-counter anti-inflammatory medication such as aspirin, naproxen, or ibuprofen.

    Your doctor will also want to see how well your shoulder responds to physical therapy. In some cases the doctor or therapist will use the gentle sound-wave vibrations of ultrasound to warm deep tissues and promote the flow of blood to the shoulder tissue. As pain subsides, you will be asked to try specific stretching and strengthening exercises. These are often preceded and followed by use of therapeutic ice.

    If these treatment methods do not offer significant improvement, your doctor may inject a corticosteroid medicine into the space under the acromion. Steroid injections are a common treatment that nevertheless must be used with caution because they occasionally lead to tendon rupture. For this reason, and because steroids are associated with other side effects over time, they do not represent the best long-term solution to impingement syndrome or other persistent shoulder injuries.

    Surgical Treatment for Impingement Syndrome?
    Surgical intervention is usually recommended if there is still no significant improvement after 6 to 12 months of conservative treatment. Contemporary surgical methods include either arthroscopy or open surgery, or sometimes a combination of the two. Either form of surgery can repair damage and relieve impingement pressure on the tendons and bursa.

    When surgery becomes necessary, the major goal is to increase the space between the acromion and the rotator cuff tendons. The first thing the surgeon will do is to remove any bone spurs under the acromion that chaff the rotator cuff tendons and the bursa. In most cases a small part of the acromion will be removed as well, to give the tendons more space and enable them to move without rubbing on the underside of the acromion. People who have an abnormal tilt to the acromion will probably need to have more of the bone removed.

    Surgery for impingement syndrome offers an opportunity to correct other related conditions as well. If there is degenerative (wear and tear) arthritis in the acromioclavicular (AC) joint in addition to impingement, the end of the clavicle may be removed. This procedure is called a resection arthroplasty. After about one inch of the clavicle has been cut away, scar tissue fills the space left between the clavicle and the acromion to form a false joint. This usually puts an end to arthritic pain in the acromioclavicular (AC) joint, as the scar tissue forms a stable, flexible connection between the clavicle and the scapula.

    Today, arthroscopy is frequently used for the surgical procedure. One or two small incisions are made on the shoulder, but repair in the joint itself is done with an arthroscope, a fiberoptic telescope. Pencil-sized instruments containing a small lens and lighting system magnify and illuminate the structures inside the joint. The arthroscope is inserted into the joint and attached to a miniature television camera, allowing a magnified view of spaces in the joint that would otherwise be inaccessible. This technology makes possible very precise treatment of specific parts of an injury, using a laser to cut away damaged tissue. One advantage of arthroscopy is that you can often go home the same day.

    The orthopedic surgeon, who takes into account the many factors that go into each individual case, determines the surgical method used. Sometimes open incision is preferred to arthroscopy. In these cases, a cut of about 3 or 4 inches is made over the top of the shoulder and the same procedures are followed in repairing the joint. Open surgery usually requires that you stay overnight in the hospital.

    After surgery, your arm will be protected with a sling, an immobilizer, or a splint or cast. In most cases your shoulder therapist will begin working with you the morning after your surgery, showing you how to do simple exercises to help prevent stiffness and swelling. Even if the shoulder itself is not exercised right way, it is important to gently move your fingers, hands, and elbow -- this controls swelling and helps prevent stiffness. You will be asked to refrain from lifting anything at first, as this may strain the muscles as they heal.

    If your doctor has prescribed a sling, you should remove it only at those times during the day when you perform home exercises advised by the physical therapist. Exercising the joint is critical to prevent a stiff or “frozen” shoulder. The use of ice, which decreases the size of blood vessels in the sore area, helps prevent inflammation.

    Your physical therapist will work with you to develop strength in the tendons of the rotator cuff. Stabilizing and strengthening the muscles of the shoulder through the consistent practice of a series of exercises decreases the possibility of impingement or other related conditions returning to the shoulder or upper arm.

    Possible Complications of Surgery for Impingement Syndrome?
    Although surgery for impingement syndrome is usually without any significant problems, there may occasionally be unforeseen complications associated with anesthesia, including respiratory or cardiac malfunction. The surgery itself may be complicated by infection, injury to nerves and blood vessels, fracture, weakness, stiffness or instability of the joint, pain, or the need for additional surgeries.

    Improvement to the shoulder is determined not only by surgery but also by your general condition and rehabilitative effort. In many cases, the tendons and muscles of the shoulder have been weakened from prolonged misuse or degeneration, and strengthening them will require a gentle, steady process of changing habitual ways of moving your arm.

    Keeping in mind that it is likely to be several months before you achieve maximal results, you can almost always look forward to a more mobile, pain-free joint. Taking care of impingement syndrome also means you are less likely to be subject to chronic bouts of impairment from related conditions such as bursitis, arthritis, or tendinitis.





    The information provided herein is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting a licensed physician.

    (c)2000 DynoMed.com, LLC, Indianapolis, IN
    Link from: http://www.dynomed.com/encyclopedia/..._Syndrome.html

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    What are Rotator Cuff injuries?
    The tendons of four muscles in the upper arm form the rotator cuff, blending together to help stabilize the shoulder. Tendons attach muscles to bone and are the mechanisms that enable muscles to move bones. It is because of the rotator cuff tendons, which connect the long bone of the arm (the humerus) to the scapula (the shoulder blade) that we can raise and rotate our arms. The rotator cuff also keeps the humerus tightly in the socket (glenoid) when the arm is raised. The tough fibers of the rotator cuff bend as the shoulder changes position.

    For normal shoulder function, each muscle must be healthy, securely attached, coordinated, and conditioned. When there are full or partial tears to the rotator cuff tendons, movement of the arm up or away from the body is impaired, making it difficult or impossible to rotate the arm in its ball-and-socket joint.

    Causes of Rotator Cuff Injuries?
    Most often associated with baseball players, injuries to the rotator cuff tendons of the shoulder can happen to anyone over time. Rotator cuff tendons can be injured or torn by excessive force, such as lifting a very heavy object with the arm extended or trying to catch a heavy object as it falls. Occasionally these accidents happen to young people, but typically a rotator cuff tear occurs to a person who is middle-aged or older who has experienced problems with the shoulder for some time before the injuring event. That person may try to lift something or to participate in an activity that exceeds the strength of the tendons, and the rotator cuff tears acutely, resulting in an inability to raise the arm. The triggering event may or may not be particularly painful.

    The flexible, elegant design of the shoulder gives it great range of motion but limited stability. It is prone to injury as we age. As long as the parts of this, the most mobile joint in the body, are in good working order the shoulder moves painlessly and easily. When injury or conditions such as arthritis, tendinitis, or bursitis affect the shoulder joint, pain and the loss of mobility result.

    As we age, rotator cuff tendons can be subject to a great deal of wear and tear, resulting in the gradual degeneration of the tissue. Activities requiring overhead reaching put particular pressure on the rotator cuff tendons, and any form of repetitive movement, chronic misuse, or recurring stress may result in a condition known as impingement. Impingement syndrome is the improper alignment of tissue or bone that results in rubbing or chafing.

    One reason rotator cuff tendons tend to weaken over time is that they contain areas where there is a very poor blood supply. Parts of the human body that have good blood supply are better able to repair and maintain themselves. The areas of poor blood supply in the rotator cuff tendons make them especially vulnerable to degeneration with aging. This may help explain why the rotator cuff tear is such a common injury in later life. The part of the rotator cuff that tears is usually one that has been weakened by degeneration and impingement.
    Symptoms of Rotator Cuff Injuries?
    If you have torn a tendon in the rotator cuff, there will probably be tenderness and soreness in the shoulder, especially after any strenuous movement. A fully ruptured tendon may make it impossible to raise the arm or even move it away from the side of the body. You may have the sensation of a chronic vague discomfort or a more intense acute pain. Many people with rotator cuff injuries complain of not being able to sleep on the injured side, as there is pain with any pressure on the shoulder.

    Rupture of the rotator cuff tendons does not usually occur in a shoulder that is perfectly healthy. Most shoulders with rotator cuff tears have a history of other problems. Diagnosis and treatment involves addressing these related conditions (such as bursitis, tendinitis, and acromioclavicular [AC] joint arthrosis) as well. The conditions may overlap and share common symptoms, such as a “catching” sensation when you try to move the arm, stiffness or chronic soreness, and the presence of bone spurs. On some occasions cuff tears are gradual and progressive, producing no apparent symptoms but an increasing weakness in the shoulder joint. There may be tears affecting both shoulders.

    Treatment of Rotator Cuff Injuries?
    Rotator cuff tears can usually be identified fairly easily in a physical examination. Signs of a complete tear are often quite obvious. If your doctor can assist you in moving the arm through a range of motion, yet you are unable to complete the same movements using your own strength, a tear in the tendons is very likely.

    A special test called an arthogram is often used to affirm a rotator cuff tear. For this test, dye is injected into the shoulder joint before x-rays are taken. If there is indication that dye has leaked out of the place where it was injected into the joint, there is likely to be a rotator cuff tear at that location.

    The MRI scan is a radiographic test that is frequently used to examine the rotator cuff tendons and determine whether or not they are torn. With an MRI scan, magnetic waves are used to create pictures that look like slices of the shoulder. Unlike x-rays, which show only the bones of the shoulder, the MRI scan shows tendons and any damage to them. Both the MRI scan and the arthogram are widely used to confirm a diagnosis of rotator cuff tear. Sometimes ultrasound is used as well.

    If the rotator cuff tear is not complete, your doctor will probably recommend conservative treatment methods to control pain and promote healing in the shoulder. The treatment regimen known as R.I.C.E. can be very effective in some cases. Rest, ice, compression, and elevation are components of this treatment. It is important to rest the injury, as well as to initiate physical therapy as soon any acute pain has subsided. Anti-inflammatory medication such as non-steroid anti-inflammatory drugs (NSAIDs) are often prescribed for pain relief. If the recommendations of a physical therapist are followed on an ongoing and continuous basis, many partial tears will become very manageable with this treatment.

    Sometimes cortisone injections are given to patients who are still experiencing pain after several weeks of conservative care. While cortisone can be very effective in offering temporary symptomatic relief, there is some risk of cortisone (a steroid) causing further rupture of the tendons. For this reason, and because steroids are associated with other side effects over time, they do not represent the best long-term solution to rotator cuff tears or other persistent shoulder injuries.

    Surgery is normally recommended if a rotator cuff tear makes it impossible for you to raise your arm on your own. The timing of surgery also depends on the extent of the damage to the rotator cuff, as evidence suggests that repairing complete tears of the tendons within three months of injury results in a better outcome.

    Typical surgery for rotator cuff injuries involves making a 4-5 inch incision in the side of the shoulder. The surgeon first removes any tissue that has degenerated or does not appear healthy. Then a section of the humerus (the upper arm bone) from which the tendon tore away is prepared for tendon reattachment. The soft tissue on a portion of the humerus is removed to create a raw bony area for positioning of the torn tendon. Holes are drilled in the humerus for sutures to be used in the reattachment process. The tendon tear is then sewn together, and sutures looped through the drill holes to attach the repaired tendon to the bone. As time passes, the tendon heals to the humerus, reattaching itself in a more permanent fashion.

    Arthroscopy, another surgical method, is also used to diagnose and repair rotator cuff injuries. Arthroscopy involves using a fiberoptic endoscope to repair the joint. This procedure can often be done on an outpatient basis and is used in cases that are not as severe as complete tendon tears. Candidates for arthroscopy include patients who suffer from impingement syndrome (the improper alignment of tissue and bone that result in chronic chafing), partial rotator cuff tears, partial tears along the long head of the biceps, and chronic dislocations of the shoulder, detached socket structures, or damage to the lining membranes.

    There have been great strides in shoulder arthroscopy in recent years, making it an increasingly popular method for the diagnosis and repair of shoulder damage.

    After surgery, your shoulder is usually protected by a sling and swathe for at least one month, and physical therapy is begun almost immediately – first using passive exercises, and then moving the arm through a more active range of motion. You will be given an individualized program of rehabilitation, designed to address the particular condition of your injury.

    The doctor and physical therapist will explain the necessity of limiting sudden and stressful movements to the arm for several weeks or longer. Activities that involve pushing, pulling, and lifting will not be possible, as even the best surgical repair can be damaged if submitted to undo strain. During the first six weeks or so after surgery, the shoulder may require support from the other arm or from a pulley during movement.

    In many cases, the tendons and muscles of the shoulder have been weakened from prolonged misuse or degeneration, and strengthening them will require a gentle, steady process of changing habitual ways of moving your arm. It may be many months before maximal results are achieved.

    If initial surgical attempts to treat rotator cuff injuries fail to give you a useable shoulder, there are other more complex procedures that include tendon grafts and muscle transfers. These are rare cases, but will be discussed with you by your surgeon if they appear to be necessary. Under certain circumstances a complete shoulder replacement may be advised. Remember that all surgical procedures are tailored to meet individual needs, and that recovery depends not on surgery alone but also on your general state of heath and commitment to the rehabilitation process




    The information provided herein is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting a licensed physician.

    (c)2000 DynoMed.com, LLC, Indianapolis, IN

    http://www.dynomed.com/encyclopedia/..._Injuries.html
    Last edited by bigredlemon; 03-06-2004 at 01:19 PM.

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    Less common is the tennis elbow, simply because the forearm recieves a lot of blood and can heal itself relatively quickly. But this a possible concern for wristy players wielding powerful racquets.




    Tennis Elbow (Epicondylitis)


    What is Tennis Elbow? (Lateral Epicondylitis)
    Tennis elbow or “lateral epicondylitis,” is used to describe a painful condition that causes pain and tenderness in the bony bump on the outer part of the elbow. The condition was so named because it is frequently seen in tennis players but, in reality, very few of the patients with this disorder are actually tennis players.

    Typically, tennis elbow affects both males and females between 20 and 60 and is often associated with sporting or occupational activities that require stressful use of the forearm and hand.

    The lateral epicondyle is located on the outer side of the arm, slightly above the elbow joint. It is a projection from the humerus bone of the upper arm and serves as the point of origin for most of the forearm muscles responsible for wrist and finger straightening or extension.

    Activities such as tennis, golf, or repetitive twisting or extension of the wrist and fingers during work or play, may strain or even tear these muscles at the site where they join the bone on the outside of the elbow.

    The condition usually occurs slowly over time without a specific moment of injury, although a sudden onset of symptoms may be related to a direct blow to the outside of the elbow. Some degeneration of the tissues, which connect the muscles to the bone, may develop and reduced blood supply to the injured area is felt to play a part in tennis elbow.

    If the entire elbow is painful or there is some associated numbness or tingling, a condition other than tennis elbow may exist. In those instances, the patient should seek consultation with a physician to make sure that elbow arthritis, shoulder problems or nerve compression are not present.

    Causes of Tennis Elbow?
    Despite the name of the condition, tennis elbow can be caused by other activities besides playing racquet sports. Many commonplace activities can strain the tendons, such as:

    * Painting>
    * Carrying heavy items
    * Golf
    * Carpentry
    * Typing
    * Knitting
    * Machine Work
    * Tennis

    Basically, any activity that twists and extends the wrist can lead to tennis elbow. In rare circumstances, a direct blow to the outside of the elbow can also lead to the condition.

    Symptoms of Tennis Elbow?
    Patients with tennis elbow usually experience soreness to direct touch and pain with use. In particular, repetitive grasping, pulling or carrying objects with the elbow extended will be uncomfortable and activities which require straightening of the wrist and fingers will make the condition worse. Unfortunately, tennis elbow can be very annoying, difficult to treat and last for a long time.

    If left untreated, a dull constant pain or sharp shooting pain can be felt. Swelling may be present. Other symptoms include:

    * Pain when the wrist or hand is straightened
    * Pain felt when lifting a heavy object
    * Pain when making a fist or shaking hands
    * Shooting pains from the elbow down to the forearm or up into the upper arm

    Sometimes other conditions that are not linked to tennis elbow can cause pain in the elbow. For example, arthritis of the elbow, a pinched nerve in the neck and carpal tunnel syndrome are other conditions that cause similar symptoms. Your doctor will be able to accurately diagnose your condition by asking you about your daily and recreational activities and examining your elbow and arm. You will probably have to do movements that cause pain in the outer part of the elbow. In addition, he or she may order X-rays of the elbow.

    Direct fingertip pressure usually identifies a point of tenderness just beside the bony prominence on the outside of the elbow. The tender spot is well localized and not much larger than a quarter. Resisted extension of the wrist will also produce pain at the same area of the elbow because of the tension it puts on the site of muscle origin. Some associated – but less severe – tenderness may also be present in the fleshy forearm muscle mass just beyond the elbow.

    The examining physician will also carry out some additional tests to rule out other potential sources of elbow pain. X-rays of the elbow are usually of little help in diagnosing tennis elbow, but may aid in identifying any calcium deposits around the elbow or the presence of arthritis.

    Treatments of Tennis Elbow?
    The main goal of treatment of tennis elbow is to eliminate or reduce the discomfort so that the patient can resume regular activities without any difficulty. Like any healing tissue, the best chance for successful treatment exists when the condition is managed as soon as possible after its onset. The longer tennis elbow has been present, the more difficult it is to resolve it conservatively.

    Conservative treatment of tennis elbow first involves reducing inflammation and pain by resting the arm from those activities that both cause and worsens the symptoms. Sports and occupational use may have to be curtailed or even stopped until the discomfort has decreased considerably. The use of ice, applied directly to the tender area on the outside of the elbow may be helpful, particularly after those activities that predictably increase the symptoms. Anti-inflammatory medications may hasten the improvement of tennis elbow discomfort. For severe, chronic or resistant tennis elbow, the treating physician may elect to inject a cortisone containing solution into the inflamed area in an effort to at least temporarily speed up the healing and lessen the pain.

    Various splints and braces may be used to try and relax the muscles around the outside of the elbow and decrease the pull of these muscles on the inflamed area. During an acute or severe phase of the condition, a splint that extends the wrist may be very beneficial by both decreasing the strain on the elbow and insuring that the arm will be rested. Splinting and rest may be required for several weeks to obtain a reasonable relief of symptoms and, once the symptoms have decreased to the point that medication is no longer necessary, an exercise program designed to lessen the likelihood of recurrence can be started.

    Exercises for tennis elbow are designed to increase the strength, flexibility and endurance of the affected elbow muscles and should be carefully carried out according to a specific protocol. While therapists should be consulted to provide the routine for the orderly progression of tennis elbow rehabilitation, the program usually involves a cautious use of repetitive wrist exercises and weights. Progression to more vigorous strengthening and weight use is permitted only when the existing exercises are essentially painless. Once elbow and forearm rehabilitation has been achieved, a maintenance program is recommended.

    Several types of bands and braces designed to minimize muscle tension overload to the elbow are commercially available and may be purchased in drug or sporting goods stores or applied by therapists or physicians. These bands are most effective when the patient’s tennis elbow condition is not severe and are mainly used to decrease the likelihood of recurrence.

    Sports equipment and technique modifications are important aspects of the conservative management of tennis elbow. Using less tightly strung racquets and graphite or titanium frames is recommended to dampen ball impact and transmit less vibration to the forearm. Proper grip size also is important for torsion control of the racquet.

    Work-related tennis elbow also requires activity modification. The posture of the arm during work is important and should be reviewed and modified when necessary. Those jobs that involve a lot of forearm pronation – that is palm down towards the floor - while the wrist is extended are particularly at risk to produce the condition. Physician supported discussions with employers and supervisors can often result in favorable job changes which will lessen the chance of developing severe and chronic tennis elbow symptoms.

    If severe symptoms persist after a reasonable period of conservative treatment, surgery is recommended.

    Surgery for Tennis Elbow?
    Surgical procedures for tennis elbow vary somewhat and are based on the experience and individual preference of the treating surgeon. In general, the procedures are designed to remove the diseased and degenerated tissue around the outside of the elbow and stimulate the improvement of the blood supply to the involved area. Release of a portion or all of the origin of the affected extensor muscles may also be part of the operation.

    Surgery for tennis elbow may be performed as either an in-patient or outpatient procedure performed under regional block or general anesthesia.

    A surgical incision will be placed over the outer aspect of the elbow and the removal of deteriorated tissue and release of muscle tendon tissues will be carried out. In some instances, some bone will be removed form the bony prominence –lateral epicondyle – on the outside of the elbow. The skin will be closed with sutures or staples and a big dressing including a rigid long arm splint from the hand to the armpit will be applied.

    The fingers and thumb are usually left free for motion. Elevation of the entire upper extremity for several days and vigorous finger motion is extremely important to prevent undesirable swelling and stiffness. Use of the arm will not be possible for several weeks and patients need help for those tasks requiring two hands.

    The surgical dressing and splint will be removed at one to three weeks and all sutures will be removed at that time. Although gentle elbow motion is usually permitted at that time, a light splint or compressive dressing should be worn most of the time until the elbow is healing well and comfortable.

    At approximately four to six weeks a therapy program is initiated to restore motion and strength to the elbow. While a trained therapist may instruct and assist the patient, much of the exercise program will be carried out be the patients themselves. Advice will be given regarding the use of the elbow and arm during office and therapy visits.

    It is very common for patients to experience discomfort during the initial phases of rehabilitation following surgery for tennis elbow. There is predictable discomfort as the exercises stretch the structures around the elbow and some mild inflammation may be present around the surgical site. This reaction gradually resolves and, by three to six months, most patients experience complete or near-complete pain relief and the recovery of a satisfactory range of elbow motion. Strength recovery takes longer and may take as long as one year depending on the amount of weakness that the patient had before surgery and how vigorously strengthening exercises are carried out.

    Possible Complications of Surgery for Tennis Elbow?
    Although surgery for tennis elbow of is usually without any significant problems, there may be occasional unforeseen complications associated with anesthesia, including respiratory or cardiac malfunction. The surgery itself may be complicated by anatomic abnormalities or accidental injury to adjacent tissue structures such as tendons, nerves or blood vessels. Rarely, the post-operative discomfort and or elbow stiffness may be greater than expected and require longer therapy. Unfortunately, there are some instances when the surgery fails to resolve the symptoms of tennis elbow.

    A condition known as reflex sympathetic dystrophy may occur in a few individuals and result in generalized pain, swelling and stiffness of the entire extremity. Wound infection, although very infrequent, may occur after any surgery and hamper a positive result.

    Although the speed of recovery is variable for different patients following surgery for tennis elbow, most recover excellent elbow motion and functionally acceptable strength within a year of surgery. Pain relief is fairly predictable and almost all patients are pleased with their surgery.

    To prevent tennis elbow from reoccurring, it is important to make sure you keep the muscles strong by exercise and using the proper form whether playing tennis or lifting heavy objects. Warming up before starting to use the muscle will also help prevent the condition. After exercising, you may want to ice and stretch the elbow and arm muscles.





    The information provided herein is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting a licensed physician.

    (c)2000 DynoMed.com, LLC, Indianapolis, IN
    http://www.dynomed.com/encyclopedia/...Epicondylitis_(Tennis_Elbow).html

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    Although badminton is not listed as a cause, it definetly is, espcially badminton's clears and smashes, which probably cause more stress due to the shear speed of it. Later in this article, you'll notice that injury comes from the deacceleration phase of a swing rather than the acceleration phase. Badminton players are espcially vulnerable since they must quickly re-raise the racquet over a smash or clear, which causes far greater injury than just coming to a slow stop that players in other sports can do.




    Section C Throwing Injuries
    1. THROWING INJURIES IN THE ADULT
    Jeffrey R. Dugas MD
    James R. Andrews MD
    Introduction and Basic Science



    Although the most widely studied sport involving overhead throwing is baseball, several other sporting activities require the same type of motion. Some such sports include football, volleyball, handball, javelin, softball, racquetball, squash, and tennis (the serve) . The overhead throwing motion can be broken down into several discrete steps, which include the wind-up, early cocking, late cocking, acceleration, deceleration, and follow-through phases. The process of overhead throwing, regardless of specific sport, involves the generation of potential energy and the subsequent transfer of that potential energy to kinetic energy, which is imparted to the object being thrown. In total, the overhead throwing motion takes approximately 2 seconds to complete, with nearly 75% of that time taken up by the pre-acceleration phases.[22] [28] [29] [68]

    The first phase of throwing, the wind-up, is when the body readies itself by raising the center of gravity and the shoulder is placed in slight abduction and internal rotation. During this phase, virtually no stress is placed upon the upper extremity.[30] [33] [43] [46] The early cocking phase is when the arm is placed into the abducted, externally rotated position. In addition, the arm rotates behind the body axis approximately 15 degrees. This phase ends at the “top” of the motion just before the beginning of forward arm and body motion. Early in this phase the deltoid is active as it abducts the arm, followed by later activity in the rotator cuff musculature to cock the arm into a more externally rotated position. The third, late cocking, phase begins as the lead leg contacts the ground and ends when the arm reaches maximal external rotation of nearly 180 degrees ( Fig. 23C1-1A and B ). During this phase, the scapula retracts in order to provide a stable glenoid surface for the humeral head to compress against. The upper arm is maintained in 90 to 100 degrees of abduction and the elbow moves even with the plane of the torso. As the humerus progresses into external rotation, the humeral head translates posteriorly on the glenoid owing to increasing tightness in the anterior structures. The external rotators

    Figure 23-C1-1 Adult male pitcher at the beginning (A) and end (B) of the late cocking phase of the throwing motion. This phase begins as the foot contacts the ground and ends as the arm reaches maximum external rotation.
    (infraspinatus and teres minor) are active early in this phase, as are the supraspinatus and deltoid. The subscapularis is active toward the end of this phase as the internal rotation of the arm begins. During this phase, the rotator cuff musculature generates a compression force of 650 N.[28] The acceleration phase begins as the arm initiates its internal rotation and ends at ball release. During this phase, the arm rotates at an angular velocity greater than 7000 deg/sec. [22] [28] Despite this tremendous movement, little stress is noted in the shoulder musculature during this phase.[43] The arm is maintained in the same abduction as in the late cocking phase. Other important muscles that are active during this phase are the triceps early on, followed by the pectoralis major and latissimus dorsi later.[43] [68] The deceleration phase begins just after the ball is released and ends when humeral internal rotation ceases. This phase is heralded by tremendous loads generated by the rotator cuff muscles, as the rapidly rotating arm is slowed to a halt.[22] [28] The scapula protracts while maintaining a stable glenoid surface for the humeral head. In essence, the deceleration phase is where the energy not imparted to the ball is dissipated. Eccentric loads are seen in the posterior cuff musculature as compressive joint loads exceed 1000 N.[43] [68] Shear forces are also significant posteriorly and inferiorly. Finally, the follow-through phase concludes the throwing motion as the body regains balance and stability. During this phase, muscle firing ceases and joint compression loads drop to 400 N.[22] [28] Shear loads also diminish during this phase.

    Stresses across the elbow joint have been measured during the overhead throwing motion. Maximum elbow velocity reaches over 2300 degrees per second during the acceleration phase.[91] Just before reaching maximal external humeral rotation in the late cocking phase, valgus torque at the elbow has been measured at 64 N-m.[28] Cadaveric studies have demonstrated the tensile strength of the ulnar collateral ligament (UCL) to be approximately 32 Nm.[23] The UCL provides the most static stability against a valgus stress, taking up nearly 55% of the valgus stress at 90 degrees of elbow flexion.[60] [87] Because 55% of 64 Nm is greater than the 32 Nm tensile strength of the intact UCL, contributions from the bony architecture and surrounding soft tissues are needed to assist the UCL in providing medial elbow stability during the overhead throw. These contributions come mainly from the flexor carpi radialis and the pronator teres.[33] [35] When the medial soft tissues fatigue, more stress is placed upon the lateral radiocapitellar articulation as well as upon the UCL. With increased compression through the radiocapitellar articulation, avascular necrosis, osteochondritis dissecans, and loose body formation may occur.[9] [93] Regardless, the UCL remains the primary stabilizer to the medial side of the elbow during throwing.

    As one can see, the throwing athlete's upper extremity experiences tremendous stresses each time a throw is made. With the repetitive application of such stresses, several adaptive changes are apparent within the normal thrower's shoulder and elbow. A knowledge of these “normal” adaptations is necessary when evaluating the throwing athlete. In comparison with nonthrowers, the humeral head and glenoid of the thrower are in a more retroverted position, allowing more external rotation.[20] Throwers have been shown to have no significant difference in total range of shoulder rotation, but the arc of motion is “spun back” with increased external rotation and decreased internal rotation.[20] [47] The soft tissues about the shoulder are affected similarly with laxity of the anterior structures to allow for the increased external rotation, and contracture of the posterior capsule preventing normal internal rotation. The thrower's elbow may have an increased carrying angle (more valgus) as well as a loss of extension and hypertrophy of the flexor pronator muscle group.[47] Up to 50% of throwers without symptoms have some degree of extension loss.[47] In most cases the motion loss is due to contracture of the soft tissues anteriorly, but in some, the cause is posterior bony apposition caused by osseous overgrowth. Increased laxity is present in the UCL in the throwing elbow versus the nonthrowing elbow in pitchers.[26]

    DeLee: DeLee and Drez's Orthopaedic Sports Medicine, 2nd ed., Copyright © 2003 Elsevier
    Pages 1236-8
    Last edited by bigredlemon; 03-06-2004 at 01:36 PM.

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    Some short but helpful indicators of causes:


    Shoulder Area

    Shoulder pain may arise from pathology within the true glenohumeral joint, the periarticular structures, or the distant structures that refer pain to the shoulder region. Glenohumeral processes are discussed in Chapter 125 ; only adhesive capsulitis is discussed here. The periarticular structures surrounding the shoulder include the rotator cuff complex, subacromial/subdeltoid bursa, and long head of the biceps. Patients can misinterpret myofascial pain as shoulder pain.

    The onset, quality, location, duration, and frequency of pain are important. In addition, factors that exacerbate or improve the pain may help in the diagnosis. Acute pain after trauma suggests a tear in the rotator cuff, joint capsule, or intraarticular structures; gradual pain is less specific. Burning or radicular pain may indicate neuropathy or reflex sympathetic dystrophy. Pain localized to the anterior aspect of the shoulder is common in bicipital tendinitis, whereas rotator cuff tendinitis is more subacromial in location. Glenohumeral processes typically have constant pain referred to the lateral aspect of the upper arm; however, constant pain that is not associated with shoulder movement is an ominous symptom for malignancy or referred pain. Systemic features of fever, chills, and weight loss, visible or progressive swelling in the shoulder area, and pain aggravated by deep inspiration may indicate nonmusculoskeletal etiologies of pain. Axillary pain is usually not from a shoulder source.

    Examination of the shoulder includes inspection for asymmetry between the shoulders and palpation of various anatomic regions, including the common myofascial regions of the rhomboid, trapezius, serratus, and rotator cuff muscles. Joints participating in shoulder movement include the sternoclavicular, acromioclavicular, and glenohumeral joints. Scapulothoracic motion also contributes to shoulder movement. Passive range of motion (ROM) in abduction and internal and external rotation delineates the integrity of the glenohumeral joint. In contrast, active ROM provides information not only about the joint, but also about the function of the tendons and muscles surrounding the shoulder. Thus in acute rotator cuff tendinitis, passive ROM of the shoulder is normal (if the patient can relax and avoid guarding), whereas active ROM, particularly against resistance, is limited or painful. In adhesive capsulitis, however, both passive and active ROM are limited.

    A general examination also provides clues, particularly if the shoulder examination is normal. Evidence for other joint involvement may suggest an inflammatory arthropathy. Neurologic deficits point to neuropathic processes. Pain referred to the shoulder may originate in the neck, lungs, heart, or abdomen.


    Rotator Cuff Disorders.

    The rotator cuff complex includes the supraspinatus, infraspinatus, and teres minor muscles, which attach to the greater tuberosity of the humerus, and the subscapularis, which attaches to the lesser tuberosity ( Fig. 134-3 ). The rotator cuff is the internal and external rotator of the shoulder and also depresses the humeral head during abduction. Most common shoulder problems are caused by rotator cuff pathology, categorized as impingement syndrome, acute tendinitis, and rotator cuff tears.


    Impingement Syndrome.

    Impingement syndrome refers to compression of the rotator cuff (particularly supraspinatus and infraspinatus) and the long head of the biceps against the acromion, coracoacromial ligament, and sometimes the acromioclavicular joint. Impingement syndrome is divided into three different stages.[4] Stage I usually occurs in patients 15 to 25 years old who perform repetitive overhead activities. Edema and hemorrhage are present in the rotator cuff. Stage II occurs in active individuals between ages 25 and 50 and is typically associated with pathologic changes of fibrosis. Stage III occurs in older individuals when the cuff progressively degenerates or tears, and secondary bony changes develop in the acromion and humerus.

    The patient typically complains of pain that is often worse at night and is exacerbated by overhead activity. Pain may be localized to the area of the subacromial region or may diffusely radiate down toward the deltoid region. The pain can be intermittent or constant. In young patients, complete tear, usually resulting from trauma, is acutely painful, whereas in older patients the condition may be less symptomatic.

    Examination reveals normal passive ROM of the glenohumeral joint, but active ROM may be limited by pain. Patients often use scapulothoracic movement to help in shoulder abduction. The arc of motion is a useful test ( Fig. 134-4 ). As the patient abducts, beginning at 45 degrees, the greater tuberosity impinges the supraspinatus tendon against the acromion or coracoacromial ligament. Once the arc is beyond 120 degrees, the greater tuberosity clears the acromion, and the impingement (or pain) ceases.[1] In a rotator cuff tear, active abduction, internal rotation, and external rotation against resistance may be weak. The drop sign is positive if the patient's arm suddenly drops or gives way at 90 degrees when the arm is brought down from overhead (180 degrees) along the side.

    Radiographs in early impingement are usually normal, whereas advanced stages may reveal sclerosis and cystic changes of the distal acromion or greater tuberosity. If the rotator cuff is torn, the space between the acromion and humeral head (normally measuring greater than 5 mm) is lost, and proximal migration of the humerus occurs. Scalloping or erosions of the acromion are also present. MRI may be the most sensitive test to identify a tear, whether partial or complete.

    Treatment of impingement syndrome depends on the stage. In early disease, conservative therapy with antiinflammatory medications, rest, and physical therapy to strengthen the rotator cuff muscles is usually adequate. In stages I and II,
    1254


    Figure 134-3 Shoulder with humeral head stabilized in shallow scapular glenoid by rotator cuff and capsule. A, Posterior view. B, Cross-sectional view.


    Figure 134-4 Arc of motion test for impingement. As patient abducts, beginning at 70 degrees, greater tuberosity impinges supraspinatus tendon against acromion or coracoacromial ligament. Once arc is beyond 120 degrees, greater tuberosity clears acromion and impingement (or pain) ceases.
    corticosteroid injections into the subacromial space may also be effective. Job and recreational modifications are necessary to prevent further injury. Patients unresponsive to conservative therapy that has included two or three corticosteroid injections or patients with functional impairment should be referred to an orthopedic surgeon for consultation. Arthroscopic decompression includes division of the coracoacromial ligament and acromioplasty; the latter is most successful in patients with an intact rotator cuff. The results of open and arthroscopic decompression are similar.


    Acute Tendinitis.

    Although supraspinatus and bicipital tendinitis typically result from impingement, they may occasionally occur as separate entities. Supraspinatus tendinitis is more common. This tendon helps abduct the shoulder and maintain the strength of the arm when carrying a heavy load with the shoulder abducted; thus it is susceptible to overuse and eventual degeneration. The biceps muscle functions as a flexor of the elbow, supinator of the forearm, and forward elevator of the upper arm. Again, tendinitis occurs as a result of overuse or repetitive motion.

    In supraspinatus tendinitis, pain usually localizes in the region just above the scapular spine and lateral to the acromion, near the greater tuberosity of the humerus. Active abduction against resistance elicits severe pain, but passive motion is entirely normal. In bicipital tendinitis, pain is located anteriorly in the area of the biceps tendon, and discrete swelling is sometimes palpable in the tendon area. Supination of the hand against resistance (Yergason maneuver) is painful at the shoulder. Active and passive ROM of the shoulder are normal.

    Acute calcific tendinitis occurs secondary to calcium hydroxyapatite deposition in a tendon that has developed degeneration from overuse or impingement. It can involve any tendinous location, but the supraspinatus and bicipital tendons are common areas. Symptoms are usually acute, mimicking gout or pseudogout, and may resolve spontaneously over several days. Calcium deposits within the supraspinatus tendon may eventually rupture into the subacromial bursa, and secondary bursitis develops. Radiographs may reveal amorphous or well-delineated calcific deposits
    1255
    within the subacromial bursa, supraspinatus, or bicipital tendons. Treatment includes nonsteroidal antiinflammatory drugs (NSAIDs), local corticosteroid injection, or intramuscular adrenocorticotropic hormone (ACTH, 40 to 60 IU). Colchicine, 0.6 mg twice a day, may prevent recurrent postinjection flares. Multiple needlings, which manually disrupt the calcific deposits, and corticosteroid infiltration may help resolve resistant cases. If symptoms recur, surgical intervention may be necessary (see Chapter 125 ).


    Bursitis.

    The terms "subacromial" and "subdeltoid" bursitis have often been misused to describe pain in these regions. Acute bursitis is most likely caused by impingement syndrome or calcific tendinitis. Clinical symptoms, physical findings, and treatment are identical to those previously outlined.


    Textbook of Primary Care Medicine, 3rd ed., Copyright © 2001 Mosby, Inc.
    pages 1253-5

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    Figure 134-4 Arc of motion test for impingement. As patient abducts, beginning at 70 degrees, greater tuberosity impinges supraspinatus tendon against acromion or coracoacromial ligament. Once arc is beyond 120 degrees, greater tuberosity clears acromion and impingement (or pain) ceases.
    Attached Images Attached Images  

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    Figure 134-3 Shoulder with humeral head stabilized in shallow scapular glenoid by rotator cuff and capsule. A, Posterior view. B, Cross-sectional view.
    Attached Images Attached Images  

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    Here's some easy to read information from web md:


    http://my.webmd.com/content/article/...tselectedguid={5FE84E90-BC77-4056-A91C-9531713CA348}

    IF the link dies, then do a search there for "Impingement Syndrome". It's in the arthritis section.

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    If you begin to feel pain during smashes and clears, go to the doctor to rule out other causes. An impinged nerve needs at least two weeks to subside and a month to two to completely heal. That means no stress on it in the mean time, except rotator cuff strengthening exercises. Hot showers and rest will help too.

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    This may seem strange, but I have been playing badminton for close to 47 years and I have never had any shoulder or elbow pain or strain of any type. The only injuries I have had were twisted and badly bruised ankles, knee problems, and blistered skin on my thumb and finger when the humidity is dry, plus the infrequent hard knocks from crashing into your partner. I am of the opinion that the knees and ankles are the most highly stressed and injured parts of the body when playing badminton, simply because these parts bear the full weight of your body, not only in a static state but also dynamically.

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    The same thing applies to ankles as well. Ankles aren't injured easily because it's built to handle more weight than the rotatory cuffs. It also has decent blood going to so it can heal relatively fast.

    I injured my shoulder because i was also lifting weights on days when I wasn't playing badminton. I had bad form doing bench press, and worsened by the fact that I had badform using dumbells rather than barbells. Throw in no recovery days and it's a recipe for disaster. There's probably not as many people my age who will suffer the same injury unless they were doing as many no-no things as I was.

    As for your experience: that's great. Shoulder injuries tend to become common for people aged 50 and up because at that point, the regenerative properties of the body can't keep up with regular badminton. If you can still play that's wonderful. But if you start feeling pain during overhead and smashes, even if it's just a little bit, take at least two weeks off. Don't restart playing just because you aren't feeling pain. By the time you start to feel pain, there's already been extensive damage that would take two months to heal. It should take a week or two for the pain to completely go away, but take a month to ttwo months for the damage to heal. If you play again too early, the pain will return much more easily than otherwise.

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    Quote Originally Posted by bigredlemon
    I injured my shoulder because i was also lifting weights on days when I wasn't playing badminton.
    I think thats exactly why i am having problems right now

    I was doing Upright Rows - wide grip bench press... these and badminton lead to pain in my shoulder which i've had for atleast 2 and a half weeks.

    here is a short list of Whight Lifting Exercises to Avoid or Alter if you have problems w/your shoulders (or trying to prevent getting)

    I only wish i had known this a month ago when i started doing all this stuff


    bigredlemon I have a few questions - first i would like to know your opinion on my injury

    the level of pain is about 1-3 out of 10 .. so its not that painfull - i still have full range of motion ..and i actually played the other night for 2 hours and did'nt feel a thing - (i mean my shoulder felt great)...but after the pain came back and seems to be worse now ... so i've had this feeling of pain for just over 2 weeks

    i feel the pain mostly in the front of my shoulder it seems below the collar bone and today i noticed a slight sensation of pain at the very top of my bicep (on the front and inner arm where the shoulder meets the bicep) ... its very consistent sensation.

    i have been iceing it for the last 2 days after playing .... if i just rest it should it get better on its own?

    also if i workout w/running (exercises that dont include shoulder movement) will the added blood flow help the shoulder to heal itself

    please advise

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    Now I realize I have always been suffering from this shoulder problem. In the past, I kept telling others my right arm was giving me problem while smashing.

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    Thumbs up

    That's some great info.! I have been doing treatment on my shoulder for awhile now, but the problem seems to come back all the times. I have pain when I do smashes and clears (sometimes), also when I do my overhead smashes. I think it's whenever I do fully extended motion that causes pain. I also lift weight when I am not playing, would that give more pressure on the shoulder and injury it further more?

    I have been border by this for more than two year now, nothing seems to help! Hoping someone can help me out . Thanks

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    Quote Originally Posted by bigredlemon
    Figure 134-4 Arc of motion test for impingement. As patient abducts, beginning at 70 degrees, greater tuberosity impinges supraspinatus tendon against acromion or coracoacromial ligament. Once arc is beyond 120 degrees, greater tuberosity clears acromion and impingement (or pain) ceases.
    I try this test and i have some cliking sound coming out from the should joint (i think). Is that normal? I have some pain when I reach the 120 deg angle.

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    what I think is that before playing serious badminton, we MUST do our regular homework. This will certainly include your regular badminton drills and work on physical aspects of body.
    I regularly concentrate on my legs, racket hand shoulder & triceps and abs. I don't explicitely work on my forearms because these are the secondary muscles worked in other part excercises.
    Probably you also can try training your shoulder first for strength regularly like 3 times in a week. That might help to lessen your shoulder injuries.

    though my advice may not sound quite professional but it might work well..

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