Shoulder Pain -- November 10, 2008 -- Dr. Scott Arthur - NewsChannel5.com | Nashville News, Weather & Sports

Shoulder Pain -- November 10, 2008 -- Dr. Scott Arthur

Most common shoulder problems

The most movable joint in the body, the shoulder is also one of the most potentially unstable joints. As a result, it is the site of many common problems, including sprains, strains, dislocations, separations, tendonitis, bursitis, torn rotator cuffs, frozen shoulder, fractures and arthritis.

Shoulder structures

To better understand shoulder problems and how they occur, it helps to begin with an explanation of the shoulder's structure and how it functions. The shoulder joint is composed of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone). Two joints facilitate shoulder movement. The glenohumeral joint, commonly called the shoulder joint, is a ball-and-socket-type joint that helps move the shoulder forward and backward and allows the arm to rotate in a circular fashion or hinge out and up away from the body. In contrast to the hip joint, which more closely approximates a true ball and socket joint, the shoulder joint can be compared to a golf ball and tee, in which the ball can easily slip off the flat tee. Because the bones provide little inherent stability to the shoulder joint, it is highly dependent on surrounding soft tissues such as capsule ligaments and the muscles surrounding the rotator cuff to hold the ball in place. Whereas the hip joint is inherently quite stable because of the encircling bony anatomy, it also is relatively immobile. The shoulder, on the other hand, is relatively unstable but highly mobile, allowing an individual to place the hand in numerous positions. It is in fact, one of the most mobile joints in the human body.

Causes of shoulder problems

The shoulder is easily injured because the ball of the upper arm is larger than the shoulder socket that holds it. To remain stable, the shoulder must be anchored by its muscles, tendons, and ligaments.

Although the shoulder is easily injured during sporting activities and manual labor, the primary source of shoulder problems appears to be the natural age-related degeneration of the surrounding soft tissues such as those found in the rotator cuff. The incidence of rotator cuff problems rises dramatically as a function of age and is generally seen among individuals who are more than 60 years old. Often, the dominant and nondominant arm will be affected to a similar degree. Overuse of the shoulder can lead to more rapid age-related deterioration. Shoulder pain may be localized or may be felt in areas around the shoulder or down the arm..

Diagnoses

As with any medical issue, a shoulder problem is generally diagnosed using a three-part process:

• Medical history - The patient tells the doctor about any injury or other condition that might be causing the pain.
• Physical examination - The doctor examines the patient to feel for injury and to discover the limits of movement, location of pain and extent of joint instability.
• Tests - The doctor may order one or more of the tests listed below to make a specific diagnosis.
• Standard x-ray - an x ray is useful for diagnosing fractures or other problems of the bones. Soft tissues, such as muscles and tendons, do not show up on x-rays.
• Arthrogram - a diagnostic record that can be seen on an x-ray after injection of a contrast fluid into the shoulder joint to outline structures such as the rotator cuff. In disease or injury, this contrast fluid may either leak into an area where it does not belong, indicating a tear or opening, or be blocked from entering an area where there normally is an opening.
• Ultrasound - a noninvasive, patient-friendly procedure in which a small, hand-held scanner is placed on the skin of the shoulder. Just as ultrasound waves can be used to visualize the fetus during pregnancy, they can also be reflected off the rotator cuff and other structures to form a high-quality image of them. The accuracy of ultrasound for the rotator cuff is particularly high.
• MRI (magnetic resonance imaging) - a noninvasive procedure in which a machine with a strong magnet passes a force through the body to produce a series of cross-sectional images of the shoulder.

Symptoms and treatment

The symptoms of shoulder problems, as well as their diagnosis and treatment, vary widely, depending on the specific problem. The following is important information to know about some of the most common shoulder problems.

Dislocation

The shoulder joint is the most frequently dislocated major joint of the body. When the shoulder dislocates, the arm appears out of position. Other symptoms include pain, which may be worsened by muscle spasms; swelling; numbness; weakness; and bruising. Problems seen with a dislocated shoulder are tearing of the ligaments or tendons reinforcing the joint capsule and, less commonly, bone and/or nerve damage.

Separation

A shoulder separation occurs where the collarbone (clavicle) meets the shoulder blade (scapula). When ligaments that hold the joint together are partially or completely torn, the outer end of the clavicle may slip out of place, preventing it from properly meeting the scapula. Most often, the injury is caused by a blow to the shoulder or by falling on an outstretched hand.

Rotator Cuff Disease: tendonitis and bursitis

These conditions are closely related and may occur alone or in combination.

Tendonitis is inflammation (redness, soreness, and swelling) of a tendon. In tendonitis of the shoulder, the rotator cuff and/or biceps tendon become inflamed, usually as a result of being pinched by surrounding structures. The injury may vary from mild inflammation to involvement of most of the rotator cuff.

Torn Rotator Cuff

Rotator cuff tendons often become inflamed from overuse, aging or a fall on an outstretched hand or another traumatic cause. Sports or occupations requiring repetitive overhead motion or heavy lifting can also place a significant strain on rotator cuff muscles and tendons. Over time, as a function of aging, tendons become weaker and degenerate. Eventually, this degeneration can lead to complete tears of both muscles and tendons. These tears are surprisingly common. In fact, a tear of the rotator cuff is not necessarily an abnormal situation in older individuals if there is no significant pain or disability. Fortunately, these tears do not lead to any pain or disability in most people. However, some individuals can develop very significant pain as a result of these tears and they may require treatment.

Signs and Symptoms: Typically, a person with a rotator cuff injury feels pain over the deltoid muscle at the top and outer side of the shoulder, especially when the arm is raised or extended out from the side of the body. Motions like those involved in getting dressed can be painful. The shoulder may feel weak, especially when trying to lift the arm into a horizontal position. A person may also feel or hear a click or pop when the shoulder is moved. Pain or weakness on outward or inward rotation of the arm may indicate a tear in a rotator cuff tendon. The patient also feels pain when lowering the arm to the side after the shoulder is moved backward and the arm is raised.

Diagnosis: A doctor may detect weakness but may not be able to determine from a physical examination where the tear is located. X-rays, if taken, may appear normal. An MRI or ultrasound can help detect a full tendon tear or a partial tendon tear.

Treatment: Doctors usually recommend that patients with a rotator cuff injury rest the shoulder, apply heat or cold to the sore area and take medicine to relieve pain and inflammation. Other treatments might be added, such as electrical stimulation of muscles and nerves, ultrasound, or a cortisone injection near the inflamed area of the rotator cuff. If surgery is not an immediate consideration, exercises are added to the treatment program to build flexibility and strength and restore the shoulder's function. If there is no improvement with these conservative treatments and functional impairment persists, the doctor may perform arthroscopic or open surgical repair of the torn rotator cuff.

Treatment for rotator cuff disease usually depends on the severity of the injury, the age and health status of the patient, and the length of time a given patient may have had the condition. Patients with rotator cuff tendonitis or bursitis that does not include a complete tear of the tendon can usually be treated without surgery. Nonsurgical treatments include the use of anti-inflammatory medication and occasional steroid injections into the area of the inflamed rotator cuff, followed by rehabilitative rotator cuff strengthening exercises. These treatments are best undertaken with the guidance of a health-care professional such as a physical therapist, who works in conjunction with the treating physician.

Surgical repair of rotator cuff tears is best for:

• younger patients, especially those with small tears. Surgery leads to a high degree of successful healing and reduces concerns about the tear getting worse over time.
• individuals whose rotator cuff tears are caused by an acute, severe injury. These people should seek immediate treatment that includes surgical repair of the tendon.

Generally speaking, individuals who are older and have had shoulder pain for a longer period of time can be treated with nonoperative measures even in the presence of a complete rotator cuff tear. These people are often treated similarly to those who have pain, but do not have a rotator cuff tear. Again, anti-inflammatory medication, use of steroid injections, and rehabilitative exercises can be very effective. When treated surgically, rotator cuff tears can be repaired by either arthroscopic or traditional open surgical techniques.

Frozen Shoulder

As the name implies, movement of the shoulder is severely restricted in people with a "frozen shoulder." This condition is frequently caused by injury that leads to lack of use due to pain. Rheumatic disease progression and recent shoulder surgery can also cause frozen shoulder. Intermittent periods of use may cause inflammation. Adhesions (abnormal bands of tissue) grow between the joint surfaces, restricting motion. There is also a lack of fluid, which normally lubricates the gap between the arm bone and socket to help the shoulder joint move. It is this restricted space between the capsule and ball of the humerus that distinguishes adhesive capsulitis from a less complicated painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or those who have been in an accident, are at a higher risk for frozen shoulder. Frozen shoulder is more common among women than men. People between the ages of 40 and 70 are most likely to experience it.

Arthritis of the Shoulder

Arthritis is a degenerative disease caused by either wear and tear of the cartilage (osteoarthritis) or an inflammation (rheumatoid arthritis) of one or more joints. Arthritis not only affects joints, but may also affect supporting structures such as muscles, tendons, and ligaments. The usual signs of arthritis of the shoulder are pain and a decrease in shoulder motion.

Treat Shoulder Injuries with RICE
(Rest, Ice, Compression, and Elevation)

If you injure a shoulder, try the following:

Rest-Reduce or stop using the injured area for 48 hours.

Ice-Put an ice pack on the injured area for 20 minutes at a time, four to eight times per day. Use a cold pack, ice bag or a plastic bag filled with crushed ice that has been wrapped in a towel.

Compression-Compress the area with bandages, such as an elastic wrap, to help stabilize the shoulder. This may help reduce the swelling.

Elevation-Keep the injured area elevated above the level of the heart. Use a pillow to help elevate the injury.

If pain and stiffness persist, see a doctor.