SHOULDER PAIN

What is shoulder pain?

What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion in the arm — from scratching your back to throwing the perfect pitch.

Mobility has its price, however. It may lead to increasing problems with instability or impingement of the soft tissue or bony structures in your shoulder, resulting in pain. You may feel pain only when you move your shoulder, or all the time. The pain may be temporary, or it may continue and require medical diagnosis and treatment.

This article explains some of the common causes of shoulder pain, as well as some general treatment options. Dr van den Berg can give you more detailed information about your shoulder pain.

What causes shoulder pain?

• Bursitis ("inflammation of the bursa")

Bursae are small, fluid-filled sacs that are in joints throughout the body, including the shoulder. They act as cushions between bones and the overlying soft tissues and help reduce friction between the gliding muscles and the bone.

Sometimes, excessive use of the shoulder leads to inflammation and swelling of the bursa between the rotator cuff and part of the shoulder blade known as the acromion. The result is a condition known as subacromial bursitis. Bursitis often occurs in association with rotator cuff tendinitis. The many tissues in the shoulder can become inflamed and painful. Many daily activities, such as combing your hair or getting dressed, may become difficult.

• Tendinitis ("inflammation of the tendon")

A tendon is a cord that connects muscle to bone. Most tendinitis is a result of a wearing down of the tendon that occurs slowly over time, much like the wearing process on the sole of a shoe that eventually splits from overuse.

Generally, tendinitis is one of two types:

1. Acute: Excessive overhead activities during work or sport (such as ball throwing or tennis) can lead to acute tendinitis.


2. Chronic: Degenerative diseases like arthritis or repetitive wear and tear due to age, can lead to chronic tendinitis.

The most affected tendons in the shoulder that are diagnosed with shoulder tendonitis are the four rotator cuff tendons (rotator cuff tendonitis) and one of the biceps tendons (biceps tendonitis). The rotator cuff is made up of four small muscles and their tendons that cover the head of your humerus and keep it in the shoulder socket. Your rotator cuff helps provide shoulder motion and stability.

• Tendon Tears

Splitting and tearing of tendons may result from acute injury or degenerative changes in the tendons due to advancing age, long-term overuse and wear and tear, or a sudden injury. These tendon tears may be partial or may completely split the tendon into two pieces. In most cases of complete tears, the tendon is pulled away from its attachment to the bone. Rotator cuff and biceps tendon injuries are among the most common tendons in the shoulder to tear.

• Impingement

Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the underlying soft tissues (bursa and rotator cuff) when the arm is lifted away from the body. As the arm is lifted, the acromion rubs ("impinges") on, the rotator cuff tendons and bursa. This can lead to bursitis and tendinitis in the shoulder, causing pain and limiting movement. Over time, severe impingement can even lead to a rotator cuff tear.

• Instability of the shoulder

Shoulder instability occurs when the head of the humerus is forced out of the shoulder socket (glenoid). This can happen as a result of a sudden injury or from overuse. Shoulder dislocations can be partial, with the ball of the humerus coming just partially out of the socket (called a subluxation). A complete dislocation of the shoulder joint means the ball comes all the way out of the socket.

Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Recurring dislocations, which may be partial or complete, cause pain and unsteadiness when you raise your arm or move it away from your body. This is known as instability of the shoulder. Repeated episodes of subluxations or dislocations lead to an increased risk of developing arthritis in the joint.

• Arthritis of the shoulder

Shoulder pain can also result from arthritis. There are many types of arthritis. The most common type of arthritis in the shoulder is osteoarthritis, also known as "wear and tear" arthritis. Symptoms, such as swelling, pain, and stiffness, typically begin during middle age. Osteoarthritis develops slowly and the pain it causes worsens over time.

Osteoarthritis of the shoulder may be related to sports or work injuries and chronic wear and tear. Other types of arthritis can be related to rotator cuff tears, infection, or an inflammation of the joint lining.

Often people will avoid shoulder movements to lessen arthritis pain. This sometimes leads to a tightening or stiffening of the soft tissue parts of the shoulder joint, resulting in a painful restriction of motion.

• Fractures of the shoulder

Shoulder fractures commonly involve the clavicle (collarbone), humerus (upper arm bone), and scapula (shoulder blade). Shoulder fractures in older patients are often the result of a fall from standing height. In younger patients, shoulder fractures are often caused by a high energy injury, such as a motor vehicle accident or contact sports injury. Fractures often cause severe pain, swelling, and bruising about the shoulder.

How is the cause of shoulder pain diagnosed?

In the case of an acute injury causing intense pain, seek medical from Dr van den Berg care as soon as possible. If the pain is less severe, it may be safe to rest a few days to see if time will resolve the problem. If symptoms persist, see an orthopaedic surgeon.

Your doctor will conduct a thorough evaluation in order to determine the cause of your shoulder pain and provide you with treatment options.

The first step in the evaluation is a thorough medical history. Your doctor may ask how and when the pain started, whether it has occurred before and how it was treated, and other questions to help determine both your general health and the possible causes of your shoulder problem. Because most shoulder conditions are aggravated by specific activities, and relieved by specific activities, a medical history can be a valuable tool in finding the source of your pain.

A comprehensive examination will be required to find the causes of your shoulder pain. Dr van den Berg will look for physical abnormalities, swelling, deformity or muscle weakness, and check for tender areas. He or she will observe your shoulder range of motion and strength.

Depending on the location, severity and when the pain is experienced, the cause of shoulder pain may vary. Dr Van den Berg may ask you questions to determine these factors and make an accurate diagnosis. The following will be valuable for the diagnosis:

Where is the pain?

1. On top of the shoulder: May be caused by acromio-clavicular (AC joint) problems (AC Joint Degeneration and AC Joint Dislocation).


2. In the shoulder and outside of the upper arm: Rotator cuff problems


3. At the back of the shoulder: Possibly Arthritis of the shoulder.


4. In the neck and upper part of the shoulder: May be caused by referred problem from the neck.


5. In the neck, shoulder and radiating down the arm into the hand: Consider neurological problems like disc problems in the neck or Thoracic Outlet Syndrome.

How severe is your pain?

• Acute "blinding" pain usually occurs with calcific tendonitis of the shoulder when the calcium is being absorbed.


• Other conditions may cause intermittent pain depending on position of the arm and the activity.


• If the pain is constant and running from the neck down to the shoulder and hand it is most likely from a nerve problem in the neck or thoracic outlet.


• If the pain is more mechanical (occurring with movements only) it would suggest a damaged structure in the shoulder.

When is shoulder pain experienced?

• Shoulder pain during the night: Pain at night occurs with most shoulder problems. Usually shoulder instability does not affect sleep, but most other conditions do when a person lies down at night. The reason is that any inflammation is worse when the position of the structure is lower due to the pressure effect of gravity – in the upright position the shoulder is elevated.


• Constant or intermittent pain of the shoulder: Most mechanical reasons for pain e.g. Rotator Cuff Tears, mostly cause pain with certain movements like lifting the arm. On the other hand, certain conditions cause constant pain unrelated to movement – these would be pain from nerve conditions like referred from the neck or Thoracic Outlet Syndrome.

Your doctor may order specific tests to help identify the cause of your pain and any other problems. These include:

• X-rays: These pictures will show any injuries to the bones that make up your shoulder joint.


• Magnetic resonance imaging (MRI) and ultrasound: These imaging studies create better pictures of soft tissues. It may help your doctor identify injuries to the ligaments and tendons surrounding your shoulder joint.


• Computed tomography (CT) scan: This tool combines x-rays with computer technology to produce a very detailed view of the bones in the shoulder area.


• Electrical studies: Your doctor may order a test, such as the EMG (electromyogram), to evaluate nerve function.


• Arthroscopy: In this surgical procedure, your doctor looks inside the shoulder joint with a fiber-optic camera. Arthroscopy may show soft tissue injuries that are not apparent from the physical examination, x-rays, and other tests. In addition to helping find the cause of pain, arthroscopy may be used to correct the problem.

What are the treatment options for shoulder pain?

• Activity Changes: Treatment generally involves rest, altering your activities, and physical therapy to help you improve shoulder strength and flexibility. Common sense solutions such as avoiding overexertion or overdoing activities in which you normally do not participate can help to prevent shoulder pain.


• Medication: Your doctor may prescribe medication to reduce inflammation and pain. If medication is prescribed to relieve pain, it should be taken only as directed. Your doctor may also recommend injections of local anesthetics or steroids to relieve pain.


• Surgery: Shoulder surgery may be required to resolve some shoulder problems; however, 70-80% of patients with shoulder pain will respond to simple treatment methods such as altering activities, rest, exercise, and medication. Certain types of shoulder problems, such as recurring dislocations and some rotator cuff tears, may not benefit from exercise. In these cases, surgery may be recommended early. Surgery can involve arthroscopy to remove scar tissue or repair torn tissues, or traditional, open procedures for larger reconstructions or shoulder replacement.