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Patient Guide to Shoulder Pain

Shoulder pain should not be ignored. Early treatment can prevent further injury and chronic shoulder problems. Pain in the shoulder may also be referred from other areas of the body, e.g. disc problems the neck.

The Shoulder Joint

The structure of the shoulder joint allows more range of motion than any other joint in the body.

The shoulder actually has several joints that work together to allow a wide range of motion. Most injuries occur at the “main” shoulder joint, where the head of the upper arm meets the shoulder blade; the term “shoulder joint” refers to this joint. The other smaller shoulder joints are referred to by their specific names.

The head of the upper arm bone sits on a very small and shallow socket in the shoulder blade. This allows for the shoulder’s wide range of motion but makes it susceptible to injury. Because there is little bony stability, the shoulder relies greatly on connective tissue (e.g. ligaments, tendons, muscles) to hold the bones of the joint together and to stabilize the joint.

Causes of Shoulder Pain

The Most Common Cause of shoulder joint pain is rotator cuff tendonitis – injury and inflammation of the tendons (rotator cuff tendons) that envelope the shoulder joint. The most common cause of rotator cuff tendonitis is overuse of the shoulder, though the rotator cuff tendons may be injured suddenly as a result of a fall or accident.

Muscle strain is common in the muscles that run over the shoulders to the neck . It is often the result of holding the shoulders in a raised position for long periods of time. The muscles between the shoulder blades are often strained from slouching from long periods of time. Muscle strain varies in severity.

Other painful shoulder conditions, such as frozen shoulder, may occur for no apparent reason. (The risk of frozen shoulder increases when the shoulder is not used enough after a painful injury). The cause of calcium deposits in the shoulder, which may trigger episodes of acute inflammation of the tendons, is also unclear. Arthritis sometimes occurs in a previously injured shoulder joint.

Slap Lesion

Slap Lesion

Risk Factors

WEAK ROTATOR CUFF MUSCLES

Weak or fatigued rotator cuff muscles can lead to soft tissue injury. If the muscles that stabilize the shoulder joint (mainly the rotator cuff muscles) are weak or fatigued, the muscles fail to fully stabilize the joint. If the head of the upper arm bone is not kept in place in its socket, abnormal force is placed upon tissue surrounding the shoulder joint and can lead to injury. Shoulder tendonitis and bursitis are common.

OVERUSE

Shoulder pain is frequently caused by chronic overuse of the shoulder. The shoulder may become injured suddenly from a blow or fall, but gradual injury from chronic overuse of the shoulder is more common. Repetitive lifting, pushing, pulling, throwing, and especially overhead activities may lead to injury. Pain may be mild and intermittent in the beginning and worsen over time. Combining repetitive overhead activities with force increases the risk of injury further (e.g. stacking heavy objects on a high shelf).

Repetitive overhead activities can be particularly damaging. When the arm is raised overhead, the head of the upper arm bone migrates upward on the shoulder socket somewhat and rotator cuff tendons come into contact with the roof of the shoulder blade. Repeated contact and friction of the rotator cuff tendons often leads to irritation and inflammation of the tendons (tendonitis).

A strong rotator cuff helps keep the head of the upper arm bone from riding up excessively but some contact between the rotator cuff and bones in the joint still occurs with overhead activity. The bursa that lies under the roof of the shoulder blade may also be affected and become inflamed (bursitis). Shoulder bursitis often occurs along with shoulder tendonitis.

AGING

Aging is a major factor in rotator cuff injuries Tendons lose elasticity with aging and they become more susceptible to injury. Muscle mass also decreases with age. Both the rotator cuff muscles and tendons can be strengthened with resistance exercises.

Prevention of Shoulder Pain

Overuse shoulder injuries often can be prevented.

Weak rotator cuff muscles may be unable to adequately stabilize the shoulder joint. Rotator Cuff Exercises can help. Building up strength of the rotator cuff through exercise helps to stabilize the shoulder joint to prevent abnormal pressure on the soft tissues surrounding the joint. The muscles that control the shoulder blade also play a role in stabilizing the shoulder joint.

Avoid repetitive overhead activities. If you are involved in activities that involve repetitive overhead movements, take frequent breaks. Fatigued rotator cuff muscles lose the ability to keep the shoulder stabilized.

Avoid doing too much too soon. If you are going to engage in any overhead activity you haven’t done for a long time, such as getting back into playing tennis, endurance must be built up slowly. Exercises to strengthen the muscles you will be using in an activity reduce the chance of injury.

Warm up before engaging in sports such as swimming, tennis or throwing sports that require overhead movement.

Proper form for your sport should be learned and practiced to prevent injury.

Maintain proper posture. Muscles over the shoulders become strained from holding the shoulders in a raised position for long periods of time. Muscles in the upper back, between the shoulder blades, become strained as a result of slouching.

Treatment of Shoulder Pain

Prevent major problems by treating minor problems early. If a minor injury is not given a chance to heal before it is subjected to the same activity, pain and inflammation may become chronic.

Treatment of shoulder pain depends on the cause – seek a proper diagnosis from a qualified physician. Most shoulder injuries heal with conservative treatment. Healing takes time. The time it takes to recover depends upon several factors, e.g. the severity of injury, the type of injury, how quickly one heals, how early one begins treatment.

Typical treatment of shoulder pain (for most conditions) involves a combination of rest (not complete rest), exercise, anti-inflammatory medication, applying cold or heat to the shoulder joint and, in some cases, an injection of steroids into the shoulder joint.

Doing activities that aggravate shoulder pain often cause further damage, delay healing, and may lead to long-term problems. However, not using the shoulder at all weakens the shoulder and leaves it more vulnerable to injury. Immobilizing the shoulder may also lead to frozen shoulder. Stretching exercises help prevent this condition.

Strengthening exercises for the muscles that support the shoulder, particularly the rotator cuff (the muscles and tendons that dynamically stabilize the main shoulder joint) are a major part of treatment for most shoulder injuries, but strength training before adequate healing has taken place may cause further pain and injury. A physician or physical therapist can determine when the shoulder is ready for strengthening exercises. Shoulder Exercises can prevent injury from recurring.

Massage therapy is also used to treat many soft tissue injuries. From muscle strain to tendonitis to frozen shoulder, massage therapy increases circulation, speeds healing, improves range of motion and relieves pain.

Most shoulder pain improves with conservative treatment; however, surgery may occasionally be required (depending upon the type of and severity of the injury). Surgery may be performed to tighten loose ligaments, repair a torn tendon, remove a calcium deposit, trim a damaged tendon, etc. when conservative treatment doesn’t adequately resolve symptoms.

Diagnosis of Shoulder Pain

Many shoulder conditions have similar symptoms and it may be difficult to diagnose the problem from symptoms alone. A physician, often an orthopedist, diagnoses the cause of shoulder pain by taking into consideration the patient’s symptoms and medical history, findings of a physical examination and sometimes diagnostic testing, such as x-rays, a CT scan, or an MRI.


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Patient Guide to Shoulder Pain and Shoulder Injury

Shoulder pain is very common in individuals who play ‘overhead’ sports such as baseball, tennis and volleyball. In this group of athletes injury may be the result of an isolated traumatic event such as a fall or through repeated sporting-use causing micro-trauma to the shoulder region.

The shallow anatomical design of the shoulder joint surface is what makes it inherently unstable and prone to these types of injuries. This lack of bony support increases the dependency on the muscles and other soft tissues for stability. Any alterations in how these tissues function will raise the risk of shoulder injuries.

Rotator Cuff Tendonitis

Rotator Cuff Tendonitis

Two common structural injuries in this group of athletes are the rotator cuff and the labrum.

  • The rotator cuff is a group of muscles which extend from the shoulder blade to the arm. It insures dynamic shoulder stability by maintaining the proper relationship between the arm and the shoulder blade.
  • The shoulder joint is comprised of a ball and socket. The labrum is a fibrous tissue at the edge of the shoulder blade which extends to cover the ball at the top of the arm bone. It functions to increase the shoulder’s stability by deepening the socket
  • Typically, you are more prone to injure the labrum at a younger age. This tearing injury is called a SLAP lesion which is an acronym, (Superior Labrum extending Anterior to Posterior), referring to the location of the injury. It is a fairly common diagnosis for overhead athletes complaining of shoulder pain. Some studies have found it to be present in 83% to 91% of these athletes who require shoulder surgery.
  • Injuries to the rotator cuff are more likely to happen as we get older. Repetitive micro-trauma to these tissues results in inflamed tendons (tendonitis) and tears.

Tightness in the tissues at the back of the shoulder and weakness in the shoulder blade muscles are factors that are known to increase your risk for these injuries. An assessment by a physiotherapist can be beneficial in determining which of these factors are present and designing a program to correct these imbalances before you have pain.

If you have discomfort and pain every time you cock your arm to throw or serve, or have experienced the sudden onset of sharp pain or a loss of strength and power, you may already have an injury. Ignoring these warning signs and continuing to play through the pain can cause damage. If you are experiencing symptoms a physiotherapist can determine whether a program of stretches for the back of the shoulder and exercises to strengthen your shoulder blade muscles will allow you to return to your sport with more power to serve or throw, lowering your chance of re-injury. The earlier you seek therapy the better will be the result.

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Rotator Cuff Injury and Inflammation

Rotator cuff injury and inflammation is one of the most common causes of shoulder pain. There are three common conditions that can affect the rotator cuff: rotator cuff tendonitis, rotator cuff impingement syndrome and a rotator cuff tear. Most people with rotator cuff problems can be successfully treated by a combination of rest, painkillers, anti-inflammatories, physiotherapy and injections.

The shoulder joint

There are three bones in the shoulder region, the clavicle (collar bone), the scapula (shoulder blade) and the humerus (upper arm bone). The scapula is a triangular-shaped bone that has two important parts to it: the acromion and the glenoid. The three bones in the shoulder region form part of two main joints:

  • The acromioclavicular joint between the acromion of the scapula and the clavicle.
  • The glenohumeral joint between the glenoid of the scapula and the humerus.

There are also a number of muscles, ligaments and tendons around the shoulder. Ligaments are fibres that link bones together at a joint. Tendons are fibres that attach muscle to bone.

What is the rotator cuff?

The rotator cuff is a group of four muscles that are positioned around the shoulder joint. The muscles are named:

  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres minor

The rotator cuff muscles work as a unit. They help to stabilise the shoulder joint and also help with shoulder joint movement. The four tendons of the rotator cuff muscles join together to form one larger tendon, called the rotator cuff tendon. This tendon attaches to the head of the humerus (the bony surface at the top of the upper arm bone). There is a space underneath the acromion of the scapula, called the subacromial space. The rotator cuff tendon passes through here.

What are the types of rotator cuff injury/inflammation?

There are a number of different problems that can affect the rotator cuff and lead to rotator cuff injury or inflammation. The most common problems include:

  • Rotator cuff tendonitis
  • Rotator cuff impingement syndrome
  • Rotator cuff tear

Rotator cuff tendonitis

Who gets rotator cuff tendonitis?

Rotator cuff tendonitis is the most common cause of shoulder pain.

What causes rotator cuff tendonitis?

Rotator cuff tendonitis is caused by irritation and inflammation of the tendons of the rotator cuff muscles. It tends to have an acute (sudden) onset. There is often a specific preceding injury. It can happen because of recent overuse of the shoulder. For example, it can occur in athletes, particularly those who participate in throwing sports. In non-athletes, there may be a history of recent heavy lifting or activities involving repetitive movements of the shoulder.

Sometimes the rotator cuff tendons can become ‘calcified’. This is when calcium is deposited in the tendons due to long-standing inflammation. This is called calcific tendonitis.

What are the symptoms of rotator cuff tendonitis?

The main symptoms are an acute (sudden) onset of pain and painful movement of the shoulder. Pain is worst when you use your arm for activities above your shoulder level. This means that the pain can affect your ability to lift your arm up – for example, to comb your hair or dress yourself. Swimming, basketball and painting can be painful but writing and typing can produce little in the way of pain. Pain may also affect sleep.

How is rotator cuff tendonitis diagnosed?

Our doctor is usually able to make the diagnosis just by talking to you and examining your shoulder. They usually start by asking questions about your shoulder. These questions may include when your shoulder problems started, whether you have had any specific injury and what aggravates your shoulder problem.

They may then perform an examination of your shoulder. This usually involves moving your shoulder in various positions. One of the tests that can help to diagnose rotator cuff tendonitis is called the ‘painful arc test’. Our doctor may ask you to start with your arm by your side and then lift your arm outwards from your side in an arc. In rotator cuff tendonitis, pain is usually felt at a maximum between 70 and 120° in this arc.

Occasionally, Our doctor may suggest an X-ray of your shoulder or they may refer you for more detailed investigations such as an ultrasound scan or an MRI scan.

What are the treatment options for rotator cuff tendonitis?

  • Rest: this is the main treatment for rotator cuff tendonitis. You should stop any aggravating activities that may have brought on the tendonitis. However, do not completely rest your shoulder. You should still try to keep your shoulder mobile.
  • Painkillers: painkillers such as paracetamol are usually helpful. Occasionally, stronger painkillers may be needed.
  • Anti-inflammatories: these are painkillers but they also reduce inflammation and are commonly prescribed. Side-effects sometimes occur with anti-inflammatories. Always read the leaflet that comes with the drug packet for a full list of cautions and possible side-effects.
  • Physiotherapy: your doctor may refer you to a physiotherapist for advice and exercises.
  • Injections: these can help reduce the inflammation in the rotator cuff tendons. Injections can be repeated if the initial response is good.

Calcific tendonitis is treated in the same way with rest, anti-inflammatory drugs, steroid injections and physiotherapy. Rarely, surgery is needed. An alternative to surgery is a procedure called lithotripsy. In lithotripsy, shock waves are generated and delivered by an external power source to the affected tendon(s) using a specialised machine known as a lithotripter. This helps to break up the deposits of calcium.

What is the prognosis (outlook) for rotator cuff tendonitis?

If rotator cuff tendonitis is adequately treated, there can be complete recovery.

If treatment of any rotator cuff problem is delayed or inadequate, it can lead to the affected person being cautious about moving their shoulder because of pain. This means that the shoulder can stiffen up and can lead to adhesive capsulitis (frozen shoulder). See separate leaflet called ‘Frozen Shoulder’.

Rotator cuff impingement syndrome

What causes rotator cuff impingement syndrome?

As discussed above, the rotator cuff tendon passes in the subacromial space (the space underneath the acromion part of the scapula, or shoulder blade). In impingement syndrome, the rotator cuff tendon gets ‘trapped’ in the subacromial space. The tendon is repeatedly ‘scraped’ against the shoulder blade which can eventually lead to fraying of the tendon. This means that the tendon weakens and is more likely to tear.

Impingement syndrome can occur because of long-standing ‘wear and tear’. It can also happen due to problems with the bone of the acromion. These can include arthritis and bony spurs (protrusions).

What are the symptoms of rotator cuff impingement syndrome

Rotator cuff impingement syndrome also causes shoulder pain. However, the pain tends to be more chronic (long-standing). The pain tends to be worse during activities when your arm is raised over your head. Pain can also be worse at night time.

How is rotator cuff impingement syndrome diagnosed?

Again, our doctor will usually diagnose rotator cuff impingement syndrome just by talking to you and examining your shoulder. You will experience the same painful arc as described above when your shoulder is moved.

Our doctor may also perform a special test when they examine your shoulder called the Neer Impingement Test. In this test they ask you to straighten your arm. They then raise your arm forward, keeping your palm pointing away from your body. If this test is painful, the test is positive and rotator cuff impingement syndrome is likely.

What are the treatment options for rotator cuff impingement syndrome?

The treatment for rotator cuff impingement syndrome is similar to that for rotator cuff tendonitis. You should rest from any activity that involves repetitive movement of the shoulder. This particularly includes overhead activity such as that performed by plasterers or painters and decorators. This may mean that you have to modify or change your work activities. However, be careful to keep your shoulder mobile so that it does not stiffen up. Painkillers, anti-inflammatories, physiotherapy and injections can help.

If these treatments do not work, some people with rotator cuff impingement syndrome need to have an operation to ‘widen’ the subacromial space. This is usually referred to as a ‘decompression’ operation.

What is the outlook (prognosis) for rotator cuff impingement syndrome?

If rotator cuff impingement syndrome is not recognised and treated promptly, it can lead to excessive wear and tear of the rotator cuff tendon. This in turn can lead to weakening of the tendon and the tendon can break, or rupture, causing a rotator cuff tear.

Some people do not have any symptoms from rotator cuff impingement syndrome and may not realise that they have it until they get a rotator cuff tear.

Rotator cuff tears

Who gets rotator cuff tears?

Rotator cuff tears are most common in people over the age of 40 years.

What causes a rotator cuff tear?

Rotator cuff tears are usually tears in the rotator cuff tendon rather than in the muscles themselves. In younger people, a rotator cuff tear normally happens as a result of trauma (injury) due to a fall or accident. In older people, they are often caused by rotator cuff impingement syndrome. In impingement syndrome, repeated damage to the ‘trapped’ tendon means that the tendon frays, weakens and is more likely to tear.

Rotator cuff tears can be minor/partial or full/complete depending on the degree of damage to the tendon.

What are the symptoms of a rotator cuff tear?

Pain is the most common symptom of a rotator cuff tear. The pain tends to be over the front and outer part of the shoulder. It is worse when your shoulder is moved in certain positions. For example, when your arm is moved above your head on dressing or combing your hair, or moved forwards to reach for something.

Your shoulder or arm can also feel weak and you may have reduced movement in your shoulder. Some people feel clicking or catching when they move their shoulder.

How is a rotator cuff tear diagnosed?

  • History and examination: again, our doctor will usually be able to diagnose a rotator cuff tear by talking to you and examining your shoulder.
  • The ‘drop arm test’: one of the tests that can help to diagnose a rotator cuff tear is called the ‘drop arm test’. If our doctor carries out this test they will ask you to stand with your arm by your side. They will lift your arm outwards from your side and up towards your head. They will then ask you to move your arm back down slowly towards your side. In a rotator cuff tear, you are usually able to lower your arm slowly to 90° but when you try to lower your arm below 90°, it drops quickly to your side because of the tear.
  • Other investigations: occasionally, our doctor may suggest an X-ray of your shoulder or they may refer you for more detailed investigations such as an ultrasound or MRI scan.
  • Referral to a specialist: if our doctor suspects a complete/full tear of your rotator cuff, they may suggest that they refer you to an orthopaedic surgeon (bone and joint specialist).

What are the treatment options for a rotator cuff tear?

  • Painkillers: painkillers such as paracetamol are usually helpful in rotator cuff tears. Occasionally, stronger painkillers may be needed.
  • Anti-inflammatories: our doctor may also suggest that you take regular anti-inflammatories. These are painkillers but they also reduce inflammation and are commonly prescribed. Side-effects sometimes occur with anti-inflammatories. Always read the leaflet that comes with the drug packet for a full list of cautions and possible side-effects.
  • Ice packs: these can also help to reduce pain. A bag of frozen peas is an easy ice pack to use in the home.
  • Physiotherapy: this may be helpful for people with minor rotator cuff tears. Our doctor may refer you to a physiotherapist for advice and shoulder exercises.
  • Injections: sometimes our doctor may suggest injections around your shoulder joint as a treatment for minor tears. The idea is that the injection may help to reduce any inflammation.
  • Surgery: this is sometimes needed in large/complete tears. Surgery usually involves decompression (widening) of the space underneath the acromion and may also include repair of the rotator cuff tendon. The surgery can be done using either a keyhole or an open method.

What is the prognosis (outlook) for rotator cuff tears?

About half of people with rotator cuff tears do well with just conservative treatment. That means the rotator cuff tears heal with treatment including rest, physiotherapy, painkillers, anti-inflammatories and injections. Surgery is needed in the other half in whom this conservative treatment does not work.

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