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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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Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years.

Your risk of developing frozen shoulder increases if you’re recovering from a medical condition or procedure that affects the mobility of your arm such as a stroke or a mastectomy.

Treatment for frozen shoulder involves stretching exercises and, sometimes, the injection of corticosteroids and numbing medications into the joint capsule. In a small percentage of cases, surgery may be needed to loosen the joint capsule so that it can move more freely.

Symptoms:

Frozen shoulder typically develops slowly, and in three stages. Each of these stages can last a number of months.

  • Painful stage. During this stage, pain occurs with any movement of your shoulder, and your shoulder’s range of motion starts to become limited.
  • Frozen stage. Pain may begin to diminish during this stage. However, your shoulder becomes stiffer, and your range of motion decreases notably.
  • Thawing stage. During the thawing stage, the range of motion in your shoulder begins to improve.

For some people, the pain worsens at night, sometimes disrupting normal sleep patterns.

Causes:

The bones, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, restricting its movement.

Doctors aren’t sure why this happens to some people and not to others, although it’s more likely to occur in people who have recently experienced prolonged immobilization of their shoulder, such as after surgery or an arm fracture.

Risk Factors:

Although the exact cause is unknown, certain factors may increase your risk of developing frozen shoulder.

Age and sex
People 40 and older are more likely to experience frozen shoulder. Most of the people who develop the condition are women.

Immobility or reduced mobility
People who have experienced prolonged immobility or reduced mobility of their shoulder are at higher risk of developing frozen shoulder. Immobility may be the result of many factors, including:

  • Rotator cuff injury
  • Broken arm
  • Stroke
  • Recovery from surgery

Systemic diseases
People who have certain medical problems appear to be predisposed to develop frozen shoulder. Examples include:

  • Diabetes
  • Overactive thyroid (hyperthyroidism)
  • Underactive thyroid (hypothyroidism)
  • Cardiovascular disease
  • Tuberculosis
  • Parkinson’s disease

Diagnosis:

During the physical exam, your doctor may ask you to perform certain actions, to check for pain and evaluate your range of motion. These may include:

  • Hands up. Raise both your hands straight up in the air, like a football referee calling a touchdown.
  • Opposite shoulder. Reach across your chest to touch your opposite shoulder.
  • Back scratch. Starting with the back of your hand against the small of your back, reach upward to touch your opposite shoulder blade.

Your doctor may also ask you to relax your muscles while he or she moves your arm for you. This test can help distinguish between frozen shoulder and a rotator cuff injury.

Frozen shoulder can usually be diagnosed from signs and symptoms alone. But your doctor may suggest imaging tests such as X-rays or an MRI to rule out other structural problems.

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Shoulder Bankart Repair Surgery

What is a Bankart Repair?

The aim of a Bankart repair operation is to restore stability to the shoulder. The operation is suitable for people who have detached the labrum and ligaments at the front of the shoulder as a result of an original violent dislocation. Usually the shoulder has remained unstable and may have dislocated on a number of further occasions.

After the operation you should not suffer further dislocations and have much reduced pain.

bankart_repair1

What does Bankart Repair involve?

Bankart Repair surgery is performed under general anaesthetic and takes around an hour and a half.  Usually the nerves to the whole arm are also numbed with local anaesthetic which lasts for sixteen to twenty-four hours. This technique is called a regional block and is similar to the idea of an epidural anaesthetic frequently used in childbirth. This regional block not only means that a lighter general anaesthetic is required, reducing postoperative sickness and nausea, but also provides excellent pain relief afterwards.

The operation is carried out as a conventional open operation through an incision at the front of the shoulder, or telescopically through a number of small incisions around the shoulder.  The aim is to restore the labrum and ligaments to their original position on the edge of the socket and encouraged to heal there. The first step in the operation is to mobilise and re-position the labrum and ligaments and to create an environment in which healing can occur. Little harpoons or anchors are then inserted into the bone on the edge of the socket, which gain a good grip. Stitches on these anchors are then used to suture the labrum and ligaments back into place. The anchors and sutures then hold everything in the right place while natural healing occurs.

The incisions are closed with stitches and waterproof dressings are applied.

When will I recover?

The operation requires a one night stay in hospital and your stitches will come out at one to two weeks after the surgery. Your arm is placed into a special shoulder-immobilising sling and exercises and physiotherapy start on the day of surgery.  Your physiotherapist will teach you all you need to know for the first couple of weeks before your discharge from hospital.

As a general guideline your sling will be retained for a period of four weeks during which time you will be quite one-handed. At four weeks the sling generally goes and increased exercises and movement are encouraged. Most people can return to driving a car at around six weeks and will have regained good ordinary use of the shoulder by eight to ten weeks.

Physiotherapy and exercises continue for four to six months and sports that do not impose too much stress on the shoulder, such as running, can start again at around eight to ten weeks. Activities such as golf and swimming can be resumed at around three months. Contact sports, such rugby and football and other high demand sports such as surfing and climbing can be reintroduced at six months.

In addition to regular treatment with the physiotherapist, follow up is required with your surgeon. This is to monitor and guide progress and to look out for complications which are fortunately all rare.

What risks should I know about?

Bankart Repair is a very successful operation but there are some potential complications you should be aware of even though they are uncommon.

  • Infection can occur although it is rare and infection rates are at 1%.
  • Shoulder dislocation can occur although this risk is minimised by having the operation done very carefully and adhering to the physiotherapy regime.

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Arthroscopic Rotator Cuff Repair

Rotator cuff repair leads to good and excellent outcomes in most patients. However, structural failure of the repair occurs in a substantial number of cases and can lead to an unsatisfactory result. Several factors have been implicated, including patient related factors (eg. patient age, tear size) and extrinsic factors (eg, surgeon surgical volume, biomechanical failure). Structural failure requires a detailed patient evaluation to elucidate the cause of persistent symptoms. Function can be maintained despite a recurrent tear; therefore, a recurrent tear alone is not an indication for revision repair. The major indication for revision rotator cuff repair is the persistence clinical symptoms, despite nonsurgical management, in the absence of substantial risk factors for failure. Although the outcome is poorer than after primary repair, satisfactory results have been reported following revision repair of recurrent rotator cuff tears, particularly with arthroscopic techniques.

About rotator cuff injuries

Shoulder pain affects around one in five people in the UK and a rotator cuff injury is the most common cause.

Your shoulder joint is a ball and socket joint, formed by the ball-shaped end of your upper arm bone (humerus) and a shallow socket on the edge of your shoulder blade (scapula).

Your rotator cuff is made up of a group of four muscles (the subscapularis, supraspinatus, infraspinatus and teres minor) and their tendons. It plays a crucial role in keeping your shoulder joint stable. Tendons wrap around your shoulder joint, forming a cuff around the ball of your humerus.

On top of your shoulder joint is a bone called the acromion. In the gap between your shoulder joint and acromion is a space that some of your rotator cuff tendons run through. In this space is a fluid-filled pad called the subacromial bursa, which cushions your tendons.

Rotator cuff injury is a general term to describe inflammation (soreness and swelling) or damage to one or more of the muscles or tendons that make up your rotator cuff.

Types of rotator cuff injury

There are a number of conditions that can affect your rotator cuff. The most common are inflammation of your rotator cuff tendons and tearing of your muscles or tendons.

Rotator cuff tendonitis
If the tendons of your rotator cuff become inflamed, this is known as tendonitis. The tendons can become pinched against one of the other structures that make up your shoulder joint. This can be both the cause and the result of tendonitis. Tendonitis most often affects the tendons that run underneath your acromion. When a tendon becomes trapped or squeezed, it’s known as impingement syndrome.

Calcium is sometimes deposited in your rotator cuff tendons if they are inflamed for a long period of time. The tendons become ‘calcified’ and this is called calcific tendonitis.

Your subacromial bursa can also become inflamed – this is called bursitis.

Rotator cuff tear
This is when one or more of the muscles and tendons that make up your rotator cuff become completely or partially torn. It may be a result of trauma, such as a fall, or due to tiny tears in the tendon caused by use and wear over time. It may also be caused by impingement syndrome.

Symptoms of rotator cuff injuries

Symptoms of a rotator cuff injury include:

  • pain and tenderness in your shoulder (this may extend down your arm too), particularly when you raise your arm out to the side, reach behind you or lift or pull a heavy weight
  • pain at night, particularly when you sleep on the affected side
  • a feeling of weakness in your shoulder
  • being unable to move your shoulder as you usually would

Depending on the type of injury you have, the pain may come on gradually (common if you have tendonitis) or you may have sudden twinges of pain (common if you have a tear).

If you have any of these symptoms, contact your GP or a physiotherapist (a health professional who specialises in maintaining and improving movement and mobility).

Causes of rotator cuff injuries

Rotator cuff injuries may occur for a specific reason, for example:

  • lifting or pulling an object that is too heavy for you or lifting it in the wrong way can cause you to strain or tear a rotator cuff tendon or muscle
  • landing on an outstretched hand to break a fall can tear or strain a rotator cuff muscle or tendon

There are some things that increase the likelihood of you getting a rotator cuff injury, including the following.

  • Age – if you’re over 40, you’re at an increased risk of rotator cuff injuries because your tendons start to wear down with age and become more prone to injury.
  • Certain sports, activities and jobs – you’re more likely to have a rotator cuff injury if you do something that involves repetitive overhead motions with your arms. Examples include swimming, weight lifting, playing racquet sports and occupations such as painting, decorating or window cleaning.
  • Musculoskeletal diseases, such as rheumatoid arthritis, can cause your rotator cuff muscles to become weaker making an injury more likely.

Diagnosis of rotator cuff injuries

Your GP or physiotherapist will ask about your symptoms and examine you. He or she may ask about your medical history and any activities that may be causing your condition.

You may be referred for further tests such as an MRI scan, ultrasound scan or X-ray so that your doctor can look at your shoulder in more detail.

Treatment of rotator cuff injuries

Treatment of a rotator cuff injury depends on the type of injury you have and how severe it is.

Self-help

The following measures may help.

  • Rest your shoulder initially, avoiding any movements that cause you pain. Start to do gentle movements as soon as possible to prevent any stiffness in your shoulder.
  • Apply an ice pack or ice wrapped in a towel to your shoulder to reduce swelling and bruising. Don’t apply ice directly to your skin as it can damage your skin. Don’t use ice if you have a skin disorder that makes your skin sensitive. Also, don’t put ice on your left shoulder if you have any known heart problems.
  • Take an over-the-counter anti-inflammatory medicine, such as ibuprofen, to reduce pain and inflammation. Always read the patient information leaflet that comes with your medicine and if you have any questions ask your pharmacist for advice.

Non-surgical treatments

Stretches and strengthening exercises can help build up strength and flexibility in your shoulder. It’s important to get advice from a medical professional, such as a physiotherapist, on which exercises and stretches you should do and how to do them correctly. The exercises will be tailored to your specific injury.

If you have rotator cuff tendonitis, your doctor may recommend an injection of a medicine called a corticosteroid. This is usually only done when other treatments haven’t helped.

You may be able to have extracorporeal shock wave lithotripsy (ESWT) if you have calcific tendonitis. ESWT uses vibrations caused by sound waves to break up the calcium deposits.

Surgery

Rotator cuff injuries can usually be successfully treated without the need for surgery. However, sometimes you may need to have an operation, for example to repair a tear in your rotator cuff or to remove calcium deposits.

Rotator cuff repair surgery is done under general anaesthesia. This means you will be asleep during the operation.

In general, there are two different procedures that may be used to repair a rotator cuff injury: open surgery and shoulder arthroscopy. The type of surgery you have will depend on where your injury is, and if it’s a tear, how big it is and it’s shape.

Open surgery means that your surgeon makes a cut in the skin over your shoulder and repairs your injury through the cut. In an athroscopy, a narrow, flexible, tube-like telescopic camera called an arthroscope is inserted through a small incision in your shoulder and this is used to repair your injury. It’s commonly known as keyhole surgery.

If you have a rotator cuff tear, the two sides of your muscle or tendon will be stitched back together and, if necessary, attached back on to your humerus. Your surgeon may also carry out a procedure called debridement. This means that he or she will remove any damaged tissue, so that the remaining healthy tissue can heal.

If you have impingement syndrome, your surgeon will remove excess bone from the front part of your acromion. This will create more room for your rotator cuff and prevent pinching of the rotator cuff, when you move your arm above your head. This procedure is called subacromial decompression.

Your surgeon will be able to give you advice on which type of surgery you need for your condition.

To schedule for an appointment, call us at +65 6471 2744 or SMS to +65 9235 7641 (24 Hours)

Arthroscopy Acromioplasty

Acromioplasty, also known as subscromial decompression, is an arthroscopic surgical procedure of the acromion, top of the shoulder blade or the part of the shoulder blade extending over the shoulder joint. In the acromioplasty surgery, a small piece of the surface of the acromion that is causing damage to the tendon tissue is removed.

Atrhoscopic acromioplasty is used to treat severe cases of impingement syndrome, a condition resulting from an injury to the rotator cuff muscles and often seen in aging adults. In the impingement syndrome, the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion. This can result in pain, weakness and loss of movement at the shoulder. Motions such as reaching up behind the back and reaching up overhead to put on a coat or blouse, for example, may cause pain.

In a shoulder arthroscopic acromioplasty, a number of small incisions are made around the shoulder. The surgeon uses an athroscope and video camera to confirm the subacromial impingement. In order to release the pressue on the trapped tendon or bursa and to allow the shoulder joint to move smoothly, the surgeon then removes or shaves a section of bone from the underside of the acromion. If any other injuries such as a rotator cuff tear or slap tear are identifies, then those are also treated at the time of this surgery (e.g. rotator cuff repair).

A dramatic relief in symptoms of impingement syndrome is usually seen soon after the surgery. In some cases, it may take a couple of months for the symptoms to resolve. For complete shoulder recovery and shoulder rehab, the patient must follow through the complete course of physiotherapy.

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