Many patients come into our office complaining of Rotator Cuff Tears, when in fact very few actually have a tear. There are several etiologies to shoulder pain; Adhesive Capsulitis (frozen shoulder), Subacromial Bursitis, Supraspinatus Tendonitis, Glenohumeral Instability, Chondrocalcinosis, Osteoarthritis, Gout, Lyme Arthritis, Bicipital Tendonitis, Ganglion Cyst are but a few possible causes of shoulder pain. It is best to think of cause of injury/pain and age in making generalizations for diagnosing shoulder pain.
Cause of Injury/Pain
Diagnosing Shoulder Problems
The art of diagnosing shoulder problems is to relate the two above with a good history from the patient and a comprehensive shoulder exam. Believe it or not, there are over 50 shoulder exam tests that can be done by the examining physician alone, without the use of x-rays, MRI's, or arthrograms. The latter test may be used to confirm a clinical suspicion or in difficult cases, to aid in the diagnosis, but a patient's history of injury/pain and a good shoulder directed physical examination will usually suffice in making a diagnosis and treatment plan. Many of these problems are approached in a non-operative manner with medications, rest, ice, and physical therapy suplemented with cortisone injections on occasion. If an operation is needed, most of these conditions can be treated by arthroscopic (scope) techniques, with limited incisions and usually done as a same day surgery.
Initiating early treatment for shoulder problems is often the best curative course. If you recognize these symptoms, you should make a prompt appointment to have it evaluated further by your primary care physician or an orthopedic surgeon.
SHOULDER PAIN (PART 1)
Generally, these injuries fall into three categories: Impingement Syndrome, Instability or Rotator Cuff tears. In this first article, we will discuss Impingement Syndrome. If you’ve developed shoulder pain that is worse when raising your arm, you may have this syndrome. It usually has an insidious onset, often associated with an activity that hasn’t been done for a while such as turning over garden soil, throwing a ball or household repairs. Pain with overhead activities, shoulder stiffness or a dull pain even when your not using your shoulder are the most common symptoms.
The muscles and tendons around the shoulder allow you to move your shoulder in a variety of directions including lifting, swinging, pushing or pulling and reaching. As you raise your arm overhead, a narrow space in your shoulder called the subacromial bursa gets compressed. The bursa functions normally as a fluid filled sac that allow tendons to glide without rubbing up against each other. With overuse, this bursa swells to three times its’ normal size and presses on the tendons and muscles causing inflammation and irritation. The combination of bursa swelling (bursitis) and tendon inflammation (tendonitis) is called Impingement Syndrome.
Treatment for impingement syndrome is "Active Rest". Avoid overhead activities. Ice initially to reduce inflammation followed by heat may speed your recovery. Your physician may prescribe non-steroidal anti-inflamatories. Do not stop moving your shoulder completely or a "frozen shoulder" will develop. Pendulum exercises listed below, keep your shoulder mobile without adding to the impingement.
Stir the Pot
Bend over a table and allow your affected arm to hang free. Make gentle circles with your dangling straight arm as if stirring a pot.
In the same position as above, allow your straight arm to swing from front to back, as if throwing a bowling ball.
While standing upright, grasp your affected arm with your good arm and push forward and backward as if sawing a log.
Rock the Baby
In the same position as above, grasp your affected arm and bring it across your body as if rocking a baby.
Exercises should be done for 10 minutes, 3 times a day. If the problem persists, see your doctor. Sometimes an injection of cortisone into the shoulder is needed to resolve the problem.
SHOULDER PAIN (PART 2)
In this next series, we will discuss shoulder pain related to instability. If you have dull, aching shoulder pain with the feeling that the shoulder is going to pop out of its’ socket in certain positions, you may have instability. Starting spring sports without an adequate winter training and conditioning program can lead to instability. Also excessive weight while weight-training, before the muscles are adequately built up can cause looseness of the shoulder. Finally, some people are just genetically prone to have loose joints or be "double-jointed", which is a risk factor for instability.
Instability is different from Impingement Syndrome discussed previously in that with Instability there is a provocative position which gives the sensation the shoulder is sliding out of its’ socket. This is usually associated with a sharp pain. Occasionally the entire arm my "go dead" with numbness and tingling. On occasion the shoulder actually dislocates and requires reduction either by oneself or an emergency department physician. Previous dislocations in young individuals predisposes to instability and has a high risk of further dislocation. Traditionally, gymnast, baseball pitchers, swimmers and younger athletes have loose shoulders.
Treatment for instability is aimed at conditioning and strengthening the Rotator Cuff muscles, a group of four strong muscles which encircle the upper arm and is responsible for all its movements. Formal Physical Therapy is utilized to aid in the program. A special elastic band called Theraband is used for strengthening.
Gradually strengthening is increased while maintaining the shoulder stable within its’ socket. Ice to reduce inflammation and relieve pain, followed in three days by heat to relax aching muscles and increase the blood flow (with its reparative proteins) to the shoulder is always indicated. Over the counter pain relievers such as aspirin, Tylenol, ibuprofen or naproxen can help reduce pain and inflammation.
Occasionally surgical intervention is required for repeated shoulder dislocations. These same-day surgical procedures can generally be performed arthroscopically through three tiny ½ inch incisions with special instrumentation. Surgery does allow an individual to return to his previous level of sporting activity after rehabilitation. It is best to be evaluated by an orthopedic surgeon early for this condition as recent studies have shown better success with timely intervention.
SHOULDER PAIN (PART 3)
The Rotator Cuff consists of four muscles and their associated tendons that envelop the upper arm like an upside down shoebox. These important muscles are responsible for all the movements of the upper arm and shoulder. They aid in raising your arm to comb your hair, scratching your mid-back, swinging a golf club, carrying a suitcase and throwing a ball overhand.
Rotator Cuff Injuries can result from several sources. In younger individuals, they usually are the result of a traumatic fall. In middle age individuals, they often result from repeated overuse and end-stage impingement syndrome. In the elderly, they usually result from attrition and thinning of the rotator cuff over time. Small partial tears can cause bleeding and deposits of calcium within the tendon.
Pain and weakness with shoulder use are the primary symptoms. One of the hallmarks of rotator cuff tears is pain even when lying down flat on your back. This is because without gravity the ball of the upper arm presses into the rotator cuff tear causing pain. The quality of the pain is usually sharp. Early evaluation and initiation of a treatment program is very important. Your physician will obtain a detailed history of when your shoulder hurts. He then will do a specific examination to find the location and cause of your shoulder pain. An x-ray or MRI may be ordered to evaluate your shoulder in greater detail.
Treatment initially is aimed at non-surgical treatment. The rotator cuff has the capacity to repair itself in certain situations. Resting your shoulder with a pillow between your arm and your body when sitting or lying down can help. Do not stop using your shoulder altogether as this can cause a frozen shoulder. Gentle pendulum exercises (stir the pot, bowling, rock the baby and saw wood) can keep your shoulder active while resting it at the same time. Cold and heat can sometimes help. Your physician may prescribe anti-inflammatory medications to control the pain and inflammation. A formal physical therapy program with ultrasound treatments and electrical stimulation can reduce pain levels. If the pain is severe, your physician may inject cortisone directly into the shoulder. If conservative treatment fails, surgery may be needed. Today, many rotator cuff injuries can be treated arthroscopically through three tiny incisions as same-day surgery. Talk to your doctor for more information.