Diagnosing Shoulder Pain
Many patients come to see us complaining of Rotator Cuff Tears, and often discover that this is not the actual cause of their pain. There are several etiologies to shoulder pain: Adhesive Capsulitis (frozen shoulder), Subacromial Bursitis, Supraspinatus Tendonitis, Glenohumeral Instability, Chondrocalcinosis, Osteoarthritis, Gout, Lyme Arthritis, Bicipital Tendonitis, and Ganglion Cysts are but a few possible causes of shoulder pain. It is best to keep in mind the cause of pain and age in making generalizations for diagnosing shoulder pain.
Cause of Injury/Pain
Diagnosing Shoulder Problems
To diagnose shoulder pain, consider the the factors above along with the patient’s history and a comprehensive shoulder exam. There are over 50 different tests that can be done on the shoulder by the examining physician alone, without the use of x-rays, MRI’s, or arthrograms. Imaging tests may be used to confirm clinical suspicions, or to aid in the diagnosis of especially difficult conditions. Many of the problems that cause shoulder pain are treated in a non-operative manner with medication, rest, ice, and physical therapy supplemented with cortisone injections on occasion. If an operation is needed, most conditions can be treated using arthroscopic techniques, with limited incisions.
Initiating early treatment for shoulder pain 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: Impingement Syndrome
If you’ve developed shoulder pain that is worse when raising your arm, you may have impingement syndrome. Impingement syndrome usually has an insidious onset, often associated with an activity that hasn’t been done for a while, such as turning over garden soil or throwing a ball. Pain with overhead activities, shoulder stiffness, or dull pain even when not using the shoulder are the most common symptoms.
The muscles and tendons around the shoulder allow it to move in a variety of directions, including lifting, swinging, pushing, pulling, and reaching. As you raise your arm overhead, the narrow space in your shoulder called the subacromial bursa gets compressed. The bursa normally functions as a fluid filled sac that allows tendons to glide on each other without rubbing. With overuse, this bursa swells to 3x its’ normal size and presses on the tendons & muscles in the shoulder, causing inflammation. 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 with heat to relax the muscles & speed your recovery. Your physician may prescribe non-steroidal anti-inflammatory drugs (NSAIDs). Do not stop moving your shoulder completely, or a “frozen shoulder” will develop. The 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: Shoulder Instability
In this next section, 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 shoulder instability. Starting sports without an adequate training & conditioning program, or excessive weight while weight-training can lead to shoulder instability. Some people may be genetically prone to loose joints, or “double-jointed”, which is also a risk factor for instability.
Instability is different from Impingement Syndrome, 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 sharp pain. Occasionally the entire arm may “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 them to instability and elevates their risk of further dislocations. Traditionally, gymnasts, 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 are responsible for movement. Formal Physical Therapy is utilized to aid in the program. A special elastic band called TheraBand is often used for strengthening.
Gradually, strength is increased while maintaining the shoulder within the socket. Ice can be used to reduce inflammation and relieve pain, followed by heat to relax aching muscles and increase blood flow to the shoulder. Over-the-counter pain relievers such as Aspirin, Tylenol, ibuprofen or Naproxen can be used to 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 3 half-inch incisions using special instrumentation. Surgery does allow an individual to return to their previous level of sporting activity after rehabilitation. It is best to be evaluated by an orthopedic surgeon early, as recent studies have shown better success rates with timely intervention.
SHOULDER PAIN: Rotator Cuff Tears & Injuries
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 of 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 also be an issue, as they cause bleeding and the formation of calcium deposits 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 caused by the lack of gravity forcing the ball of the upper arm into the rotator cuff tear, causing pain. The pain is usually sharp. Early evaluation and initiation of a treatment program is very important. Your physician will obtain a detailed history of your shoulder pain. They will then 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 is initially aimed at non-surgical interventions. The rotator cuff has the capacity to repair itself, in certain situations. Resting the shoulder with a pillow between the arm and 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 as described above (stir the pot, bowling, rock the baby and saw wood) can keep your shoulder active while resting it at the same time. Icing 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 also help 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 as an outpatient surgery. Talk to your doctor for more information.