Shoulder Pain

BASIC SHOULDER ANATOMY

The shoulder joint is made of up two primary bones, the humerus and the scapula also known as the shoulder blade, These two bones make up what is called the gleno-humeral joint. The humerous has a smooth covering called articular cartilage that allows the bone to fit into the glenoid of the scapula; this allows the joint to move smoothly. The scapula has to major sites of muscle attachment that are called the acromion, and the coracoid process.

The “ball and socket” joint is a very mobile joint, and not a very stable joint. The shoulder joint has a ring of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move within. The labrum circles the shallow shoulder socket (the glenoid) to make the socket 50% deeper. This cuff of cartilage makes the shoulder joint much more stable, and allows for a very wide range of movements.

The labrum it serves as an attachment site for several ligaments and is part of the joint capsule, covering the shoulder joint, that is comprised of the ligaments that connect the bones of the shoulder, and tendons join the bones to surrounding muscles. The biceps tendon attaches the biceps muscle to the shoulder and helps to stabilize the joint.

Four small muscles originate on the scapula and pass around the shoulder where their tendons fuse together to form the rotator cuff. (Supraspinatus, Infraspinatus, Teres minor, and supscapularis muscles) The rotator cuff is a dynamic stabilizer of the shoulder joint and helps to depress the humeral head.

The numerous structures in the shoulder, along with the muscles of your upper body, work together to manage the stress your shoulder receives as you extend, flex, lift, reach and throw.

ROTATOR CUFF PATHOLOGIES

INFORMATION

As shown above, the rotator cuff is the name for the muscles/tendons that surround the shoulder joint. The rotator cuff is important in allowing the shoulder to function through a wide range of motions. In part due to the rotator cuff, the shoulder joint can move and turn through a wider range than any other joint in the body. This motion of the shoulder joint allows us to perform an amazing variety of tasks with our arms. The rotator cuff is part of this mechanism that, when healthy functions very well, but when injured can be a difficult and frustrating problem.

ROTATOR CUFF TEARS AND INJURY

In rotator cuff injuries, the most common complaint is aching located in the top and front of the shoulder, or on the outer side of the upper arm (deltoid area). The pain is usually increased when the arm is lifted to the overhead position. Frequently, the pain seems to be worse at night, and often interrupts sleep.

A rotator cuff tear occurs when there is an injury to one of the rotator cuff tendons. Rotator cuff tears occur in many shapes and sizes, but can be thought of as a hole in one of the tendons around the shoulder joint. Like most orthopedic conditions, the most common mechanisms of a rotator cuff tear are separated into ‘repetitive use’ and ‘traumatic injuries.’ Supraspinatus is the most commonly involved tendon in a rotator cuff injury

Depending on the severity of the injury, there may also be weakness in the arm and, with some complete rotator cuff tears, the arm cannot be lifted in the forward or outward direction at all. Rotator cuff tears are a common cause of shoulder pain and dysfunction, accounting for approximately 50% of significant shoulder injuries, research shows that 25% of tears are symptomatic to the individual.

SURGICAL TREATMENT

When the tendon of the rotator cuff has a complete tear, the tendon often must be repaired using surgical techniques. The choice of surgery, of course, depends on the severity of the symptoms, the health of the patient, and the functional requirements for that shoulder. In young working individuals, repair of the tendon is most often suggested. In some older individuals who do not require significant overhead lifting ability, surgical repair may not be as important, and the patient will be treated conservatively with physical therapy (see PHYSICAL THERAPY below). If chronic pain and disability are present at any age, consideration for repair of the rotator cuff should be given. In a minor operation for impingement, the shoulder is placed in a simple sling. If a full thickness tear of the rotator cuff was present and repaired, then the shoulder will be supported by an postoperative brace.

PHYSICAL THERAPY & POST OPERATIVE CARE

The brace is very helpful because it places the arm in a position that promotes better blood circulation and relieves stress on the repaired rotator cuff tissues. Physical therapy is prescribed after surgery with a program that will allow a period of time for healing of the soft tissues followed by time to regain range of motion and then strengthen the shoulder muscles, but particularly the rotator cuff. If the rotator cuff tendon has been completely torn, it may take six months or more before the atrophied muscles can resume their function and the range of motion of the arm is restored. Frequently, pain relief is much quicker and return to daily activities is often possible by two to three months. Consistent treatment by a physical therapist is most beneficial due to specific post surgical protocols that will help the patient to return to full function at the appropriate time without re-injury to the surgical correction. Again, every case is unique, as the injury becomes more severe, such as with a large bone spur and fragmentation of the tendon, then a perfect result cannot be expected. Since it is necessary to trim back the unhealthy tendon before reattaching it to the bone, a decreased range of motion of the shoulder will often result. Despite this, pain relief and return of strength are usually well worth the minor decreased mobility. The final outcome often depends on the willingness and ability of an individual patient to work on their postoperative physical therapy program.

FROZEN SHOULDER

INFORMATION & INJURY

Frozen shoulder, or adhesive capsulitis, is a condition that causes restriction of motion in the shoulder joint. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. The pain is usually located over the outer shoulder area and sometimes the upper arm. The affected individual cannot move the shoulder normally. Motion is also limited when someone else attempts to move the shoulder for the patient.

The cause of a frozen shoulder is not well understood, but it often occurs for no known reason. Frozen shoulder causes the capsule surrounding the shoulder joint to contract and form scar tissue or adhesions, therefore preventing active motion and cause movement to become painful.

Some risk factors for developing a frozen shoulder include:

• Age & Gender

Frozen shoulder most commonly affects patients between the ages of 40 to 60 years old, and it is twice as common in women than in men.

• Endocrine Disorders
  Patients with diabetes or thyroid problems are at particular risk for developing a frozen shoulder.
• Shoulder Trauma or Surgery
  Patients who sustain a shoulder injury, or undergo surgery on the shoulder can develop a frozen shoulder joint. When injury or surgery is followed by prolonged joint immobilization, the risk of developing a frozen shoulder is highest.
• Other Systemic Conditions
  Several systemic conditions such as heart disease and Parkinson’s disease have also been associated with an increased risk for developing a frozen shoulder.

PHYSICAL THERAPY TREATMENT

The normal course of a frozen shoulder as having three stages:

• Stage one: In the “freezing” stage, the patient develops a slow onset of pain. As the pain worsens, the shoulder loses motion. This stage may last from six weeks to nine months.
• Stage two: The “frozen” stage is marked by a slow improvement in pain, but the stiffness remains. This stage generally lasts four months to nine months.
• Stage three: The final stage is the “thawing,” during which shoulder motion slowly returns toward normal. This generally lasts five months to 26 months.

Physical therapy is used to restore motion. This may be under the direct supervision of a physical therapist and a home program. Therapy includes stretching or range-of-motion exercises for the shoulder. Sometimes, heat is used to help decrease pain. Examples of some of the exercises that might be recommended can be seen in the following figures.

More than 90 percent of patients improve with these relatively simple treatments. Usually, the pain resolves and motion improves. However, in some cases, even after several years the motion does not return completely and a small amount of stiffness remains. If conservative treatment is not successful, surgical intervention is aimed at stretching or releasing the contracted joint capsule of the shoulder. The most common methods include manipulation under anesthesia and shoulder arthroscopy.

LABRAL TEARS

INFORMATION

The labrum is made of a thick tissue that is susceptible to injury with trauma to the shoulder joint. When a patient sustains a shoulder injury, it is possible that the patient has a labral tear. The labrum also becomes more brittle with age, and can fray and tear as part of the aging process. Injuries to the labrum can occur from acute trauma or repetitive shoulder motion. Examples of traumatic injury include:

• Falling on an outstretched arm
• A direct blow to the shoulder
• A sudden pull, such as when trying to lift a heavy object
• A violent overhead reach, such as when trying to stop a fall or slide

Symptoms of a labral tear depend on where the tear is located, but may include:

• Pain with specific activities Pain, usually with overhead activities
• Catching, locking, popping, or grinding
• Occasional night pain or pain with daily activities
• A sense of instability in the shoulder
• Decreased range of motion
• Loss of strength

The most common patterns of labral tears are:

• A SLAP tear is a type of labral tear most commonly seen in overhead throwing athletes such as baseball players and tennis players. The torn labrum seen in a SLAP tear is at the top of the shoulder socket where the biceps tendon attaches to the shoulder.
• A Bankart lesion is a labral tear that occurs when a shoulder dislocates. When the shoulder comes out of joint, the labrum is torn, and makes the shoulder more susceptible to future dislocations.
• Posterior labral tears are less common, but sometimes seen in athletes in a condition called internal impingement. In this syndrome, the rotator cuff and labrum are pinched together in the back of the shoulder.

TREATMENT (SURGICAL & NON-SURGICAL)

The treatment of a torn labrum depends on the type of tear that has occurred. Doctors and physical therapists who deal with people who have labral tears can help outline an individualized treatment program. Physical therapy exercises are used to reach full motion of the joint and to strengthen the rotator cuff muscles and to improve the stability of the shoulder and scapular stabilizers. If these conservative measures are insufficient, your physician may recommend arthroscopic surgery. Most labral tears do not require surgery; however, in patients who have persistent symptoms despite more conservative treatments, surgery may be necessary.

PHYSICAL THERAPY & POST OPERATIVE CARE

After surgery, you will need to keep your shoulder in a sling for 3 to 4 weeks. Physical therapy will be prescribed in order to work on gentle, passive, pain-free range-of-motion exercises. Once the sling is removed, the exercises in physical therapy will progress to gradually start to strengthen your biceps, rotator cuff muscles, and other spacular stabliziers. Generally it will be 3 to 4 months before the shoulder is fully healed and the patient will be returned to full function.

IMPINGEMENT SYNDROME & TENDONITIS

INFORMATION

Impingement is one of the most common causes of pain in the adult shoulder. Impingement commonly causes local swelling and tenderness in the front of the shoulder. It results from pressure on the rotator cuff from part of the shoulder blade (scapula) as the arm is lifted. The uppermost tendon of the rotator cuff, the supraspinatus tendon, passes beneath the bone on the top of the shoulder, called the acromion. In some individuals, the space between the of the acromion and the top of the humeral head is quite narrow. The rotator cuff tendon and the lubricating tissue, can be pinched when the arm is raised into a forward position. With repetitive impingement, the tendons and bursa can become inflamed and swollen and cause the painful situation known as “chronic impingement syndrome.” When the rotator cuff tendon and its overlying bursa become inflamed and swollen with impingement syndrome, the tendon may begin to break down near its attachment on the humerus bone. With continued impingement, the tendon is progressively damaged, and finally, may tear completely away from the bone.

Impingement is common in both young athletes and middle-aged people. Those who do repetitive lifting or overhead activities using the arm along with young athletes who use their arms overhead for swimming, baseball, and tennis are particularly vulnerable. Pain may also develop as the result of minor trauma or spontaneously with no apparent cause.

Beginning symptoms may be mild. Patients frequently do not seek treatment at an early stage.

• Minor pain that is present both with activity and at rest
• Pain radiating from the front of the shoulder to the side of the arm
• Sudden pain with lifting and reaching movements
• Athletes in overhead sports may have pain when throwing or serving a tennis ball

There may be pain and stiffness when the arm is lifted. There may also be pain when the arm is lowered from an elevated position. As the problem progresses, there may be pain at night. Strength and motion may be lost. In advanced cases, loss of motion may progress to a “frozen shoulder.” In acute bursitis, the shoulder may be severely tender. All movement may be limited and painful.

TREATMENT (SURGICAL & NON-SURGICAL)

Initial treatment is nonsurgical. The doctor may suggest rest and avoiding overhead activities. Along with physical therapy care involving stretching exercises to improve range of motion in a stiff shoulder will also help. Treatment may take several weeks. Many patients experience a gradual improvement and return to function.

When nonsurgical treatment does not relieve pain, the doctor may recommend surgery. The goal of surgery is to remove the impingement and create more space for the rotator cuff. This allows the humeral head to move freely in the subacromial space and to lift the arm without pain. The most common surgical treatment is subacromial decompression or anterior acromioplasty.

PHYSICAL THERAPY & POST OPERATIVE CARE

After surgery, the arm may be placed in a sling for a short period of time. This allows for early healing. As soon as comfort allows, the sling may be removed to begin exercise and use of the arm. The surgeon will provide an exercise program based on the patient’s needs and the findings at surgery. Physical therapy care in order to exercise the shoulder appropriately to regain range of motion of the shoulder and strength of the arm. It typically takes two to four months to achieve complete relief of pain.

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