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 Shoulder Pain 

Anatomy

The shoulder joint has three bones: the shoulder blade (scapula), the collarbone (clavicle), and the upper arm bone (humerus). The head of the upper arm bone (humeral head) rests in a shallow (cup)socket in the shoulder blade called the glenoid. The head of the upper arm bone is usually much larger than the socket, and a soft fibrous tissue rim called the labrum surrounds the socket to help stabilize the joint. The rim deepens the glenoid(cup) by up to 50% so that the head of the upper arm bone fits better. In addition, it serves as an attachment site for several ligaments and tendons.

Risk Factors/Prevention

Injuries to the tissue rim surrounding the shoulder socket can occur from simple incedence acute trauma or repetitive shoulder motion (as seen in atheletes eg:swimmers,throwing games)

 Examples of traumatic injury include:

  • Falling on an outstretched hand
  • A direct blow to the point of 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 or in road traffic accident.

Throwing athletes or weightlifters can experience glenoid labrum tears as a result of repetitive shoulder motion.

Clinical features

The symptoms of a tear in the shoulder socket rim are very similar to those of other shoulder injuries. Symptoms include

  • Pain, usually with overhead activities (above shoulder level)
  • Catching, locking,clicking, popping, or grinding
  • Occasional night pain or pain in day to day activities
  • A sense of instability in the shoulder
  • Decreased range of motion
  • Loss of strength
  • Lack of confidence in shoulder

Diagnosis

If a person is experiencing shoulder pain, his/her doctor will take a history of the injury. He/she may be able to remember a specific incident or you may note that the pain gradually increased. The doctor will do several physical tests to check range of motion, stability,power, and pain. In addition, the doctor will intially request x-rays to see if there are any other reasons for your problems.

Because the rim of the shoulder socket is soft tissue, x-rays will not show damage to it. The doctor may order a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan. In both instances, a contrast medium may be injected to help detect tears. Ultimately, however, the diagnosis will be made on findings of clinical examination and arthroscopic surgery.

Tears can be located either above (superior) or below (inferior) the mid point of the glenoid socket.

A SLAP lesion (superior labrum, anterior [front] to posterior [back]) is a tear of the rim above the middle of the socket that may also involve the biceps tendon.

 The tear of the glenoid rim often occur with other shoulder injuries, such as a dislocated shoulder (full or partial dislocation).

Treatment

Until the final diagnosis is made, your physician may prescribe medication to reduce pain & swelling and rest to relieve symptoms.

Rehabilitation exercises to strengthen the rotator cuff muscles will also be demonstrated by a physiotherapist. If these conservative measures are insufficient,  physician may recommend arthroscopic surgery.

During arthroscopic surgery, the examination of the rim and the biceps tendon will be done. If the injury is confined to the rim itself, without involving the tendon, the shoulder is still stable. The surgeon remove the torn flap and correct any other associated problems. If the tear extends into the biceps tendon or if the tendon is detached, the shoulder is unstable. The surgeon will need to repair and reattach the tendon using tacks,or sutures anchors of various types.

Tears below the middle of the socket are also associated with shoulder instability. The surgeon will reattach the ligament and tighten the shoulder socket by folding over and "pleating" the tissues called shoulder stabilization.(please see recurrent dislocation of shoulder)

Rehabilitation

After surgery, patient  need to keep his/her shoulder in a sling for 3 to 4 weeks. Physiotherapist will also demonstrate gentle, passive, pain-free range-of-motion exercises.After 4-6 weeks the sling is removed, patient will need to do range of motion and flexibility exercises and gradually start to strengthen biceps. Athletes can usually begin doing sport-specific exercises at 6 weeks after surgery, although it will be 3 to 4 months before the shoulder is fully healed.

Rotator Cuff Tears

The rotator cuff consist of four muscles and several tendons that form a covering hood around the top of the upper arm bone (humerus). These muscles form a hood around the head of the humerus. The rotator cuff holds the humerus in place in the shoulder joint by leavering the head down within the socket when you lift your hand above shoulder level and enables the arm to rotate.

Rotator cuff tear is a common cause of pain and disability among adults. Most tears occur in the supraspinatus muscle, but other parts of the cuff may be involved.

Anatomy

The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint. The rotator cuff is constitutes of four muscles and their tendons. These combine to form a " cuff " over the upper end of the arm (head of the humerus). The rotator cuff covers the head of the humerus and stabilizes the shoulder joint.The four muscles of the cuff (supraspinatus, infraspinatus, subscapularis, and teres minor muscles) are attached to the shoulder blade(scapula) on the back through a single tendon unit. The unit is attached on the side and front of the shoulder on the greater & lessor tuberosity of the humerus.

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Cause

The  tear could be either be partial or complete.The partial tear could be on the top or under surface if the rotator cuff muscle

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A tear can occur within the muscle

The rotator cuff can be torn from a single episode of injury. Patients often report recurrent shoulder pain for several months and a specific injury that triggered the onset of the pain. A cuff tear may also happen at the same time as another injury to the shoulder, such as a fracture or dislocation.

Most tears, however, are the result of repetitive overuse of these muscles and tendons over a period of years. People who are especially at risk for overuse are those who engage in repetitive overhead motions. These include participants in sports such as baseball, tennis, weight lifting, and rowing, javelin throw, wrestling,cricket.

Rotator cuff tears are most common in people who are over the age of 40. Younger people tend to have rotator cuff tears following acute trauma or repetitive overhead work or sports activity.

Rotator cuff tear may often happen as a result of wear and tear specially in people of above age 55-60years

Clinical features

Some of the symptoms of a rotator cuff tear include:

  • Wasting  or thinning of the muscles about the shoulder
  • Pain when lifting the arm above shoulder level.
  • Pain when lowering the arm from a fully raised position
  • Weakness when lifting or rotating the arm
  • Crepitus or clicking sensation when moving the shoulder in certain positions
  • Some have inability to lifting the arm up

Symptoms of a rotator cuff tear may develop right away after a trauma, such as a lifting heavy weight or a fall on the affected arm. When the tear occurs with an injury, there may be sudden acute pain, a snapping sensation and an immediate weakness of the arm. Symptoms may also develop gradually with repetitive overhead activity or following long-term wear. Pain in the front of the shoulder radiates down the side of the arm. At first, the pain may be mild and only present with overhead activities, such as reaching or lifting. It may be relieved by over-the-counter medication such as paracetamol or combiflam.

Over time the pain may become noticeable at rest or without any activity at all. There may be pain when lying on the affected side and at night.

Diagnosis

Diagnosis of a rotator cuff tear is based on the symptoms and physical examination. X-rays may be helpful but imaging studies, such as MRI (magnetic resonance imaging) or ultrasound, are more specific in showing the tear.

The  doctor will examine the shoulder to see whether it is tender in any area or whether there is a deformity. He will measure the range of motion of the shoulder in several different directions(forward,backward,sideways) and will test the strength/power of the arm musculature. The doctor will also check for instability or other problems with the shoulder joint.                     

Magnetic resonance image shows a full-thickness rotator cuff tear within the tendon. The doctor may also examine the neck to make sure that the pain is not coming from a " pinched nerve " in the cervical spine and to rule out other conditions, such as osteoarthritis or rheumatoid arthritis of cervical spine.

Plain X-rays of a shoulder with a rotator cuff tear are usually normal or show a small spur. For this reason, the doctor may order an additional study, such as an ultrasound or MRI. These can better visualize soft tissue structures such as the rotator cuff tendon.

An MRI specially with contrast also called MR-Arthrogram can sometimes tell how large the tear is, as well as its location within the tendon itself or where the tendon attaches to bone.

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Nonsurgical Options

In many instances, nonsurgical treatment can provide pain relief and can improve the function of the shoulder.

Nonsurgical treatment options may include:

  • Rest and limited overhead activity
  • Use of a sling
  • Anti-inflammatory medication
  • Local injection mainly steroid &local anesthetic
  • Strengthening exercise and physical therapy

Surgical Treatment

Your orthopaedic surgeon may recommend surgery if

  • Conservative  treatment does not relieve symptoms
  • The tear has just occurred and is very painful
  • The tear is in the shoulder of the highly demand arm of an active person
  • If maximum strength in the arm is needed for overhead work or sports

The type of surgery performed depends on the size, shape, and location of the tear. A partial tear may require only a trimming or smoothing procedure, called a " debridement. "as long as sufficient tendon thickness is left behind. A complete tear within the thickest part of the tendon is repaired by suturing the two sides of the tendon back together. If the tendon is torn away from where it inserts into the bone of the arm (humerus), it is repaired directly to bone.

Most surgical repairs can be done on an outpatient basis.

In the operating room, your surgeon may remove some part of the offending hooked  portion of the scapula, the acromion as part of the procedure. The hook is thought to cause " impingement " on the tendon. This may lead to a tear. Other conditions such as arthritis of the AC joint or tearing of the biceps tendon may also be addressed.

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Left, Arthroscopic view of the rotator cuff from within the joint shows the rotator cuff (RC), the head of the humerus (HH), and the biceps tendon (B).

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Left, Arthroscopic view of rotator cuff tear. A large gap can be seen between the edge of the rotator cuff and humeral head. In general, three approaches are available for surgical repair. These surgical options are:

  • Arthroscopic Repair. A telescope and small, pencil-sized instruments are inserted through small incisions instead of a large incision. The arthroscope is connected to a television monitor and the surgeon can perform the repair under video control.
  • Mini-Open Repair. Newer techniques and instruments allow surgeons to perform a complete rotator cuff repair through a small incision, typically 4 cm to 6 cm.
  • Open Surgical Repair. A traditional open surgical incision is often required if the tear is large or complex or if additional reconstruction, such as a tendon transfer, has to be done. In some severe cases, where arthritis has developed, one option is to replace the shoulder joint. This option is very sparingly used in present time.

Rehabilitation

After surgery, the arm is immobilized to allow the tear to heal. The length of immobilization depends upon the severity of the tear. Generally 6 weeks exercise program will help regain motion and strength in the shoulder. This program begins with passive motion and advances to active and resistive exercises. Complete recovery may take several months.

  • A strong commitment to rehabilitation is important to achieve a good surgical outcome. The doctor will examine the outcome to advise when it is safe to return to overhead work and sports activity.

 

Frozen Shoulder

Frozen shoulder is characterized by pain and loss of motion or stiffness in the shoulder. Frozen shoulder most commonly affects patients between the ages of 40 and 60 years, with no clear predisposition based on sex, arm dominance, or occupation.

Cause

 

Anatomy of the shoulder, showing the ligaments and bones.The causes of frozen shoulder are not fully understood. The process involves thickening and contracture of the capsule surrounding the shoulder joint.

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Frozen shoulder occurs much more commonly in individuals with diabetes, affecting 10 percent to 20 percent of these individuals. Sometimes the onset of diabetes is accidently diagnosed after the patient is seen for pain and stiffness in shoulder. Other medical problems associated with increased risk of frozen shoulder include: hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease ,post traumatic or following a surgery.

Frozen shoulder can develop after a shoulder is immobilized for a period of time. Attempts to prevent frozen shoulder include early motion of the shoulder after it has been injured.

Clinicak features

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 hallmark of the disorder is restricted motion or stiffness in the shoulder in all direction. The affected individual cannot move the shoulder normally. Motion is also limited when someone else attempts to move the shoulder for the patient.

Some physicians have described the normal course of a frozen shoulder as having three stages:

Diagnosis

A doctor can diagnose frozen shoulder based on the patient's symptoms and a physical examination.

X-rays or MRI (magnetic resonance imaging) studies vary sometimes used to rule out other causes of shoulder stiffness and pain, such as a rotator cuff tear.  

Treatment

Frozen shoulder will generally get better on its own. However, this takes some time, occasionally up to two to three years. Treatment is aimed at pain control and restoring motion.

Nonsurgical Treatment

Pain control can be achieved with anti-inflammatory medications. These can include pills taken by mouth, such as ibuprofen, or by injection, such as corticosteroids.

 

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Physical therapy is used to restore motion. This may be under the direct supervision of a physical therapist or via 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.

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Codmans or pendulam exercise

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Shoulder extension(isometrics)

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Shoulder External Rotation(isometrics)

shoulder internal rotation

Shoulder internal rotation(isometrics)

 If these methods fail, nerve blocks are sometimes used to limit pain and allow more aggressive physical therapy.

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.

Surgical Treatment

Surgical intervention is considered when there is no improvement in pain or shoulder motion after an appropriate course of physical therapy and anti-inflammatory medications. When more invasive measures are considered, the patient must always consider that most individuals will get better if given sufficient time and that surgery always has risk involved.

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:

Manipulation under anesthesia involves putting the patient to sleep and forcing the shoulder to move. This process causes the capsule to stretch or tear in an uncontrollable fashion.

With shoulder arthroscopy, the surgeon makes several small incisions around the shoulder. A small camera and instruments are inserted through the incisions. These instruments are used to cut through the tight portions of the joint capsule and release the shoulder in a controlled fashion.

Often, manipulation and arthroscopy are used together in combination to obtain maximum results. Most patients have very good results with these procedures.

After surgery, physical therapy is important to maintain the motion that was achieved with surgery which starts immediately day 1 after the surgery has to be maintained for 6-8 weeks. Recovery time varies, from six weeks to three

 

 

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