Shoulder pain is one of the most common complaints. The shoulder region is made up of many different bones/ligaments/muscles and tendons. It is a very mobile joint and therefore it is predisposed to many different types of injuries.
Shoulder pain can be caused by an injury or it can result from overuse. A patient may experience shoulder pain only when they move the arm into certain positions, or they may have pain all the time. Shoulder pain can be either sharp or dull and ache. Patient’s may experience shoulder pain for a short period of time or for several weeks. All these different characteristics of the pain may elude to different causes.
Most shoulder pain falls into 6 major categories:
- Tendon inflammation or tear (including bursitis/tendinitis/tendinosis)
- Muscular (muscle strain/inflammation)
- Rare (cyst/tumour/infection/referred pain – nerve related)
Tendon inflammation or tear (including bursitis/tendinitis/tendinosis)
A tendon is a cord that connects muscle to bone. Most tendinitis results from wearing down of the tendon, slowly over time. Similar to the wearing process on the sole of a shoe that eventually splits from overuse.
Generally, tendinitis is one of two types:
- Acute. Excessive ball throwing or other overhead activities during work or sport can lead to acute tendinitis.
- Chronic. Degenerative diseases like arthritis or repetitive wear and tear due to age, can lead to chronic tendinitis.
The most commonly affected tendons in the shoulder are the four rotator cuff tendons and one of the biceps tendons. The rotator cuff is made up of four small muscles and their tendons that cover the head of your upper arm bone. They help keep it in the shoulder socket. The rotator cuff helps provide shoulder motion and stability.
Splitting and tearing of tendons can result from acute injury or degenerative changes in the tendons. Degenerative changes are due to advancing age, long-term overuse and wear and tear, or a sudden injury. These tears can be partial or may completely split the tendon into two pieces. Rotator cuff and biceps tendon injuries are among the most common of these injuries.
Excessive use of the shoulder can lead to inflammation and swelling of the bursa between the rotator cuff and part of the shoulder blade known as the acromion. This results in a condition known as subacromial bursitis. Bursitis can often occur in association with rotator cuff tendinitis. The tissues in the shoulder can become inflamed and painful. Certain daily activities, such as combing your hair or getting dressed, can become difficult.
Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the underlying soft tissues when the arm is lifted away from the body. When the arm is lifted, the acromion rubs, or “impinges” on, the rotator cuff tendons and bursa. This can lead to bursitis and tendinitis, causing pain and limiting movement. Over time, severe impingement can even lead to a rotator cuff tear.
Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse.
Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.
Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Recurring dislocations, which may be partial or complete, cause pain and unsteadiness when you raise your arm or move it away from your body. Repeated episodes of subluxations or dislocations lead to an increased risk of developing arthritis in the joint.
Sometimes the major muscles such as the deltoid or trapezius muscle can become acutely inflamed because of an acute strain or overuse. This can result in pain and tenderness over the muscle. Patient’s can also experience pain when they move their arm or neck in certain directions.
Shoulder pain can due to arthritis. There are many types of arthritis. The most common type of arthritis in the shoulder is osteoarthritis, also known as “wear and tear” arthritis. Arthritis can either occur in the actual shoulder joint (ball and socket joint) or the AC joint (acromioclavicular joint). Symptoms may include swelling, pain, and stiffness. Further more these symptoms typically begin during middle age. Osteoarthritis develops slowly and the pain it causes almost always worsens over time.
Osteoarthritis, may be related to sports or work injuries and chronic wear and tear. Other types of arthritis can be due to rotator cuff tears, infection, or an inflammation of the joint lining.
Patients will avoid shoulder movements in an attempt to lessen arthritis pain. This sometimes can consequently lead to a tightening or stiffening of the soft tissue parts of the joint, resulting in a painful restriction of motion.
Fractures are broken bones. Shoulder fractures commonly involve either the clavicle (collarbone), humerus (upper arm bone), or scapula (shoulder blade).
Shoulder fractures in older patients are almost always as a result of a fall from standing height. However in younger patients, shoulder fractures are often caused by a high energy injury, such as a motor vehicle accident or contact sports injury.
Fractures almost always cause severe pain, swelling, and bruising about the shoulder.
What should I do if I have Shoulder Pain?
Obviously if you have sustained a dislocation or fractured bone as a result of an acute injury, or are suffering from intense pain, then you require immediate medical attention either by calling an ambulance or presenting to your local emergency department for urgent medical attention.
Things you can do yourself
However, in the setting where the pain is less severe it may be safe to rest for a few days. The first thing is to asses if it was as a direct cause of an injury or did it come on slowly? Often the first thing to do is:
- Rest and limit activity for a short period of time
- Ice the shoulder
- Take basic analgesics such as Panadol/Neurofen
What should I do if the pain doesn’t settle down?
If the pain fails to settle down after a few days then you may need to present to your local doctor or a Sports Doctor for further assessment.
First of all you require a thorough medical history. Your doctor may ask how and when the pain started, whether it has occurred before and how it was treated, and other questions to help determine both your general health and the possible causes of your shoulder problem. Because most shoulder conditions are aggravated by specific activities, and relieved by specific activities, a medical history is especially relevant in finding the source of your pain.
A comprehensive examination is almost always required to find the causes of your shoulder pain. Your doctor will therefore look for physical abnormalities, swelling, deformity or muscle weakness, and check for tender areas. He or she will observe your shoulder range of motion and strength.
What tests may I need?
Your doctor may order specific tests to help identify the cause of your pain and any other problems.
X-rays. These pictures will show any injuries to the bones that make up your shoulder joint.
Magnetic resonance imaging (MRI) and ultrasound. These imaging studies create better pictures of soft tissues. It may help your doctor identify injuries to the ligaments and tendons surrounding your shoulder joint.
Computed tomography (CT) scan. This tool combines x-rays with computer technology to produce a very detailed view of the bones in the shoulder area.
Electrical studies. Your doctor may order a tests, such as the EMG (electromyogram), to evaluate nerve function.
Arthrogram. During this x-ray study, dye is injected into the shoulder to better show the joint and its surrounding muscles and tendons.
Treatment of shoulder pain
Often, most causes of shoulder pain can be identified and treated non-operatively through:
- Targeted physiotherapy/exercise program
- Basic analgesics
- Identification of causing agent and activity modification/change
- Shockwave therapy
- Cortisone injection
- Platelet Rich Plasma Injection (PRP)
In the rare event that these measures fail to settle the shoulder pain. Or if the cause of the pain is as a result of acute injury which may have caused tendon rupture, dislocation or impingement (that fails to settle with rest and activity modification) then surgery may be the only option.
In this surgical procedure, the surgeon looks inside the joint with a camera. Arthroscopy may show soft tissue injuries that are not apparent from the physical examination, x-rays, and other tests. In addition to helping find the cause of pain, arthroscopy may be used to correct the problem.
To obtain more information or to make an appointment to see a Sports Doctor please call 3831 8888.