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One Mercado Street, Suite 202 Durango, CO 81301 Phone: 970.247.5362 Toll Free: 800.524.9821 Fax: 970.259.6045 |
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Anatomy | Causes and treatments for shoulder pain What hurts? - Shoulder Shoulder Quick Links: The shoulder is made up of three bones—the scapula (shoulder blade), the humerus (arm bone), and the clavicle (collar bone). There are three different joints that make up the shoulder as well—the glenohumeral joint and the acromioclavicular joint are the main two, while the third is the sternoclavicular joint. The glenohumeral joint is the main shoulder joint. There are several muscles around the shoulder that help with the motion and help to provide stability to the shoulder joint. Probably the most important set of muscles is the rotator cuff. These muscles connect the shoulder blade to the humerus. The shoulder can be described as several joints that combine with tendons and muscles to allow a full range of motion to the arm, from scratching your back to throwing the perfect pitch. Mobility may come with a price, however. The shoulder movement can lead to increasing problems with instability or impingement of soft tissue resulting in pain. Pain may be felt only when the shoulder is moved, or all of the time. The pain may be acute and disappear in a short time, or it may continue and require medical diagnosis and treatment. Common Causes and Treatments of Shoulder Pain Many causes of shoulder pain are problems related to the soft tissue rather than the bones. The majority of these problems fall into three major categories:
Other much more rare causes of shoulder pain are tumors, infection and nerve-related problems. Impingement is one of the most common causes of pain in the shoulder. It may be due to “bursitis” or “tendonitis”. It occurs from pressure on the rotator cuff muscles from the acromion when the shoulder is lifted. The rotator cuff muscles sit between the head of the humerus and the acromion. They attach the shoulder blade to the humerus and help to lift the arm overhead. Unfortunately these muscles can get pinched between these two bones, causing pain. The pain is especially bad with overhead activities and often at night. There is a small sac of fluid that lies between the muscles and the acromion called the bursa. The pain from impingement can be due to inflammation in the bursa-bursitis-or in the tendons-tendonitis. [Top] Tendonitis A tendon is a cord which connects muscle to bone or other tissue. Similar to the wearing process on the sole of a shoe which eventually splits from overuse, most tendonitis is a result of the wearing process that takes place over a period of years. Typically, Tendonitis is one of several types:
When you come in to discuss your pain with your orthopedic surgeon, you will talk about the history of your symptoms and a complete physical exam will be done. X-rays will also be obtained. They may show a hook, or spur, on the undersurface of the acromion, as shown on the x-ray to the left below, vs. the more normal, flat acromion seen below on the right. An MRI may even be done at some point.
Treatment Usually treatment starts with nonsurgical options including rest, avoidance of aggravating activities, anti-inflammatories such as Naprosyn or Ibuprofen, home exercises or physical therapy. Sometimes a steroid injection will be discussed. If these nonsurgical options fail to give you good relief, then surgery may be an option and can be discussed with your surgeon. [Top] Rotator Cuff - Tendon Tears Muscle is connected to the bone via a tendon and sometimes that tendon can be torn away from the bone or torn in half. These tendons are pulled or torn because they are overloaded and stretched beyond their normal capacity; often times with a sudden quick load. It can also occur when one becomes inflexible, when there is muscle in balance, such as one group of muscle is stronger than the opposing muscle, or if the muscles are poorly conditioned, and from chronic wear or tendonitis over several years. Symptoms and Diagnosis: The patient’s symptoms may include pain and weakness with lifting the arm, thinning of the muscles around the shoulder, and even crackling of the shoulder as it is moved. If you have these symptoms after an acute injury or if they have developed over time, you should see an orthopedic surgeon. The surgeon will get a good history and perform a physical exam. They will generally get x-rays, which often are normal or show small changes, and may order an MRI as well. The MRI can show a partial or complete tear in the tendon.
Treatment Nonsurgical treatment can provide pain relief and improved function for some patients. These options include rest, ice, anti-inflammatories such as Naprosyn, Ibuprofen, etc,, Steroid injections, and therapy. Depending on the patient’s age and the chronicity of the tear, surgical treatment is necessary to repair a torn tendon or a tendon that has pulled away from the bone. If the torn tendon is not repaired the shoulder function will deteriorate with time and the patient will lose range of motion and may develop arthritis. Unfortunately, if the tear has already been present, but undiagnosed, for a long period of time, the tear may not be repairable. Often times, in these circumstances cortisone injections and/or physical therapy may help control the patient’s symptoms. The surgery is usually done as an outpatient surgery and can be done arthroscopically, mini-open, or open fashion. Your surgeon will discuss these options with you and will help you determine which option is best for you. It takes at least 6 months to return to full activities after a rotator cuff is repaired. [Top] Shoulder Separations These occur when the two bones at the acromioclavicular (AC) joint, the clavicle and the acromion, don’t line up correctly. These usually result from a fall directly onto the shoulder which disrupts the ligaments on the undersurface of the clavicle. These ligaments hold the clavicle in place. The force of the fall determines the significance of the injury. The harder the fall means that more damage to the ligaments occurs and there is more deformity. The mild injuries generally require a sling for 5-10 days and then the patient may start using their arm as they can tolerate. If the bones are significantly separated, surgery may be needed and should be discussed with your orthopedic surgeon.
The picture on the left shows a normal shoulder with the AC joint circled. The picture on the right shows a grade 3 AC separation. Shoulder Dislocations A dislocation occurs when the ball of the humerus falls out of the socket. It can occur in any direction, but the most common is anteriorly and happens when the arm is overhead and forcefully pushed outward. Treatment Young patients have a very high likelihood of redislocating their shoulders. Once you get into your mid and later 30’s the chance of recurrent dislocations begins to decrease. The sling is maintained for everyone for several days, but your doctor will encourage elbow and some shoulder range of motion exercises. They will also discuss formal physical therapy with you to help regain your range of motion and eventually you will begin strengthening exercises. For some young patients, after their first dislocation, and for those that have recurrent dislocations, your doctor may talk to you about surgery to repair or tighten the torn ligaments of your shoulder. This helps to restabilize your shoulder and can often be done arthroscopically today. Sometimes it still requires a full incision.
In the left hand picture, the ball of the shoulder is not sitting in the socket, meaning the shoulder joint is dislocated. Compare this to the picture on the right, where the shoulder is NOT dislocated, and the ball and socket line up normally. Fractures Clavicle (collarbone) fractures are very common shoulder injuries and result from a fall onto the shoulder. Patients may complain of a bump and pain about their shoulder. They may feel the bone ends moving when they attempt to move their arm and movement will likely be very painful. They will also have swelling and bruising. Your doctor will ask you questions about your injury and symptoms and perform a physical examination. An x-ray will be needed to fully evaluate the fracture. This will help the doctor determine if the fracture can be treated without surgery. If this is the case, the patient is generally placed in a sling and given pain medications. The patient is instructed to come out of the sling several times a day to work on elbow and wrist range of motion from the beginning. As the pain in the shoulder decreases in 10-14 days the patient is encouraged to start gentle and progressive shoulder motion as well. Sometimes formal therapy is required. If the fracture is significantly displaced, your doctor may discuss surgical options with you. This usually requires and incision and realignment of the bones that are then stabilized with a plate and screws.
There are several different types of fractures that can occur about the shoulder. These should be evaluated and treated by your orthopedic surgeon. [Top] There are many types of arthritis: osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis are probably the most common types. Osteoarthritis is the most common type of arthritis in the shoulder. It is generally a slow progressive type of arthritis that is often present as we age and is commonly thought of “wear and tear” arthritis. There may be a genetic predisposition, but workload, activity, and prior injury all play a role in the development of osteoarthritis. It occurs as the cartilage on the ends of the bones starts to wear out and get thin. Eventually, the cartilage wears out completely and the humerus rubs on the socket bone. Post-traumatic arthritis is very similar to osteoarthritis and results from a prior injury to the shoulder such as torn ligaments or cartilage, or a fracture involving the joint. Rheumatoid arthritis is an inflammatory arthritis that is usually an autoimmune disease that destroys the cartilage in many joints in the body. It can be often treated/controlled with medication for a period of time. Causes When the cartilage deteriorates, there are no more smooth surfaces to rub on each other during motion. The cushioning effect is also lost, which leads to two bones rubbing on one another. While bone is well suited to weight bearing, it does not work well as a surface through which motion occurs. It’s analogous to the rim of a wheel being well-suited to the loads of a car provided it’s surfaced with a tire. Without the tire, the rim does not function well. At any rate, in the absence of cartilage, the joint undergoes a cascade of events including the release of chemicals and cells within the joint, disruption of normal joint fluid content, formation of bone spurs, development of cysts within the bones, and even the formation of loose bits of bone floating loose within the joint (loose bodies). These abnormalities are likely the causes of the pain associated with arthritis. Symptoms Patients usually complain of a deep achy pain, sometimes it may be localized to only one part of the shoulder joint, but it may also involve the entire joint. It starts slowly, generally with increased activity, and progresses over the years to pain that may even occur at rest and may keep patients from sleeping. In the early stages it limits vigorous activity, but eventually may limit every day activities such as washing one’s hair, brushing one’s teeth, or getting dressed. In addition to pain, patients may complain of catching or locking of their shoulder. In addition to discussing your symptoms, the doctor will do a physical exam and get x-rays. X-rays are very useful and show the loss of space between the bones that occurs as the arthritis worsens. MRI’s are usually not needed for the diagnosis of arthritis. Nonsurgical Treatment Most of the time the first treatments for arthritis do not include surgery. Often times the early treatments include activity modification, such as ride a bike, swim, or walk instead of run, and other activities that do not hurt. Exercises including strengthening and stretching and maybe even physical therapy may be helpful. Weight loss, if needed, can be very helpful for some patients. Other alternative therapies that may or may not help your symptoms include acupuncture, massage, herbalism, and magnetic therapy. The success of these treatments is usually short-lived in our experience and, while the number of such options available to patients is great, the research supporting their use as a cure is weak. Often times ice and over the counter medications such as Tylenol, ibuprofen and naprosyn are helpful during this time and can allow patients to remain active. Other prescription anti-inflammatory medications may also be prescribed, for example Celebrex or Relafen. Another over the counter medication that is very helpful to some patients, and completely not helpful to others, is glucosamine and chondroitin. These are oral supplements and the two molecules are found in normal cartilage. Rather than building new cartilage, they may act to decrease the swelling and thus reduce the pain, again, only in some patients. They may interact with your other medications, so make sure to check with your doctor or pharmacist to make sure it is ok to take if you are on other medications. Some side effects include nausea, vomiting, and headaches. Another thing your doctor may recommend is an injection of “cortisone”. Cortisone has some anti-inflammatory affect and may help to decrease the pain. They help some patients, sometimes for several months, but they don’t help everyone. A cortisone shot is a one shot deal that can be repeated a few times a year. Despite all these nonsurgical options, none of them actually treats the underlying cause of the arthritis, the loss of cartilage, and therefore the patient eventually may want and need surgery. A discussion with your doctor can help determine which, if any, of these treatments is best for you. Surgical Treatment Eventually, activity modification and the above methods of treatment will no longer provide adequate pain relief, and you and your doctor will discuss surgery. Depending on the extent of your arthritis, the entire joint may be replaced and can be discussed with your surgeon.
More information may be obtained on any of these subjects at the American Academy of Orthopedic Surgeons website under patient information. Go to http://aaos.org/ and choose patient information on your left. [Top] Quick navigation links: Sitemap | Home | Patient Rights | About Durango Orthopedics in Colorado | Physician Bios | Locations in Colorado and New Mexico: Durango, Pagosa Springs, Aztec, New Mexico | Hip Pain | Knee Pain | Shoulder Pain | Arm & Hand Pain | Foot & Ankle Pain | Anatomy Library | Medical Animations | Exercise Library | Prevention | Appointments | Patient Testimonials | Billing & Insurance | Patient Forms | Emergency Disclaimer: The pictures displayed in www.durangoorthopedics.com are images of actual patients and employees who have consented to have their picture in this website.
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Generally, the first time someone dislocates their arm, they have to go to the emergency room to have it “put back in place”. Sometimes this requires sedation. Once the shoulder is reduced back into its normal position the pain is markedly improved. The arm is placed in a sling and it is recommended that you follow up with an orthopedic surgeon. A complete history of the injury, your symptoms, and a physical exam will be done. X-rays and an MRI may also be done if needed. Depending on your age and activity level the orthopedic doctor will talk to you about different treatment options.
