Painful Shoulder

Normal AnatomyNormal Anatomy

Considerations The shoulder is the most mobile joint in the

human body. The joint includes four tendons.The purpose of a tendon is

to hold muscle to bone. Together,these four "rotator cuff" tendonsstabilize the upper arm bone to theshoulder socket and allow a widerange of motion in the shoulder.

DefinitionShoulder pain involves any pain in or around

the shoulder joint.

Any swelling, inflammation, tearing, or bony Any swelling, inflammation, tearing, or bony changes around these tendons causes pain when a changes around these tendons causes pain when a person tries to move the arm above the head, person tries to move the arm above the head, behind the back, or straight out in front.behind the back, or straight out in front.

Mechanism of the pain

Reasons beyond that painReasons beyond that painBecause of its high level of mobility, the Because of its high level of mobility, the

shoulder has heavy reliance on the muscles around shoulder has heavy reliance on the muscles around the shoulder to act as dynamic stabilisers during the shoulder to act as dynamic stabilisers during movement of the arm. Dysfunction of the stabilising movement of the arm. Dysfunction of the stabilising mechanics, either at the shoulder joint itself or around mechanics, either at the shoulder joint itself or around the shoulder blade, combined with or without the shoulder blade, combined with or without abnormalities in the anatomical arrangement of the abnormalities in the anatomical arrangement of the structures around the joint, or biomechanical faults structures around the joint, or biomechanical faults make the shoulder particularly prone to pain and make the shoulder particularly prone to pain and injury.injury.

How common are theseconditions?

Around 11 patients out every 1000 visit their GPs Around 11 patients out every 1000 visit their GPs with shoulder complaints each year.with shoulder complaints each year.

Most Common Causes:

Frozen Shoulder. (Idiopathic Adhesive Capsulitis).

Painful Arc Syndrome.

Frozen shoulder• Frozen shoulder is clinical syndrome charachterized by gross Frozen shoulder is clinical syndrome charachterized by gross

restriction of shoulder movement associated with contraction restriction of shoulder movement associated with contraction and thickening of the joint capsule.affect middle age.and thickening of the joint capsule.affect middle age.

• Also associated with severe pain disturb sleeping, Also associated with severe pain disturb sleeping,

• There is frequently history of a minor trauma lead to shoulder There is frequently history of a minor trauma lead to shoulder cuff tearing, initiating prolonged inflammatory changes and cuff tearing, initiating prolonged inflammatory changes and contraction of shoulder cuff responsible of symptoms.contraction of shoulder cuff responsible of symptoms.

• If there is no improvement with appropriate treatment for 4 If there is no improvement with appropriate treatment for 4 monthes , manipulation of the shoulder under general monthes , manipulation of the shoulder under general anasthesia.anasthesia.

Other Causes

Bursitis / Rotator Cuff TendonitisBursitis / Rotator Cuff TendonitisThe most common diagnosis in patients with shoulder pain is The most common diagnosis in patients with shoulder pain is bursitis or tendonitis of the rotator cuff. bursitis or tendonitis of the rotator cuff.

Rotator Cuff TearRotator Cuff TearRotator cuff tears occur when the tendons of the rotator cuff Rotator cuff tears occur when the tendons of the rotator cuff separate from the bone. Surgery is sometimes necessary for separate from the bone. Surgery is sometimes necessary for this condition. this condition.

Calcific TendonitisCalcific TendonitisCalcific tendonitis is a condition of calcium deposits within a Calcific tendonitis is a condition of calcium deposits within a tendon -- most commonly within the rotator cuff tendons. tendon -- most commonly within the rotator cuff tendons. Treatment of calcific tendonitis depends on the extent of Treatment of calcific tendonitis depends on the extent of symptoms. symptoms.

Shoulder InstabilityInstability is a problem that causes a loose joint. Instability can be caused by a traumatic injury (dislocation), or may be a developed condition.

Shoulder DislocationA dislocation is an injury that occurs when the top of the arm bone becomes disconnected from the scapula.

Shoulder SeparationAlso called an AC separation, these injuries are the result of a disruption of the acromioclavicular joint. This is a very different injury from a dislocation!

Labral TearA Bankart lesion is a type of labral tear most commonly due to dislocation of the joint. Bankart lesions cause problems of persistent instability.

SLAP LesionThe SLAP lesion is also a type of labral tear. The most common cause is a fall onto an outstretched hand.

ArthritisShoulder arthritis is less common than knee and hip arthritis, but when severe may require a joint replacement surgery.

Biceps Tendon RuptureA proximal biceps tendon rupture occurs when the tendon of the biceps muscle ruptures near the joint.

Referred shoulder pain • Whiplash • Fractured humerus • Ruptured bicep tendon • Disc conditions • Thoracic outlet syndrome • Ectopic pregnancy • Diaphragm irritation • Diaphragm conditions • Liver abscess • Referred gallbladder pain

Referred shoulder pain• Gallbladder conditions - usually right shoulder pain. • Gallstones • Cholangitis • Cholecystitis • Internal bleeding (see Bleeding symptoms) - often

causing shoulder-tip pain • Referred heart pain • Angina • Heart attack • Polymyalgia rheumatica

Diagnosis

Determining the source of the problem in the shoulder is Determining the source of the problem in the shoulder is essential to recommending the right method of essential to recommending the right method of treatment. treatment.

The first step is a thorough medical history. The first step is a thorough medical history.

Next, perform a physical examination including the Next, perform a physical examination including the movementsmovements

Shoulder movements

Investigation:Plain X-ray of the shoulder:Plain X-ray of the shoulder: - Antro-posterior.- Antro-posterior. - Lateral.- Lateral.CT.Scan; CT.Scan; provides a more detailed view of the shoulder area provides a more detailed view of the shoulder area

MRI and ultrasound are other valuable diagnostic tools because MRI and ultrasound are other valuable diagnostic tools because they provide images of the soft tissues without using they provide images of the soft tissues without using radiation .radiation .

Special investigations. Special investigations.

If you suspect infections :If you suspect infections :WBCWBC Blood cultureBlood cultureChest x-rayChest x-ray Aspiration of joint Aspiration of joint

EMG (electromyogram), which can indicate nerve damage EMG (electromyogram), which can indicate nerve damage

an arthrogram, an X-ray study in which dye is injected into an arthrogram, an X-ray study in which dye is injected into the shoulder to allow the orthopaedist to better see the joint the shoulder to allow the orthopaedist to better see the joint and its surrounding muscles and tendons and its surrounding muscles and tendons

Arthroscopy : is a surgical procedure in which the Arthroscopy : is a surgical procedure in which the orthopaedist looks inside the joint with a lighted telescope. orthopaedist looks inside the joint with a lighted telescope. It is sometimes used to diagnose causes of shoulder pain It is sometimes used to diagnose causes of shoulder pain and indicate soft tissue injuries that are not apparent in the and indicate soft tissue injuries that are not apparent in the physical examination, X-rays and other tests.physical examination, X-rays and other tests.

Normal Antro-posterior view

Normal Lateral View

Treatment• It depends entirely on the cause of the problem.

• Shoulder Pain Treatment Basics :Rest:– The first treatment for many common conditions is to

rest the joint, and allow the acute inflammation to subside.– Acute rotator cuff tears require immobilization in a sling.

But It is important to use caution when resting the joint, because prolonged immobilization can cause a frozen shoulder.

Ice and Heat Application: Ice packs and heat pads are among the most commonly used

treatments for shoulder pain.

Stretching: Stretching the muscles and tendons that surround the joint can help with some causes of shoulder pain.

Physical Therapy: Physical therapy is an important aspect of treatment of almost all orthopedic conditions. Physical therapists use different modalities to increase strength, regain mobility, and help return patients to their pre-injury level of activity. Some specific exercises may help you stregthen the muscles around the joint and relieve some of the pain associated with many conditions.

Treatment Medications :

Anti-Inflammatory MedicationAnti-Inflammatory Medication

Cortisone injectionsCortisone injections

Common Causes of Pain and Dysfunction of the Shoulder

• rotator cuff strains/tears • rotator cuff tendinitis • glenohumeral (shoulder joint) instability • glenohumeral dislocation/subluxation • acromioclavicular joint injury • fractures of the clavicle (collar bone), or scapula (shoulder

blade) • adhesive capsulitis (frozen shoulder) • biceps tendinitis • referred pain from the cervical or thoracic spine • referred pain from soft tissues • nerve entrapments (eg suprascapular, long thoracic) or brachial

plexus injury • levator scapula syndrome

Prevention• If you have had shoulder pain in the past, If you have had shoulder pain in the past,

use ice and ibuprofen after exercising. use ice and ibuprofen after exercising.

• Learn proper exercises to stretch and Learn proper exercises to stretch and strengthen your rotator cuff tendons and strengthen your rotator cuff tendons and shoulder muscles. A doctor or physical shoulder muscles. A doctor or physical therapist can help. therapist can help.

• If you are recovering from tendinitis, If you are recovering from tendinitis, continue to perform range-of-motion continue to perform range-of-motion exercises to avoid "frozen shoulder." exercises to avoid "frozen shoulder."

• In sports-related activities, learn proper In sports-related activities, learn proper technique to prevent painful and technique to prevent painful and expensive shoulder problems. expensive shoulder problems.

References• Clinical Orthopaedic Examination McRae• AAOS: American Academy of Orthopaedic

Surgeons• Essential orthopedics and trauma