Shoulder pain is a common ailment. The incidence of shoulder pain tends to increase with age.This pain may be caused by a number of different shoulder conditions related to a traumatic event or overuse. The pain may be acute or chronic. Injury may occur to the muscles, ligaments, tendons, and bones.Common shoulder conditions include:
- AC separation
- Labral Tear
- Rotator Cuff Tear
Depending on the condition, individuals may experience pain, loss of strength, limited range of motion, and other debilitating symptoms.
Shoulder problems may be diagnosed by taking a thorough history, performing a physical examination (assessing ROM, strength, etc.), and diagnostic testing such as MRI, CT scan, and plain x-rays.
Treatment for the shoulder pain depends on the location and cause of the pain. Many shoulder conditions can be effectively treated through non-surgical methods such as rest, applying ice or heat, stretching, physical therapy, activity modification and anti-inflammatory medication (taken by mouth or cortisone injection). Some patients may require surgery as the first line of treatment (certain fractures, large rotator cuff tears, etc.) and many of these procedures can be done arthroscopically. Surgery is often successful in repairing shoulder problems thus alleviating pain and restoring function to the joint.
Bursitis is a painful inflammation of a bursa. Bursae are small sacs that allow for smooth gliding of structures. This includes a tendon that glides near a bone (subacromial space of the shoulder) or skin gliding over a bone (about the elbow or over the kneecap). These sacs can get inflamed resulting in swelling of the sacs. Bursitis usually results either from repetitive stress or sudden injury. Once bursitis occurs, there can be painful friction and associated soft tissue swelling. In the shoulder, the subacromial bursa lets the rotator cuff tendon glide smoothly under the acromion (bone on the top of the shoulder). This bursa frequently gets inflamed and can cause pain with lifting the arm overhead and reaching behind the back. Pain is typically along the side of the shoulder and is aggravated by laying on the shoulder for example while sleeping.
Bursitis typically responds to conservative treatment. This includes oral anti-inflammatory medication, rest, ice and avoiding the activity that caused the problem. If the bursitis does not improve over a few weeks, then patients should see their physicians to further assess the problem. Once the diagnosis of bursitis is confirmed, a cortisone injection into the subacromial bursa may be helpful when the pain is significant and/or physical therapy may be prescribed to work on restoring range of motion and/or strength. In the case where a rotator cuff tear may be suspected, further imaging with MRI or ultrasound may be ordered. If bursitis does not improve with conservative treatment typically over a 6 month period, then surgery to remove the bursa arthroscopically is an option for treatment.
The rotator cuff refers to a group of tendons that attach to the humeral head (the ball of the shoulder joint). These tendons connect the muscles of the rotator cuff to the bone. These muscles help to raise the arm overhead and rotate the shoulder inward and outward. The rotator cuff also helps to maintain the humeral head in contact with the glenoid (the socket) providing dynamic stability to the joint and maintaining proper contact to allow for shoulder full range of motion and strength. These tendons can become partially or completely torn as a result of repetitive overuse injury (most common cause) or a single traumatic event (e.g. a fall or lifting a heavy object). Due to degeneration of the tendon with age, this condition is more common in individuals over the age of 40. As we age, the tendon becomes more susceptible to tearing. Younger or older athletes who use their arms overhead repetitively (e.g. baseball pitchers) or laborers who do repetitive overhead lifting or work are at higher risk for developing rotator cuff tears.
Treatment for a less severe rotator cuff injury is similar to the treatment for bursitis. These less severe injuries include partial thickness tears (tear that does not extend through the entire thickness of the tendon) and small full thickness rotator cuff tears. In addition conservative treatment is prescribed for larger rotator cuff tears in an older patient population or patients with medical conditions that don’t allow for rotator cuff repair. While the conservative management may not allow a tear to completely heal, the partial thickness tear and small rotator cuff tear can be well tolerated and resolution of pain and restoration of full function can be achieved without surgery. Rotator cuff tears that are large, typically, are recommended to have the tears fixed without doing conservative treatment because these larger tears have a tendency to progress in size with time and surgery gives the best chance to obtain a pain-free and functional shoulder. Surgery may also be offered in the partial thickness and small rotator cuff tear groups if conservative treatment does not improve their pain and/or function satisfactorily.
The labrum is a cartilage ring that attaches to the outside of the bony socket (glenoid). It helps to deepen the socket and aid in stability. It is also the attachment point for the biceps tendon and the ligaments (soft tissue structure that holds bones in contact with each other). It can be injured when there is a traumatic event such as with a dislocation. It can also be injured with repetitive use. Overhead athletes such as pitchers can injure the superior labrum due to repetitive tension on the biceps tendon and edge loading of the socket by the ball. Labral tears can also develop due to repetitive loading of the shoulder such as with weight lifting, gymnastics or linemen who have to keep their arms extended. Symptoms of a labral tear include pain, feeling of instability, clicking or catching and decreased range of motion. Labral tears can be hard to diagnose even with MRI.
Treatment of a labral tear depends on the type and the severity of the tear. Many labral tears can be effectively treated without surgery. This includes rest, anti-inflammatory and physical therapy. Surgery, generally arthroscopic, may be required for cases that do not respond to conservative treatment. This typically is done by re-attaching the labrum to the bone using suture anchors or in some cases shaving some torn fragments of labrum. If the labrum is repaired, patients need to remain in a sling after surgery for several weeks to protect the repair as opposed to wearing a sling for a few days if the labrum is simply shaved.
A shoulder is deemed unstable if the ball dislocates or slips partially out of the socket. Patients may have “loose” shoulders to begin with and some people develop instability following a traumatic event. Typically, patients with “loose” shoulders are treated with physical therapy to strengthen the muscles around the shoulder to provide improved stability. Most times, physical therapy works for these patients. In terms of traumatic instability, patients who are older (e.g. > 40 years old) typically do not have recurrent episodes of instability after the initial traumatic event. However, unfortunately, these patients have a higher chance of injuring other structures in the shoulder most notably the rotator cuff tendon. Younger patients have an increased chance of recurrent instability and that chance of re-dislocating the shoulder later increases with younger age. Imaging work-up includes plain x-rays and sometimes CT scan to assess for bone injury and an MRI to assess for soft tissue injury to the ligaments and the labrum.
Typical first line treatment is conservative. This includes rest and physical therapy. Physical therapy helps to regain motion and strength. If patients fail conservative treatment, then surgical stabilization can be performed. Nowadays, this is typically done arthroscopically. During this procedure, the torn labrum and ligaments are repaired using suture anchors placed in the glenoid. The sutures from these anchors are placed around the torn labrum and through the torn ligaments. The labrum is placed back onto the rim of the glenoid to help re-establish deepening of the socket (bumper effect) and the ligaments are tightened to re-establish stability. After surgery, patients are maintained in a sling typically 4 weeks and then physical therapy is started. For patients who not only have ligament tearing and labral tearing but also bone injury, a bone replacing or repairing procedure may be necessary. This is typically done through a larger incision and not arthroscopically.