By Jay S. Bender, MD
Shoulder problems are one of the most common reasons patients come to our offices. Just about everyone has had some episode of shoulder pain at some point. Patients can have pain, weakness, catching, grinding, clicking, stiffness and occasionally numbness in and around the shoulder. Often lifting or moving the arm against resistance seems to make symptoms worse, as does any type of overhead activity. Many everyday motions, sports and various work-place activities require these same motions making just about everyone at risk for shoulder problems.
Everything from driving a car to golfing, from working to sleeping can cause shoulder complaints that prompt an appointment. Trying to distinguish the various causes of pain can be challenging as many non-shoulder problems are often present as shoulder pain. Cardiac, lung, gastrointestinal and neurological problems can all mimic true shoulder pathology such as bursitis or a tear of the rotator cuff.
To help sort this out, your doctor will start by listening to you describe your specific symptoms. Learning how the pain started, its location, preceding events and aggravating and mitigating factors will help narrow down the cause of your pain. A good physical exam that includes an evaluation of motion, strength, stability and neurovascular function will help to narrow the diagnosis further. Often, diagnostic studies such as an x-ray, arthrogram, MRI scans and injection tests may be needed. Occasionally, special nerve studies will be necessary to finalize the diagnosis.
The most common shoulder problems include rotator cuff tendinosis/bursitis, partial or complete rotator cuff tears, adhesive capsulitis, bicepital tendinosis or rupture, shoulder instability and arthritis of the acromioclavicular (AC) joint and of the glenohumeral (GH) or shoulder joint proper.
The diagnosis of tendinosis or bursitis of the shoulder is really a series of problems that start with simple inflammation and can end with a full thickness rotator cuff tear. The rotator cuff describes the tendons of four different muscles that attach to the top part of the humerus at the shoulder joint. Starting in our 30s, we can have external irritation or trauma to the tendons that result in inflammation. Later, the inflammation becomes fibrotic and scars, then degeneration of the tendon occurs. In its early stages, rotator cuff disease can be easily treated with anti-inflammatory drugs and physical therapy. Occasionally, injections of cortisone are given to decrease inflammation and pain. Later, surgery may be necessary to remove bone spurs that irritate the rotator cuff or to repair a torn rotator cuff back to the bone. End-stage rotator cuff disease is associated with advanced arthritis and may even require a shoulder replacement to control symptoms.
As its name implies, bicepital tendonitis is the inflammation of the biceps tendon that runs from the shoulder joint to the elbow. Left untreated, it can ultimately rupture causing weakness and some cosmetic changes to the arm. The treatment for inflammation of the biceps tendon is similar to the rotator cuff starting with anti-inflammatory drugs and, in its worst form, a ruptured biceps tendon is reattached to the humerus with screws and sutures.
Adhesive capsulitis, also known as frozen shoulder, is associated with severely limited motion. Pain is encountered when the shoulder is moved past the point of the scarred soft tissues. It is more common in diabetics or those with thyroid diseases and often responds to physical therapy. For more difficult cases, the shoulder is manipulated under anesthesia. Rarely, surgery is recommended to release the scarred tissues and return the shoulder to a more normal motion.
Arthritic issues of the shoulder need to differentiate between the AC joint and the GH joint. The AC joint is where the collarbone meets the point of the shoulder. Pain from across the chest types of motion usually indicate arthritis of this joint while pain with other motions usually indicate arthritis of the GH joint or shoulder joint proper. As with arthritis elsewhere in the body, the first things to consider are the use of anti-inflammatory agents, glucosamine with or without chondrotin sulfate and MSM, activity modification and rehabilitation exercises. Selective use of cortisone injections can also be very helpful. When initial measures don’t work, arthroscopic removal of bone spurs and cartilage tears can be helpful. For the most difficult cases, several types of joint replacements are now available including resurfacing options and new designs that compensate for rotator cuff deficiencies.
These are just a few of the most common shoulder issues your orthopedist can treat. Although somewhat overwhelming at first, a good dialogue with your doctor and a thorough exam should lead you to a diagnosis and the start of a comprehensive treatment plan.