Arthritis of the Shoulder
Although most people think of the shoulder as a single joint, there are really two joints in the area of the shoulder. One is located where the collarbone (clavicle) meets the tip of the shoulder bone (acromion). This is called the acromioclavicular or AC joint. The junction of the upper arm bone (humerus) with the shoulder blade (scapula) is called the glenohumeral joint. Both joints may be affected by arthritis.
To provide you with effective treatment, your physician will need to determine which joint is affected and what type of arthritis you have. Three major types of arthritis generally affect the shoulder.
- Osteoarthritis, or "wear-and-tear" arthritis, is a degenerative condition that destroys the smooth outer covering (articular cartilage) of bone. It usually affects people over 50 years of age and is more common in the AC joint than in the glenohumeral shoulder joint.
- Rheumatoid arthritis is a systemic inflammatory condition of the joint lining. It can affect people of any age and usually affects multiple joints on both sides of the body.
- Posttraumatic arthritis is a form of osteoarthritis that develops after an injury such as a fracture or dislocation of the shoulder. Arthritis can also develop after a rotator cuff tear.
Signs and symptoms
The most common symptom of arthritis of the shoulder is pain, which is aggravated by activity and progressively worsens. If the glenohumeral shoulder joint is affected, the pain is centered in the back of the shoulder and may intensify with changes in the weather. The pain of arthritis in the AC joint is focused on the front of the shoulder. Someone with rheumatoid arthritis may have pain in all these areas if both shoulder joints are affected.
Limited motion is another symptom. It may become more difficult to lift your arm to comb your hair or reach up to a shelf. You may hear a clicking or snapping sound (crepitus) as you move your shoulder.
As the disease progresses, any movement of the shoulder causes pain, night pain is common and sleeping may be difficult.
A physical examination and X-rays are needed to properly diagnose arthritis of the shoulder. During the physical examination, your physician will look for:
- Weakness (atrophy) in the muscles
- Tenderness to touch
- Extent of passive (assisted) and active (self-directed) range of motion
- Any signs of injury to the muscles, tendons and ligaments surrounding the joint as well as signs of previous injuries
- Involvement of other joints (an indication of rheumatoid arthritis)
- Crepitus with movement
- Pain when pressure is placed on the joint X-rays of an arthritic shoulder show a narrowing of the joint space, changes in the bone and the formation of bone spurs (osteophytes). If an injection of a local anesthetic into the joint temporarily relieves the pain, the diagnosis is confirmed.
As with other arthritic conditions, initial treatment of arthritis of the shoulder is conservative:
- Rest or change activities to avoid provoking pain; you may need to modify the way you move your arm to do things.
- Take nonsteroidal anti-inflammatory medications such as aspirin or ibuprofen to reduce inflammation.
- Ice the shoulder for 20 to 30 minutes two or three times a day to reduce inflammation and ease pain.
- If you have rheumatoid arthritis, your doctor may prescribe a disease-modifying drug such as methotrexate or recommend a series of corticosteroid injections.
- Dietary supplements such as glucosamine and chondroitin sulfate may be helpful.
If conservative treatment does not reduce pain, there are surgical options. As with all surgeries, there are some risks and possible complications. Your orthopaedic surgeon will do all that is possible to minimize these risks.
Arthritis of the glenohumeral joint can be treated by replacing the entire shoulder joint with a prosthesis (total shoulder arthroplasty) or by replacing the head of the upper arm bone (hemiarthroplasty). The most common surgical procedure used to treat arthritis of the AC joint is a resection arthroplasty. In this procedure, a small piece of bone from the end of the collarbone is removed, leaving a space that later fills with scar tissue. Surgical treatment of arthritis of the shoulder is generally very effective in reducing pain and restoring motion.
Arthroscopic Shoulder Surgery: Thermal Capsulorrhaphy
No joint has greater range of motion than the shoulder. But this flexibility is also a liability, because it makes the shoulder prone to dislocation and instability. The upper arm bone (humerus) sits in a saucer-shaped part of the shoulder blade (scapula) called the glenoid. A circle of ligaments, tendons, muscles and cartilage form a capsule around the joint to maintain stability.
Trauma or overuse can cause these soft tissues to stretch or tear. Then they can no longer provide the necessary support. A feeling of "looseness" may develop and the shoulder may "pop out" with some activities. Pain and weakness may interfere with daily activities such as work, sports, or sleep.
An emerging trend
In recent years, arthroscopic techniques that use heat to "shrink" and tighten the tissues have been developed to treat several types of shoulder instability. The new procedure, called thermal capsulorrhaphy (kap-sue-lore'-a-fee), works because the molecular structure of tissue changes in response to heat. Tendons and ligaments are primarily composed of collagen, a type of protein. When collagen is heated to the appropriate temperature, it contracts and "shrinks." The body perceives this as an injury and the tissues rebuild around the shorter collagen fibers, resulting in a tighter, and theoretically more stable, shoulder.
Initially, laser devices that used light to heat the tissues were developed, but the high cost of equipment and other concerns prompted researchers to investigate other methods. Today, radiofrequencies inside the thermal probe can also be used to generate the necessary temperatures. These devices generate vibrations within the intracellular molecules, creating heat.
What to expect
Thermal capsulorrhaphy is an outpatient procedure performed while the patient is under general anesthetic. The surgeon makes two or three small incisions called portals and inserts the pencil-sized arthroscopic instruments. One instrument enables the surgeon to view the joint and another provides the heat source. The surgeon is able to see changes in color and texture in the tissues as the thermal probe is brushed back and forth across them. The entire procedure usually takes less than 30 minutes.
After surgery, patients must wear a sling for at least three weeks. There is little postoperative pain, but the patient must be careful not to raise or turn the arm because this will stretch the tissues before they have healed in their shortened state. The physician will also prescribe a rehabilitation program designed to strengthen the muscles and restore a full range of motion. Patients may be able to safely return to certain sports in as little as four to six months.
Early studies indicate that thermal capsulorrhaphy may be beneficial in treating several kinds of shoulder instability. However, the technique is so new that long-term results are not yet available. Some people may continue to experience shoulder instability and may eventually require open surgery to shorten and tighten the tendons. Others may develop a condition called capsulitis, which is a stiffening or tightness in the joint.
Thermal capsulorrhaphy is not appropriate for every patient. Your doctor will discuss various options with you, based on the underlying cause and the degree of laxity in your shoulder. Traumatic injuries may require surgical repair. If the damage is significant, the orthopaedic surgeon may use an open technique that tightens and reattaches the tissue. A hospital stay is necessary and rehabilitation can take nine to 12 months. Overuse injuries can often be treated with an aggressive rehabilitation program, but if nonoperative treatment fails, surgery may be recommended.
A broken collarbone (fractured clavicle) is a common injury among two very different groups of people: children and athletes. Many babies are born with collarbones that broke during the passage down the birth canal. A child's collarbone can easily crack from a direct blow or fall because the collarbone doesn't completely harden until a person is about 20 years old. An athlete who falls may break the collarbone because the force of the fall is transmitted from the elbow and shoulder to the collarbone.
The collarbone is considered part of the shoulder and helps connect the arm to the body. It lies above several important nerves and blood vessels. However, these vital structures are rarely injured when the collarbone breaks. The collarbone is a long bone, and most breaks occur in the middle section.
Signs of a break
- Sagging shoulder (down and forward).
- Inability to lift the arm because of pain.
- A grinding sensation if an attempt is made to raise the arm.
- A deformity or "bump" over the fracture site.
- Although a fragment of bone rarely breaks through the skin, it may push the skin into a "tent" formation.
Although a broken collarbone is usually obvious, your orthopaedist will do a careful examination to make sure that no nerves or blood vessels were damaged. An X-ray is often recommended to pinpoint the location and severity of the break.
Most broken collarbones heal well with conservative treatment and surgery is rarely necessary.
- A simple arm sling can usually be used to immobilize the arm. A child may have to wear the sling for 3 to 4 weeks; an adult may have to wear it for 6 to 8 weeks.
- Depending on the location of the break, your physician may apply a figure-of-eight strap to help maintain shoulder position.
- Analgesics such as acetaminophen or nonsteroidal anti-inflammatory medications such as aspirin or ibuprofen will help reduce pain.
- A large bump will develop as part of the healing process. This usually disappears over time, but a small bump may remain.
- Range of motion and strengthening exercises can begin as soon as the pain subsides. However, you should not return to sports activities until full shoulder strength returns.
- In rare cases, depending on the location of the break and the involvement of shoulder ligaments, surgery is needed. Surgery usually gives good results.
Burners and Stingers
Burners and stingers are a common injury in contact or collision sports. The injury is named for the "stinging" or "burning" pain that radiates (spreads) from the shoulder to the hand. This can feel like an electric shot or "lightening bolt" down the arm and can be accompanied by a warm sensation.
Nerve roots exit the spinal canal of the neck and come together to form cords of nerves that ultimately provide sensation to all of the arm muscles. The nerve roots are named for the level at which they exit the spinal canal (i.e., C5 refers to cervical nerve root 5 and exits the spinal cord at the 5th cervical spinal body). When a burner or stinger occurs, one potential area of injury is where the nerve root exits the spinal canal.
As the nerve roots move away from the spinal canal, they join to form larger bundles or cords. In the upper extremity this is called the brachial plexus. All of the nerve supply to the arms runs through this plexus. This is also a potential site of injury that can cause a burner or stinger.
This is a common injury in contact sports. In fact, up to 70 percent of all college football players report having experienced a burner or stinger during in their 4-year career.
Mechanism of Injury
Athletes who engage in contact sports are more likely to suffer this injury. The two most common sports for burners and stingers are:
- American football
Tackling or blocking in football is the most common athletic activity causing a burner or stinger. Football defensive players and lineman therefore frequently suffer this injury.
Another possible mechanism is a fall onto the head, such as in a wrestling takedown or a football tackle.
The injury is to the nerve supply of the upper limb, either at the neck or shoulder. In most cases, the injuries are temporary and symptoms resolve quickly. A "burning" or "electric" shock sensation is often felt. The arm may feel "dead" or numb immediately following the injury, and weakness is common. The symptoms most commonly occur in one arm only. Symptoms usually last seconds to minutes, but in 5 percent to 10 percent of cases, they can last hours, days or even longer.
An orthopaedist makes the diagnosis based upon the history of injury and your symptoms. X-rays, magnetic resonance imaging (MRI) and other nerve studies are not usually needed. More extensive work-up is required if you have:
- Weakness lasting more than several days
- Neck pain
- Symptoms in both arms
- History of recurrent stingers/burners
In addition to the type of sport, another risk factor may be the size of the spinal canal. It has been suggested that athletes with recurrent stingers or burners may have a smaller spinal canal than players who do not suffer recurrent injury. This is a condition termed cervical or spinal stenosis.
Treatment Options: Nonsurgical
Treatment begins by removing the athlete from further injury. Athletes are not allowed to return to sports activity until their symptoms have been completely resolved. This can take a few minutes or several days. Athletes should never be allowed to return to sports if they have weakness or neck pain.
Although the injury gets better with time, the athlete may need to work with a trainer or therapist to regain strength and motion if the symptoms last for several days.
The shoulder joint is your body's most mobile joint. It can turn in many directions, but this advantage also makes your shoulder joint easy to dislocate. A partial dislocation (subluxation) means the head of the upper arm bone (humerus) is partially out of the socket (glenoid). A complete dislocation means it's all the way out. Both partial and complete dislocation cause pain and unsteadiness in your shoulder. Your muscles may have spasms from the disruption, and this can make it hurt more. When your shoulder dislocates time and again, you have shoulder instability.
Symptoms to look for include swelling, numbness, weakness and bruising. Sometimes dislocation may tear ligaments or tendons in your shoulder. Once in awhile, the dislocation may damage your nerves.
Your shoulder joint can dislocate forward, backward or downward. A common type of shoulder dislocation is when your shoulder slips forward (anterior instability). This means your upper arm bone moved forward and down out of its joint. It may happen when you put your arm in a throwing position.
Your doctor will examine your shoulder and may order an X-ray. It's important for you to tell your doctor how it happened. Was it an injury? Have you ever dislocated your shoulder before? Your doctor will place the ball of the upper arm bone (humerus) back into the joint socket. This process is called closed reduction. Your severe pain stops almost immediately once your shoulder joint is back in place.
Rest and rehabilitation
Your doctor may immobilize your shoulder in a sling or other device for several weeks following treatment. You should get plenty of rest and ice the sore area 3-4 times a day. After the pain and swelling go down, your doctor will prescribe rehabilitation exercises for you. These help restore your shoulder's range of motion and strengthen your muscles. Rehab may also help you prevent dislocating your shoulder again in the future. You begin by doing gentle muscle toning exercises. Later, you can work up to using weights.
If your shoulder dislocation becomes a chronic condition, a brace can sometimes help. However, if therapy and bracing fail, then you may need surgery to repair or tighten torn or stretched ligaments, which help hold the joint in place.
Erb's Palsy (Brachial Plexus Injury)
If your newborn can move one arm but not the other, he or she may have a condition called Erb's palsy. The inability to move the arm is a symptom of an injury to the brachial plexus (BRAY-key-el PLEK-sis), a network of nerves that provides movement and sensation to the arm, hand and fingers. One or two of every 1,000 babies have this condition. Most infants with Erb's palsy will recover both movement and sensation in the affected arm without surgery. But parents must be watchful and active participants in the treatment process to ensure maximum functional recovery.
How it happens
The nerves to the arm, hand and fingers exit the spinal cord between the bones (vertebrae) of the neck and travel into the arm below the collarbone (clavicle). The nerves to the arm exit high in the neck; those that go to the hand and fingers exit lower in the neck, just above the chest. These nerves branch and join together near where the neck joins the shoulder, in an area called the brachial plexus.
Brachial plexus injuries in newborns usually occur during a difficult delivery, such as with a large baby, a breech presentation, or a prolonged labor, when the person assisting the delivery must exert some force to pull the baby from the birth canal. One side of the baby's neck is stretched, which can damage the nerves by stretching or tearing them. If the upper nerves are affected, the condition is called Erb's palsy. The infant may not be able to move the arm, but may be able to move the fingers. Injuries that involve both the upper and lower nerves are more severe and result in a condition called global palsy.
There are four types of nerve injuries to the brachial plexus.
- Avulsion injuries. The nerve is torn from its attachment to the spinal cord. This is the most serious type of injury.
- Rupture injuries. The nerve is torn, but not at the spinal cord.
- Neuroma injuries. These injuries result from scar tissue that forms and puts pressure on the nerve.
- Stretch injuries. These injuries, known as neurapraxia (new-rah-PRAK-see-ah) are the most common. The nerve is damaged but not torn. Normally, these injuries heal on their own, usually within three months.
The symptoms of a nerve injury (paralysis and loss of feeling) are the same, regardless of the type of injury. However, the severity of the injury does affect both treatment decisions and the extent of recovery possible.
A newborn with Erb's palsy will have the arm straight down at the side and will not move it. Sometimes, the arm may be slightly turned, with a bent wrist and straight fingers. A droopy eyelid on the affected side may indicate a more severe injury. The doctor may order an X-ray or magnetic resonance image (MRI) to see if there is any damage to the bones and joints of the neck and shoulder. The doctor may also use an electromyogram (EMG) or nerve conduction studies (NCS) to see if any nerve signals are present in the upper arm muscle.
Because most newborns with Erb's palsy recover without surgery, your baby will be examined again at one month and at three months to see if the nerves are recovering by themselves. It may take up to two years for complete recovery. During this time, range of motion exercises are very important to keep the baby's joints from getting stiff.
If there is no change over the first three months, nerve surgery may be helpful. However, nerve surgery will not restore normal function or help infants over one year old. After surgery, the infant will wear a splint for approximately three weeks. Because nerves grow at a rate of one inch per month, it may take several months, or even years, for nerves repaired at the neck to reach the muscles of the lower arm and hand.
Some children with brachial plexus injuries will continue to have weakness in the shoulder, arm or hand. They may find it difficult to raise the hand over the head, to turn the hand palm up, or to extend the wrist. In some of these cases, a surgical procedure called tendon transfer may be helpful. Tendons are the connective tissues between muscle and bone. The surgeon will separate the tendon from its normal attachment and reattach it in a different place. This is often helpful in improving shoulder and wrist motions as well as elbow position and hand grip.
Tendon transfers are generally performed when the child is old enough to follow instructions. After surgery, the child will have to wear a cast for about six weeks and a splint at night for up to six months. Physical therapy may continue for up to one year after surgery.
Your doctor will discuss the various treatment options with you and make a specific recommendation based on your child's individual situation. Do not hesitate to ask questions; there is much that parents can do to help ensure a good functional outcome.
Because your baby cannot move the affected arm alone, it is important that you take an active part in keeping the joints limber and the functioning muscles fit. Your doctor will recommend physical therapy and range of motion exercises. Do these exercises with your baby every day, two or three times a day, beginning when your baby is about three weeks old. The exercises will maintain a range of motion in the shoulder, elbow, wrist and hand and prevent the joint from becoming permanently stiff, a condition called a joint contracture.
Sometimes, the affected arm is noticeably smaller than the unaffected arm. This occurs because the arm is not used as much. Although the size difference is permanent, it will not increase with age. You should also remember that your child is very adaptable. Be supportive and encouraging; focus on what your child can do. This will help your child develop a healthy sense of self-esteem and adjust to any functional limitations.
Fracture of the Shoulder Blade (Scapula)
Triangular, mobile and protected by a complex of surrounding muscles, the shoulder blade (scapula) is rarely broken. Scapula fractures represent less than 1 percent of all broken bones. High-energy, blunt trauma such as a motorcycle or car crash or falling from significant height can fracture the scapula and cause other major injuries such as broken ribs or damage to the head, lungs or spinal cord. Symptoms include:
- Extreme pain when you move the arm.
- Swelling around the back of the shoulder.
- Skin abrasions.
Without treatment, a fractured scapula can result in chronic shoulder pain and disability.
Classification and evaluation
To give you appropriate treatment, your doctor will probably need to take X-rays of your shoulder and chest to describe and classify the location(s) of fracture to the scapula. In some cases, your doctor may also need to use other diagnostic imaging tools such as CT scan (computerized tomography).
One or more parts of the scapula may be fractured:
- Scapular body (50-60 percent of cases).
- Scapular neck (25 percent).
Your doctor will evaluate the position and posture of the shoulder and treat any soft tissue damage (i.e., abrasions, open wounds, and muscular trauma). Your doctor may want a detailed neurovascular examination, which may not be possible if you have other severe injuries.
Nonsurgical treatment with a simple sling works for most fractures of the scapula. The immobilization devices holds your shoulder in place while the bone heals. In many cases, your doctor may want you to start early range of motion exercises within the first week after the injury. Other fractures may need 2 to 4 weeks of immobilization. Your shoulder may feel stiff when the doctor removes the sling. Begin limited active use of your shoulder immediately. Continue passive stretching exercises until complete shoulder motion returns. This may take 6 months to a year.
If you have an isolated scapular body fracture, your doctor may want you to stay in the hospital. Certain types of scapular fractures may need further evaluation:
- Fractures of the glenoid articular surface in which bone has moved out of place (displaced) significantly.
- Fractures of the neck of the scapula with severe angular deformity.
- Fractures of the acromion process with impingement syndrome.
In these cases, you may need surgery in which the doctor uses plates and screws to hold together the bone.
Frozen shoulder (adhesive capsulitis) is a disorder characterized by pain and loss of motion or stiffness in the shoulder. It affects about two percent of the general population. It is more common in women between the ages of 40 years to 70 years old. The causes of frozen shoulder are not fully understood. The process involves thickening and contracture of the capsule surrounding the shoulder joint. A doctor can diagnose frozen shoulder based on the history of the patient's symptoms and physical examination. X-rays or MRI (magnetic resonance imaging) studies are sometimes used to rule out other causes of shoulder stiffness and pain, such as rotator cuff tear.
Frozen shoulder occurs much more commonly in individuals with diabetes, affecting 10 percent to 20 percent of these individuals. Other medical problems associated with increased risk of frozen shoulder include: hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease or surgery. Frozen shoulder can develop after a shoulder is injured or immobilized for a period of time. Attempts to prevent frozen shoulder include early motion of the shoulder after it has been injured.
Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. The pain is usually located over the outer shoulder area and sometimes the upper arm. The hallmark of the disorder is restricted motion or stiffness in the shoulder. The affected individual cannot move the shoulder normally. Motion is also limited when someone else attempts to move the shoulder for the patient. Some physicians have described the normal course of a frozen shoulder as having three stages:
- Stage one: In the "freezing" stage, which may last from six weeks to nine months, the patient develops a slow onset of pain. As the pain worsens, the shoulder loses motion.
- Stage two: The "frozen" stage is marked by a slow improvement in pain, but the stiffness remains. This stage generally lasts four months to nine months.
- Stage three: The final stage is the "thawing", during which shoulder motion slowly returns toward normal. This generally lasts five months to 26 months.
Frozen shoulder will generally get better on its own. However, this takes some time, occasionally up to two to three years. If you have a stiff and painful shoulder, see your physician to make sure no other injuries are present.
Treatment is aimed at pain control and restoration of motion. The first goal is pain control. This can be achieved with anti-inflammatory medications. These include pills taken by mouth, such as ibuprofen or Naprosyn, as well as injections, such as corticosteroids. To restore motion, physical therapy is usually started. This may be under the direct supervision of a therapist or via a home program. Therapy includes stretching or range-of-motion exercises for the shoulder. Sometimes heat is used to help decrease pain.
If these methods fail, nerve blocks are sometimes used to limit pain and allow more aggressive physical therapy. More than 90 percent of patients improve with these relatively simple treatments. Usually, the pain resolves and motion improves. However, in some cases, even after several years the motion does not return completely and a small amount of stiffness remains. In the long run, this small loss of motion does not seem to cause functional limitations.
Treatment Options: Surgical
Surgical intervention is considered when there is no improvement in pain or shoulder motion after an appropriate course of physical therapy and anti-inflammatory medications. When more invasive measures are considered, the patient must always consider that most individuals will get better if given sufficient time and that surgery always has risk involved.
Surgical intervention is aimed at stretching or releasing the contracted joint capsule of the shoulder. The most common methods include manipulation under anesthesia and shoulder arthroscopy:
- Manipulation under anesthesia involves putting the patient to sleep and "manipulating" or forcing the shoulder to move. This process causes the capsule to stretch or tear.
- With shoulder arthroscopy, the surgeon makes several small incisions around the shoulder. A small camera and instruments are inserted through the incisions. They are used to cut through the tight portions of the joint capsule.
Often, manipulation and arthroscopy are used together in combination to obtain maximum results. Most patients have very good results with these procedures. After surgery, physical therapy is important to maintain the motion that was achieved with surgery. Recovery time varies. Some patients require six weeks to three months off of work depending on their occupation and speed of recovery.
Research on the Horizon/What's New?
Although several theories exist, the cause of frozen shoulder is not known. Further research is needed to determine its exact cause. If the cause could be determined, better preventative measures or treatments could be developed. Most patients affected by frozen shoulder do get better with time. Many surgeons have reported the results of various physical therapy regimes as well as surgery. Further research could help determine which treatments work best, or if treatment changes the normal course of the disease.
Rotator Cuff Tears
Rotator cuff tear is a common cause of pain and disability in the adult population. The rotator cuff is made up of four muscles and their tendons. These combine to form a "cuff" over the upper end of the arm (head of the humerus). The four muscles - supraspinatus, infraspinatus, subscapularis, and teres minor - originate from the "wing bone"(scapula), and together form a single tendon unit. This inserts on the greater tuberosity of the humerus. The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint.
Most tears occur in the supraspinatus but other parts of the tendon may be involved.
Rotator cuff tear is most common in people who are over the age of 40. It may occur in younger patients following acute trauma or repetitive overhead work or sports activity. Common examples are:
- Workers who do overhead activities such as painting, stocking shelves or construction
- Athletes such as swimmers, pitchers and tennis players
- A cuff tear may also happen with another injury to the shoulder, such as a fracture or dislocation.
Symptoms of a rotator cuff tear may develop acutely or have a more gradual onset. Acute pain usually follows trauma such as a lifting injury or a fall on the affected arm. More commonly, the onset is gradual and may be caused by repetitive overhead activity or by wear and degeneration of the tendon. You may feel pain in the front of your shoulder that radiates down the side of your arm. At first the pain may be mild and only present with overhead activities such as reaching or lifting. It may be relieved by over-the-counter medication such as aspirin or ibuprofen. Over time the pain may become noticeable at rest or with no activity at all. There may be pain when you lie on the affected side and at night. Other symptoms may include stiffness and loss of motion. You may have difficulty using your arm to reach overhead to comb your hair or difficulty placing your arm behind your back to fasten a button.
When the tear occurs with an injury, there may be sudden acute pain, a snapping sensation and an immediate weakness of the arm.
Diagnosis of a rotator cuff tear is based on your symptoms, your doctor's examination, X-rays, and imaging studies such as MRI (magnetic resonance imaging). Your doctor will examine your shoulder to see if it is tender in any area or if there is a deformity. He or she will measure the range of motion of your shoulder in several different directions and test the strength of your arm. The doctor will also check for instability and problems with the AC (acromioclavicular) joint.
The doctor may also examine your neck to make sure that your pain is not coming from a "pinched nerve" in your cervical spine and to rule out other conditions such as osteoarthritis or rheumatoid arthritis.
Some of the signs of a rotator cuff tear include:
- Atrophy or thinning of the muscles about the shoulder
- Pain when you lift your arm
- Pain when you lower your arm from a fully raised position
- Weakness when you lift or rotate your arm
- Crepitus or crackling sensation when you move your shoulder in certain positions
Plain X-rays of a shoulder with a rotator cuff tear are usually normal or show a small spur. For this reason, your doctor may order an additional study such as an ultrasound or MRI. These can better visualize soft tissue structures such as the rotator cuff tendon.
An MRI can sometimes distinguish between a full thickness (complete) tear of the tendon and a partial tear. It can show the doctor if the tear is within the tendon itself, or if the tendon is detached from bone.
In some circumstances, an Arthrogram, in which local anaesthetic and dye is injected into the joint, may also be helpful.
Once a diagnosis of rotator cuff tear has been made, your orthopaedic surgeon will recommend the most effective treatment. In many instances, non-surgical treatment can provide pain relief and can improve the function of your shoulder.
Treatment options may include:
- Rest and limited overhead activity
- Use of a sling
- Anti-inflammatory medication
- Steroid injection
- Strengthening exercise and physical therapy
It may take several weeks or months to restore the strength and mobility to your shoulder.
Treatment Options: Surgical
Your orthopaedic surgeon may recommend surgery if nonoperative treatment does not relieve your symptoms. Surgery may also be considered if the tear is acute and painful, if it is the dominant arm of an active individual or if you need maximum strength in your arm for overhead work or sports.
The type of surgery performed depends on the size, shape and location of the tear. A partial tear may require only a trimming or smoothing procedure called a "debridement." A complete tear within the substance of the tendon is repaired by suturing the two sides of the tendon. If the tendon is torn from its insertion on the greater tuberosity of the humerus, it can be repaired directly to bone.
Many surgical repairs can be done on an outpatient basis.
In the operating room, your surgeon may remove part of the front portion of the scapula, the acromion as part of the procedure. The acromion is thought to cause "impingement" on the tendon. This may lead to a tear. Other conditions such as arthritis of the AC joint or tearing of the biceps tendon may also be addressed.
In general, three approaches are available for surgical repair. These include :
A fiberoptic scope and small instruments are inserted through small puncture wounds instead of an open incision. The scope is connected to a television monitor and the surgeon can perform the repair under video control.
Newer techniques and instruments allow surgeons to perform a complete rotator cuff repair through a small incision, typically 4 cm to 6 cm.
Open Surgical Repair
A traditional open surgical incision is often required if the tear is large or complex or if additional reconstruction such as a tendon transfer has to be done. In some severe cases, where arthritis has developed, shoulder replacement is an option.
Your surgeon will recommend which technique is best for you.
After surgery, the arm is immobilized to allow the tear to heal. The length of immobilization depends upon the severity of the tear. You will be given an exercise program to help regain motion and strength in the shoulder. This begins with passive motion. It advances to active and resistive exercises. Your orthopaedic surgeon may recommend that you work with a physical therapist. Complete recovery may take several months.
A strong commitment to rehabilitation is important to achieve a good surgical outcome. The doctor will advise you when it is safe to return to overhead work and sports activity.
Research on the Horizon/What's New?
Future developments in the treatment of rotator cuff disease include newer arthroscopic and mini-open surgical techniques. These allow for smaller, less painful incisions and faster recovery time. Many techniques now use dissolvable anchors. These hold stitches in place or hold stitches down to bone until the repair has healed and then are absorbed by the body. Research is also being done on "orthobiologic" tissue implants. These promote growth of new tissue in the body, and help with the healing process.
Rupture of the Biceps Tendon
A pro football player attempts an arm tackle and hears a pop in his upper arm. A weightlifter doing curls suddenly feels his shoulder "bubble." A woman rearranging the living room furniture gets a sharp pain in her shoulder. Each of these individuals just ruptured their biceps tendon.
Tendons attach muscle to bone. The biceps muscle in the upper arm splits near the shoulder into a long head and a short head. Both attach to the shoulder in different places. At the other end of the muscle, the distal biceps tendon connects to the smaller bone (radius) in the lower arm. These connections help the muscle stabilize the shoulder, rotate the lower arm and accelerate or decelerate the arm during overhead motions such as pitching.
The long head of the biceps tendon is vulnerable to injury because it travels through the shoulder joint to its attachment point. If it tears, you may lose some strength in your arms and be unable to turn your arm from palm down to palm up. Because the torn tendon can no longer keep the muscle taut, you may also notice a bulge in the upper arm (Popeye muscle). If the distal tendon tears, you may be unable to lift items or bend your elbow.
Ruptures of the distal tendon near the elbow are rare. They usually occur when an unexpected force is applied to a bent arm. For example, a snowboarder can rupture the distal biceps tendon if he or she uses the arm to try to break a fall during a turn.
The proximal biceps tendons near the shoulder tear more easily. Tears can be either partial or complete. Often, these tendons are already frayed, particularly if you are over 40 years of age, have a history of shoulder pain, and participate in activities that involve overhead motions. Among the elderly, biceps tendon ruptures near the shoulder are often associated with rotator cuff tears.
Signs and symptoms
- Sudden, sharp pain in the upper arm.
- Sometimes, an audible snap.
- A bulge in the upper arm above the elbow, and a dent closer to the shoulder.
- Bruising from the middle of the upper arm down toward the elbow.
- Pain or tenderness at the shoulder.
Diagnosis and treatment
Your physician will examine your arm and ask you to bend the arm and tighten the biceps muscle. The doctor may apply pressure to the top of the arm to see if there is any pain. If you have a history of shoulder pain, your doctor may request an MRI or a special X-ray called an arthrogram to see if you have also torn the rotator cuff muscle.
Conservative treatment is usually all that is needed for tears in the proximal biceps tendons.
- Ice applications keep down the swelling.
- Nonsteroidal anti-inflammatory medications such as ibuprofen reduce pain.
- You should also rest the muscle, limiting your activity when you feel pain or weakness.
- To keep the shoulder mobile and strengthen the surrounding muscles, your doctor may prescribe some flexibility and strengthening exercises.
- Surgical repair of a complete tendon tear can be done for younger individuals whose work involves heavy labor or lifting.
Complete tears of the distal biceps tendon require surgery to reattach the tendon to the bone. Range of motion exercises can begin as early as two weeks after surgery, although forceful biceps activity is often restricted for four to six months. Partial tears of the distal biceps tendon may be treated either conservatively or surgically. You and your orthopaedic surgeon should discuss the options for your specific case.
Impingement is one of the most common causes of pain in the adult shoulder. It results from pressure on the rotator cuff from part of the shoulder blade (scapula) as the arm is lifted.
The rotator cuff is a tendon linking four muscles - the supraspinatus, the infraspinatus, the subscapularis, and the teres minor. These muscles cover the "ball" of the shoulder (head of the humerus). The muscles work together to lift and rotate the shoulder.
The acromion is the front edge of the shoulder blade. It sits over and in front of the humeral head. As the arm is lifted, the acromion rubs or "impinges" on the surface of the rotator cuff. This causes pain and limits movement.
The pain may be due to a "bursitis" or inflammation of the bursa overlying the rotator cuff or a "tendonitis" of the cuff itself. In some circumstances, a partial tear of the rotator cuff may cause impingement pain.
Impingement is common in both young athletes and middle-aged people. Young athletes who use their arms overhead for swimming, baseball and tennis are particularly vulnerable. Those who do repetitive lifting or overhead activities using the arm such as paper hanging, construction or painting are also susceptible. Pain may also develop as the result of minor trauma or spontaneously with no apparent cause.
Beginning symptoms may be mild. Patients frequently do not seek treatment at an early stage.
- You may first be aware of minor pain that's present both with activity and at rest.
- You may have pain radiating from the front of the shoulder to the side of the arm.
- You may note sudden pain with lifting and reaching movement.
- Athletes in overhead sports may have pain when throwing or serving a tennis ball.
Impingement commonly causes local swelling and tenderness in the front of the shoulder. There may be pain and stiffness when you attempt to lift your arm. There may also be pain when you lower the arm from an elevated position.
As the problem progresses, you may have pain at night. You may lose strength and motion. You may have difficulty with activities that place the arm behind the back, such as buttoning or zippering. In advanced cases, loss of motion may progress to a "frozen shoulder." In acute bursitis, the shoulder may be severely tender. All movement may be limited and painful.
To diagnose shoulder impingement, an orthopaedic surgeon reviews the symptoms and physically examines the shoulder.
He or she may take X-rays. A special X-ray view called an "outlet view" sometimes will show a small bone spur on the front edge of the acromion (see Figures 3a and 3b). The doctor may request further imaging studies, such as an MRI (magnetic resonance imaging). These can show fluid or inflammation in the bursa and rotator cuff. In some cases, partial tearing of the rotator cuff will be identified.
An impingement test, injection of local anesthetic into the bursa, can help to confirm the diagnosis.
Initial treatment is conservative. The doctor may suggest that you rest and avoid overhead activities. He or she might prescribe a course of oral non-steroidal anti-inflammatory medication. Stretching exercises to improve range of motion in a stiff shoulder will also help.
Many patients benefit from injection of local anesthetic and a cortisone preparation to the affected area. The doctor might also recommend a program of supervised physical therapy. Treatment may take several weeks to months. Many patients experience a gradual improvement and return to function.
Treatment Options: Surgical
When conservative treatment does not relieve pain, the doctor may recommend surgery. The goal of surgery is to remove the impingement and create more space for the rotator cuff. This allows the humeral head to move freely in the subacromial space and to lift the arm without pain. The most common surgical treatment is subacromial decompression or anterior acromioplasty. This may be performed by either arthroscopic or open techniques:
Arthroscopic technique: In an arthroscopic procedure, two or three small puncture wounds are made. The joint is examined through a fiberoptic scope connected to a television camera. Small instruments are used to remove bone and soft tissue.
Open technique: Open surgery requires placement of a small incision in the front of the shoulder. This allows for direct visualization of the acromion and rotator cuff.
In most cases the front (anterior) edge of the acromion is removed along with some of the bursal tissue. The surgeon may also treat other conditions present in the shoulder at the time of impingement surgery. These can include acromioclavicular arthritis, biceps tendonitis or a partial rotator cuff tear.
After surgery, the arm may be placed in a sling for a short period of time. This allows for early healing. As soon as you are comfortable, you may remove the sling and begin exercise and use of the arm. The surgeon will provide a rehabilitation program based on your needs and the findings at surgery. This will include exercises to regain range of motion of the shoulder and strength of the arm. It may take two to four months to achieve complete relief of pain.
Shoulder Joint Replacement
Many people know someone with an artificial knee or hip joint. Shoulder replacement is less common. But it is just as successful in relieving joint pain. Shoulder replacement surgery started in the United States in the 1950s. It was used as a treatment for severe shoulder fractures. Over the years, this surgery has come to be used for many other painful conditions of the shoulder. These include:
- Osteoarthritis (degenerative joint disease)
- Rheumatoid arthritis
- Post-traumatic arthritis
- Rotator cuff tear arthropathy (a combination of severe arthritis and a massive non-reparable rotator cuff tendon tear)
- Avascular necrosis (osteonecrosis)
- Failed previous shoulder replacement surgery
- Severe fractures
Today, many surgeons use shoulder replacement surgery. About 23,000 people have the surgery each year. This compares to more than 700,000 Americans a year who have knee and hip replacement surgery.
The shoulder is a ball-and-socket joint that enables you to raise, twist and bend your arm. It also lets you move your arm forward, to the side and behind you. In a normal shoulder, the rounded end of the upper arm bone (head of the humerus) glides against the small dish-like socket (glenoid) in the shoulder blade (scapula). These joint surfaces are normally covered with smooth cartilage. They allow the shoulder to rotate through a greater range of motion than any other joint in the body.
The surrounding muscles and tendons provide stability and support. Unfortunately, conditions like those listed above can lead to loss of the cartilage and mechanical deterioration of the shoulder joint. The result can be pain. You can have a stiff shoulder that grinds or clunks. This can lead to a loss of strength, decreased range of motion in the shoulder and impaired function. X-rays of the shoulder would show:
- Loss of the normal cartilage joint space
- Flattening or irregularity in the shape of the bone
- Bone spurs
- loose pieces of bone and cartilage floating inside the joint
In severe cases, bone-on-bone arthritis may lead to erosion--wearing away of the bone.
Osteoarthritis is a common reason people have shoulder replacement surgery. Osteoarthritis is sometimes called "wear-and-tear" arthritis. It affects mainly older individuals in all walks of life. Over time, the shoulder joint slowly becomes stiff and painful. Unfortunately there is no way to prevent the development of osteoarthritis.
A severe fracture of the shoulder is another common reason people have shoulder replacements. When the shoulder is injured by a hard fall or car accident, it may be very difficult for a doctor to put the pieces back together. When the head of the upper arm bone is shattered, the blood supply to the bone pieces is interrupted. In this case, a surgeon may recommend a shoulder replacement. Older patients with osteoporosis are most at risk for a severe shoulder fracture.
Patients with a massive long-standing rotator cuff tear may develop cuff tear arthropathy. In this injury, the changes in the shoulder joint due to the rotator cuff tear may lead to arthritis and destruction of the joint cartilage.
Avascular necrosis is a condition in which the bone of the humeral head dies due to lack of blood supply. Chronic steroid use, deep sea diving, severe fracture of the shoulder, sickle cell disease and heavy alcohol use are risk factors for avascular necrosis.
Patients with arthritis typically describe a deep ache within the shoulder joint. Initially, the pain feels worse with movement and activity, and eases with rest. As the arthritis progresses, the pain may occur even when you rest. By the time a patient sees a physician for the shoulder pain, he or she often has pain at night. This pain may be severe enough to prevent a good night's sleep. The patient's shoulder may make grinding or grating noises when moved. Or the shoulder may catch, grab, clunk or lock up. Over time, the patient may notice loss of motion and/or weakness in the affected shoulder. Simple daily activities like reaching into a cupboard, dressing, toileting and washing the opposite armpit may become increasingly difficult.
Treatment of an arthritic shoulder starts with rest, exercise and taking arthritis medications. Resting the shoulder and applying moist heat can ease mild pain. After strenuous activity, an ice pack may be more effective at decreasing pain and swelling.
Physical therapy may be helpful when arthritis is in early stages. It helps maintain joint motion and strengthen the shoulder muscles. Physical therapy is less effective when the arthritis has advanced to the point that bone rubs on bone. When this is the case, physical therapy may make the shoulder hurt more.
Arthritis medications, called nonsteroidal anti-inflammatories (NSAIDs), can control arthritis pain. Certain NSAIDs may be purchased over-the-counter, while others require a prescription. Periodic cortisone injections into the shoulder joint can provide temporary pain relief. Excessive cortisone shots can have adverse effects, however.
Treatment Options: Surgical
If nonoperative treatments fail, shoulder replacement surgery may be needed. Shoulder replacements are usually done to relieve pain.
There are several different types of shoulder replacements. The usual total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem, and a plastic socket.
The components come in various sizes. If the bone is of good quality, your surgeon may choose to use a non-cemented or press-fit humeral component. If the bone is soft, the humeral component may be implanted with bone cement. In most cases, an all-plastic glenoid component is implanted with bone cement. Implantation of a glenoid component is not advised if:
- The glenoid has good cartilage.
- The glenoid bone is severely deficient.
- The rotator cuff tendons are irreparably torn.
Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement.
Depending on the condition of the shoulder, your surgeon may replace only the ball. Sometimes, this decision is made in the operating room at the time of the surgery. Some surgeons replace the ball when it is severely fractured and the socket is normal.
Another type of shoulder replacement is called reverse total shoulder replacement. This surgery was developed in Europe in the 1980s. It was approved by the Food and Drug Administration (FDA) for use in the United States in 2004. Reverse total shoulder replacement is used for people who have:
- Completely torn rotator cuffs and
- The effects of severe arthritis (cuff tear arthropathy) or
- Had a previous shoulder replacement that failed
For these individuals, a conventional total shoulder replacement can still leave them with pain. They may also be unable to lift their arm up past a 90-degree angle. Not being unable to lift one's arm away from the side can be severely debilitating. In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder bone and a plastic socket is attached to the upper arm bone. This allows the patient to use the deltoid muscle instead of the torn rotator cuff to lift the arm. This video shows a patient with rotator cuff arthropathy in both shoulders demonstrating her ability to lift her left arm above the horizontal after left reverse total shoulder replacement.
Shoulder replacement surgery is highly technical. It should be performed by a surgical team with experience in this procedure. Each case is individual. Your surgeon will evaluate your situation carefully before making any decisions. Do not hesitate to ask what type of implant will be used in your situation. Ask why that choice is right for you.
Before surgery, patients see their internist or family practice physician for a preoperative medical evaluation. Cardiac patients should see their cardiologist as well. Two weeks before surgery, you should stop taking the following medications that thin the blood and can lead to excessive bleeding during surgery:
- Nonsteroidal anti-inflammatory medications (aspirin and ibuprofen such as Motrin® and Advil®)
- Most arthritis medications
The surgery is performed on an inpatient basis. Most patients are discharged from the hospital on the second or third day after the operation.
A careful, well-planned rehabilitation program is critical to the success of a shoulder replacement. You usually start gentle physical therapy on the first day after the operation. You wear an arm sling during the day for the first several weeks after surgery. You wear the sling at night for 4 to 6 weeks. Most patients are able to perform simple activities such as eating, dressing and grooming within 2 weeks after surgery. Driving a car is not allowed for 6 weeks after surgery.
Here are some "do's and don'ts" for when you return home:
- Don't use the arm to push yourself up in bed or from a chair because this requires forceful contraction of muscles.
- Do follow the program of home exercises prescribed for you. You may need to do the exercises 4 to 5 times a day for a month or more.
- Don't overdo it! If your shoulder pain was severe before the surgery, the experience of pain-free motion may lull you into thinking that you can do more than is prescribed. Early overuse of the shoulder may result in severe limitations in motion.
- Don't lift anything heavier than a glass of water for the first 6 weeks after surgery.
- Do ask for assistance. Your physician may be able to recommend an agency or facility if you do not have home support.
- Don't participate in contact sports or do any repetitive heavy lifting after your shoulder replacement.
- Do avoid placing your arm in any extreme position, such as straight out to the side or behind your body for the first 6 weeks after surgery.
Many thousands of patients have experienced an improved quality of life after shoulder joint replacement surgery. They experience less pain, improved motion and strength, and better function .
Shoulder Joint Tear (Glenoid Labrum Tear)
Advances in medical technology are enabling today's doctors to identify and treat injuries that went unnoticed 20 years ago. For example, physicians can now use miniaturized television cameras to see inside a joint. With this tool, they have been able to identify and treat a shoulder injury called a glenoid labrum tear.
The shoulder joint involves three bones: the shoulder blade (scapula), the collarbone (clavicle) and the upper arm bone (humerus). The head of the upper arm bone (humeral head) rests in a shallow socket in the shoulder blade called the glenoid. Because the head of the upper arm bone is usually much larger than the socket, a soft fibrous tissue rim called the labrum surrounds the socket to help stabilize the joint. The rim deepens the socket by up to 50 percent so that the head of the upper arm bone fits better. In addition, it serves as an attachment site for several ligaments.
Injuries to the tissue rim surrounding the shoulder socket can occur from acute trauma or repetitive shoulder motion. Examples of traumatic injury include:
- Falling on an outstretched arm
- Direct blow to the shoulder
- Sudden pull, such as when trying to lift a heavy object
- Violent overhead reach, such as when trying to stop a fall or slide
Throwing athletes or weightlifters can experience tears due to repetitive shoulder motion.
Tears can be located either above (superior) or below (inferior) the middle of the glenoid socket. A SLAP lesion (superior labrum, anterior [front] to posterior [back]) is a tear of the rim above the middle of the socket that may also involve the biceps tendon. A tear of the rim below the middle of the glenoid socket that also involves the inferior glenohumeral ligament is called a Bankart lesion. Tears of the glenoid rim often occur with other shoulder injuries, such as a dislocated shoulder (full or partial dislocation).
Signs and symptoms
It is difficult to diagnose a tear in the shoulder socket rim because the symptoms are very similar to other shoulder injuries. Symptoms include
- Pain, usually with overhead activities
- Catching, locking, popping or grinding
- Occasional night pain or pain with daily activities
- A sense of instability in the shoulder
- Decreased range of motion
- Loss of strength
If you are experiencing shoulder pain, your doctor will take a history of your injury. You may be able to remember a specific incident or you may note that the pain gradually increased. The doctor will do several physical tests to check range of motion, stability and pain. In addition, the doctor will request X-rays to see if there are any other reasons for your problems.
Because the rim of the shoulder socket is soft tissue, X-rays will not show damage to it. The doctor may order a computed tomography (CT) scan or magnetic resonance image (MRI). In both cases, a contrast medium may be injected to help detect tears. Ultimately, however, the diagnosis will be made with arthroscopic surgery.
Until the final diagnosis is made, your physician may prescribe anti-inflammatory medication and rest to relieve symptoms. Rehabilitation exercises to strengthen the rotator cuff muscles may also be recommended. If these conservative measures are insufficient, your physician may recommend arthroscopic surgery.
During the surgery, the doctor will examine the rim and the biceps tendon. If the injury is confined to the rim itself, without involving the tendon, the shoulder is still stable. The surgeon will remove the torn flap and correct any other associated problems. If the tear extends into the biceps tendon or if the tendon is detached, the result is an unstable joint. The surgeon will need to repair and reattach the tendon using absorbable tacks, wires or sutures.
Tears below the middle of the socket are also associated with shoulder instability. The surgeon will reattach the ligament and tighten the shoulder socket by folding over and "pleating" the tissues.
After surgery, you will need to keep your shoulder in a sling for three to four weeks. Your physician will also prescribe gentle, passive, pain-free range-of-motion exercises. When the sling is removed, you will need to do motion and flexibility exercises and gradually start to strengthen your biceps. Athletes can usually begin doing sports-specific exercises after six weeks, although it will be three to four months before the shoulder is fully healed.
What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion to the arm, from scratching your back to throwing the perfect pitch. Mobility has its price, however. It may lead to increasing problems with instability or impingement of soft tissue resulting in pain. You may feel pain only when the shoulder is moved, or all of the time. The pain may be temporary and disappear in a short time, or it may continue and require medical diagnosis and treatment.
What causes shoulder pain?
Most shoulder problems involve the soft tissues, muscles, ligaments and tendons, rather than bones. And most of these problems fall into three major categories:
Other much more rare causes of shoulder pain are tumors, infection and nerve-related problems.
Tendinitis-A tendon is a cord which connects muscle to bone or other tissue. Most tendinitis is a result of the wearing process that takes place over a period of years, much like the wearing process on the sole of a shoe which eventually splits from overuse. Generally, tendinitis is one of several types:
- acute tendinitis following some overuse problem such as excessive ball throwing and other sports- or work-related activities.
- chronic tendinitis resulting from degenerative disease or repetitive wear and tear due to age.
- the splitting and tearing of tendons which may result from acute injury or degenerative changes in the tendons due to advancing age. Rotator cuff injuries are among the most common of these disorders. The rotator cuff is the arrangement of muscles and their tendons which provides shoulder motion and stability.
Sometimes, excessive use of the shoulder leads to inflammation and swelling of a bursa, a condition known as bursitis. Bursas are fluid-filled sacs located around the joints which lessen the friction caused by movement of the shoulder. Bursitis often occurs in association with rotator cuff tendinitis. Sometimes the many tissues in the shoulder become inflamed and painful, limiting the use of the shoulder. The joint may stiffen as a result, a condition called a "frozen shoulder." Fortunately, with appropriate care, this condition will resolve itself.
Injury/Instability-Sometimes the bones in one of the shoulder joints move (or, in an injury, are forced) out of their normal position. This condition, instability, can result in dislocation of one of the joints in the shoulder. Recurring dislocations, which may be partial or complete, cause pain and unsteadiness when you raise your arm or move it away from your body. When you lift your arm over your head, the shoulder may feel as if it is slipping out of place or an uncomfortable, unusual feeling that some people refer to as having a "dead" arm.
Arthritis-Shoulder pain can also result from arthritis. There are many types of arthritis, but generally it involves wear and tear changes with inflammation of the joint, causing swelling, pain and stiffness. Arthritis may be related to sports or work injuries.
Often people will avoid shoulder movements in an attempt to lessen the pain arising from these conditions. This sometimes leads to a tightening or stiffening of the soft tissue parts of the joint, resulting in a painful restriction of motion.
Treatment generally involves altering activities, rest and physical therapy to help you improve shoulder strength and flexibility. Medication may be prescribed to reduce inflammation and reduce pain. If medication is prescribed to relieve pain, it should be taken only as directed. Injections of drugs may also be used to treat pain.
Surgery may be required to resolve shoulder problems; however, 90 percent of patients with shoulder pain will respond to simple treatment methods such as altering activities, rest, exercise and medication. Certain types of shoulder problems, such as recurring dislocation and some rotator cuff tears may require surgery.
Common sense solutions such as avoiding overexertion or overdoing activities in which you normally don't participate can help to prevent shoulder pain.
When should you seek medical care?
Many patients ignore temporary minimal shoulder symptoms with few bad effects. In the case of an acute injury, if the pain is intense, you should seek medical care as soon as possible. If the pain is less severe, it may be safe to wait a few days to see if time will alleviate the problem. If symptoms persist, an orthopaedist may provide timely diagnosis and treatment. Orthopaedists are specifically trained in the workings of the musculoskeletal system, including the diagnosis, treatment and prevention of problems involving muscles, bones, joints, ligaments and tendons.
Diagnosis of shoulder pain
Determining the source of the problem in the shoulder is essential to recommending the right method of treatment. Therefore, a comprehensive examination will be required to find the causes of your shoulder pain.
The first step is a thorough medical history. Your orthopaedist may ask how and when the pain started, whether it has occurred before and how it was treated, and other questions to help determine your general health as well as the possible causes of your shoulder problem. Because many shoulder conditions are aggravated by specific activities, and relieved by specific activities, a medical history can be a valuable tool in finding the source of and treating your pain.
Next, your orthopaedist will perform a physical examination, which may include looking for physical abnormalities, swelling, deformity or muscle weakness, or feeling for tender areas, and observing the range of shoulder motion, how far and in which direction you can move your arm.
X-ray studies may be required so your orthopaedist can look closely at the bones and joints in your shoulder. Other diagnostic techniques that may be used include CT scan (computerized tomography), which provides a more detailed view of the shoulder area; electrical studies such as the EMG (electromyogram), which can indicate nerve damage; or an arthrogram, an X-ray study in which dye is injected into the shoulder to allow the orthopaedist to better see the joint and its surrounding muscles and tendons. MRI (Magnetic Resonance Imaging) and ultrasound are other valuable diagnostic tools for orthopaedists, because they provide images of the soft tissues without using radiation. Arthroscopy is a surgical procedure in which the orthopaedist looks inside the joint with a lighted telescope. It is sometimes used to diagnose causes of shoulder pain. Arthroscopy may indicate soft tissue injuries that are not apparent in the physical examination, X-rays and other tests.
Your orthopaedist is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.
This brochure has been prepared by the American Academy of Orthopaedic Surgeons and is intended to contain information on the subject from recognized authorities. However, it does not represent official policy of the Academy and its text should not be construed as excluding other acceptable viewpoints.
A shoulder separation is not truly an injury to the shoulder joint. The injury actually involves the acromioclavicular joint (also called the AC joint). The AC joint is where the collarbone (clavicle) meets the highest point of the wingbone (acromion).
Mechanism of injury
The most common cause for a separation of the AC joint is from a fall directly onto the shoulder. The fall injures the ligaments that surround and stabilize the AC joint.
If the force is severe enough, the ligaments attaching to the underside of the clavicle are torn. This causes the "separation" of the collarbone and wingbone, the wingbone actually moves downward from the weight of the arm. This creates a "bump" or bulge above the shoulder.
The injury can range from a little change in configuration with mild pain, to quite deforming and very painful. Good pain-free function often returns even with a lot of deformity. The greater the deformity, the longer it takes for pain-free function to return.
A mild shoulder separation involves a sprain of the AC ligament that does not move the collarbone and looks normal on X-rays.
A more serious injury tears the AC ligament and sprains or slightly tears the coracoclavicular (CC) ligament, putting the collarbone out of alignment to some extent.
The most severe shoulder separation completely tears both the AC and CC ligaments and puts the shoulder joint noticeably out of position.
The injury is easy to identify when it causes deformity. When there is less deformity, the location of pain and X-rays help the doctor make the diagnosis. Sometimes having the patient hold a weight in the hand can increase the deformity, which makes the injury more obvious on X-rays.
Nonsurgical treatments such as a sling, cold packs and medications can often help manage the pain. Sometimes a doctor may use more complicated supports to help lessen AC joint motion, reduce the deformity and lessen pain.
Most people return to near full function with this injury, even if there is a persistent, significant deformity. Some people have continued pain in the area of the AC joint even with only a mild deformity. This may be due to:
- Abnormal contact between the bone ends when the joint is in motion
- Development of arthritis
- Injury to a disk-like piece of cushioning cartilage that is often found between the bone ends of this joint
- It is worthwhile to wait and see if reasonable function returns without surgical treatment.
Treatment Options: Surgical
Surgery can be considered if pain persists or the deformity is severe. A surgeon might recommend trimming back the end of the collarbone so that it doesn't rub against the AC. Where there is significant deformity, reconstructing the ligaments that attach to the underside of the collarbone is helpful. This type of surgery works well even if it is done long after the problem started.
Whether treated conservatively or with surgery, the shoulder will require rehabilitation to restore and rebuild motion, strength and flexibility.
Rotator Cuff, Impingement
Your shoulder is the most flexible joint in your body. It allows you to place and rotate your arm in many positions in front, above, to the side and behind your body. This flexibility also makes your shoulder susceptible to instability and injury. This brochure will help you understand how your shoulder works and the common causes of shoulder problems, the available treatment options and exercises and activities to enable you to regain pain-free use of your shoulder.
Depending on the nature of the problem, conservative nonoperative methods of treatment often are recommended before surgery. However, in some instances, delaying the surgical repair of a shoulder can increase the likelihood that the problem will be more difficult to treat later. Early, correct diagnosis and treatment of shoulder problems can make a significant difference in the long run.
How the Normal Shoulder Works
The shoulder is a ball-and-socket joint. It is made up of three bones: the upper arm bone (humerus), shoulder blade (scapula) and collarbone (clavicle).
The ball at the top end of the arm bone fits into the small socket (glenoid) of the shoulder blade to form the shoulder joint (glenohumeral joint). The socket of the glenoid is surrounded by a soft-tissue rim (labrum). A smooth, durable surface (articular cartilage) on the head of the arm bone, and a thin inner lining (synovium) of the joint allows the smooth motion of the shoulder joint.
The upper part of the shoulder blade (acromion) projects over the shoulder joint. One end of the collarbone is joined with the shoulder blade by the acromioclavicular (AC) joint; the other end of the collarbone is joined with the breastbone (sternum) by the sternoclavicular joint. The joint capsule is a thin sheet of fibers that surrounds the shoulder joint. The capsule allows a wide range of motion yet provides stability. The rotator cuff is a group of muscles and tendons that attach your upper arm to your shoulder blade. The rotator cuff covers the shoulder joint and joint capsule. The muscles attached to the rotator cuff enable you to lift your arm, reach overhead, and take part in activities such as throwing or swimming.
A sac-like membrane (bursa) between the rotator cuff and the shoulder blade cushions and helps lubricate the motion between these two structures.
Shoulder Problems and Treatments
Bursitis or Tendinitis can occur with overuse from repetitive activities such as swimming, painting or weight lifting. These activities cause rubbing or squeezing (impingement) of the rotator cuff under the acromion and in the acromioclavicular joint. Initially, these problems are treated by modifying the activity which causes the symptoms of pain and with a rehabilitation program for the shoulder.
Impingement and Partial Rotator Cuff Tears Partial thickness rotator cuff tears can be associated with chronic inflammation and the development of spurs on the underside of the acromion or the AC joint. The conservative nonoperative treatment is modification of activity, light exercise and occasionally, a cortisone injection. Nonoperative treatment is successful in a majority of cases, but if it is not successful, surgery often is needed to remove the spurs on the underside of the acromion and to repair the rotator cuff.
Full Thickness Rotator Cuff Tears are most often the result of impingement, partial thickness rotator cuff tears, heavy lifting or falls. Nonoperative treatment with modification of activity is successful in a majority of cases. If you continue to have pain, surgery may be needed. Surgery may be necessary to repair full thickness rotator cuff tears. Arthroscopic techniques allow shaving of spurs, evaluation of the rotator cuff and repair of some tears. Both techniques require extensive rehabilitation to restore the function of the 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 sudden injury or from overuse of the shoulder ligaments.
The two basic forms of shoulder instability are subluxations and dislocations. A subluxation is a partial or incomplete dislocation. If your shoulder is partially out of the shoulder socket, it eventually may dislocate. Even a minor injury may push the arm bone out of its socket. A dislocation is when the head of the arm bone slips out of the shoulder socket. Some patients have chronic instability, shoulder dislocations occur repeatedly.
Patients with repeat dislocation usually require surgery. Open surgical repair may require a short stay in the hospital. Arthroscopic surgical repair is often done on an outpatient basis. Following either procedure, extensive rehabilitation, often including physical therapy, is necessary for healing.
Fractured Collarbone and AC Joint Separation are common injuries of children and others who fall on the side of their shoulder when playing. Most of these injuries are treated nonoperatively with slings or splints. Severe displaced fractures or AC joint separation may require surgical repair.
Fractured Head of the Arm Bone is a common result of falls on an outstretched arm, particularly by older people with osteoporosis. If fragmented or displaced, it may require open surgical repair and possibly replacement with an artificial joint (prosthesis).
Osteoarthritis and Rheumatoid Arthritis can cause destruction of the shoulder joint and surrounding tissue, as well as degeneration and tearing of the capsule or the rotator cuff. Osteoarthritis occurs when the articular surface of the joint wears thin. Rheumatoid arthritis is associated with chronic inflammation of the synovium lining which can produce chemicals that eventually destroy the inner lining of the joint, including the articular surface.
Shoulder replacement is recommended for patients with painful shoulders and limited motion. The treatment options are either replacement of the head of the bone or replacement of the entire socket. Your orthopaedic surgeon will discuss with you the best option.
The orthopaedic evaluation of your shoulder consists of three components:
- A medical history to gather information about current complaints; duration of symptoms, pain and limitations; injuries; and past treatment with medications or surgery.
- physical examination to assess swelling, tenderness, range of motion, strength or weakness, instability and/or deformity of the shoulder.
- Diagnostic tests such as X-rays taken with the shoulder in various positions. An MRI (Magnetic Resonance Imaging) may be helpful in assessing soft tissues in the shoulder. A CT (Computerized Tomography) scan may be used to evaluate the bony parts of your shoulder.
Your orthopaedic surgeon will review the results of your evaluation with you and discuss the best treatment. You and your doctor may agree that surgery is the best treatment option. He or she will explain the potential risks and complications that may occur. Your doctor may discuss donating your own blood to be used if needed during surgery.
Some surgical procedures require you to be hospitalized for a number of days. Your doctor may discuss planning for the period after surgery. You may need to either stay in an extended care facility or have someone help you when you return home.
Types of Surgical Procedures
You may be given the option to have an arthroscopic procedure or an open surgical procedure.
Arthroscopy allows the orthopaedic surgeon to insert a pencil-thin device with a small lens and lighting system into tiny incisions to look inside the joint. The images inside the joint are relayed to a TV monitor, allowing the doctor to make a diagnosis. Other surgical instruments can be inserted to make repairs, based on what is with the arthroscope. Arthroscopy often can be done on an outpatient basis.
Open surgery may be necessary and, in some cases, associated with better results than arthroscopy; open surgery often can be done through small incisions of just a few inches.
Recovery and rehabilitation is related to the type of surgery performed inside the shoulder, rather than whether there was an arthroscopic or open surgical procedure.
Possible Complications After Surgery
There are always some risks with any surgery, even arthroscopic procedures. These include possible infection, and damage to surrounding nerves and blood vessels. However, modern surgical techniques and close monitoring have significantly minimized the occurrence of these problems.
After surgery, some pain, tenderness and stiffness is normal. You should be alert for certain signs and symptoms that may suggest the development of complications.
Be sure to call your doctor if you develop any of these symptoms after surgery.
Prevention of Future Problems
It’s important that you continue a shoulder exercise program with daily stretching and strengthening. In general, patients who faithfully comply with the therapies and exercises prescribed by their orthopaedic surgeon and physical therapist will have the best medical outcome after surgery.
Your orthopaedic surgeon is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.
vThis brochure has been prepared by the American Academy of Orthopaedic Surgeons and is intended to contain current information on the subject from recognized authorities. However, it does not represent official policy of the Academy and its text should not be construed as excluding other acceptable viewpoints. Persons with questions about a medical condition should consult a physician who is informed about the condition and the various modes of treatment available.
About 13.7 million people went to the doctor's office in 2003 for a shoulder problem, including 3.7 million visits for shoulder and upper arm sprains and strains. (Source: National Center for Health Statistics; Centers for Disease Control and Prevention 2003 National Ambulatory Medical Care Survey.)
Shoulder injuries can be caused by sports activities that involve excessive overhead motion like swimming, tennis, pitching and weightlifting. People involved in everyday activities like washing walls, hanging curtains, and gardening also can get shoulder injuries due to excessive overhead arm motion.
Athletes are especially susceptible to shoulder problems. A shoulder problem can develop slowly in athletes through repetitive, intensive training routines.
Here are some facts about the shoulder from the American Academy of Orthopaedic Surgeons.
What are the warning signs of a shoulder injury?
If you are experiencing pain in your shoulder ask yourself these questions:
- Is the shoulder stiff? Can you rotate your arm in all the normal positions?
- Does it feel like your shoulder could pop out or slide out of the socket?
- Do you lack the strength in your shoulder to carry out your daily activities?
If you answer "yes" to any one of these questions, you should consult an orthopaedic surgeon for help in determining the severity of the problem.
What types of shoulder injuries are most prevalent?
Most problems in the shoulder involve the muscles, ligaments, and tendons rather than bones. Orthopaedic surgeons group shoulder problems into the following categories.
Sometimes, one of the shoulder joints moves or is forced out of its normal position. This condition is called instability, and can result in a dislocation of one of the joints in the shoulder. Individuals suffering from an instability problem will experience pain when they raise their arm. They also may feel as if their shoulder is slipping out of place.
Impingement is caused by excessive rubbing of the rotator cuff and the top part of your shoulder blade called the acromion. Impingement problems can be sustained when participating in a sports activity that requires excessive overhead motion. If you do not seek medical care for the inflammation in your shoulder, it could eventually lead to a more serious injury.
Why is the rotator cuff so important?
The rotator cuff is one of the most important components of the shoulder. It is comprised of a group of muscles and tendons that hold the shoulder joint in place. The rotator cuff provides individuals with the ability to lift their arm and reach overhead. If injured, it can become difficult for people to recover the full shoulder function needed to properly participate in the sports activity.
What causes a shoulder injury to become worse?
Some people will have a tendency to ignore the pain, and "play through" shoulder injuries which only aggravates the condition, and possibly causes more problems. People also may underestimate the extent of the injury because steady pain, weakness in the arm, or limitation of joint motion will become almost second nature to them.
How are shoulder injuries treated?
Early detection is the key to preventing serious shoulder injuries. Many times, orthopaedic surgeons will prescribe a series of exercises aimed at strengthening shoulder muscles. Anti-inflammatory medication also may be prescribed to reduce pain and swelling.
Here is a series of shoulder exercises aimed at helping individuals strengthen their shoulder muscles and prevent injuries.
- Basic Shoulder Strengthening Exercise: Attach elastic tubing to a doorknob at home. Gently pull the elastic tubing toward your body. Hold for a count of 5. Repeat 5 times with each arm. Perform twice a day.
- Wall Push-Up Exercise: Stand facing a wall with your hands on the wall and your feet shoulder-width apart. Slowly perform a push-up. Repeat 5 times. Hold for a count of 5. Perform twice a day.
- Shoulder Press-Up Exercise: Sit upright on a chair with armrests; your feet should be touching the floor. Use your arms to slowly rise off the chair. Hold for a count of 5. Repeat 5 times. Perform twice a day.
Thoracic Outlet Syndrome
A syndrome is a combination of signs and symptoms that characterizes an abnormal condition. A physician must review all of these signs and symptoms in order to make a diagnosis. That's certainly the case with thoracic outlet syndrome, or TOS.
TOS gets its name from the space (the thoracic outlet) between your collarbone (clavicle) and your first rib. This narrow passageway is crowded with blood vessels, muscles, and nerves. If the shoulder muscles in your chest are not strong enough to hold the collarbone in place, it can slip down and forward, putting pressure on the nerves and blood vessels that lie under it. Symptoms vary, depending on which structures (nerves or blood vessels) are being compressed. Pressure on the blood vessels can reduce the flow of blood to your arms and hands, making them feel cool and tire easily. Pressure on the nerves can leave you with a vague, aching pain in your neck, shoulder, arm or hand. Overhead activities are particularly difficult.
TOS can result from injury, disease, or a congenital abnormality. Poor posture and obesity can obesity can aggravate the condition, which is more common in women than in men. Psychological changes are often seen in patients with thoracic outlet syndrome. It is not clear whether these precede the onset of the syndrome or are the result of dealing with the pain and frustration of diagnosing and treating this condition.
When you visit your doctor, he or she will ask you about the history of your symptoms, give you a physical examination and try to reproduce your symptoms through a series of tests to diagnose TOS. There may be a depression in the shoulder, or a swelling or discoloration in the arm. Range of motion may also be limited. X-rays may be recommended; an MRI (magnetic resonance imaging), nerve conduction tests, or ultrasound may be used to rule out other possible causes for your symptoms. Your doctor may order special blood circulation tests and elecrodiagnostic tests to aid in making the diagnosis of TOS.
The treatment for TOS is conservative, and does not usually involve surgery.
- Physical therapy can help strengthen the muscles surrounding the shoulder so that they are better able to support the collarbone.
- Postural exercises can help you stand and sit straighter, which lessens the pressure on the nerves and blood vessels.
- Nonsteroidal anti-inflammatory drugs, like aspirin or ibuprofen, can ease the pain.
- If you are overweight, your physician may recommend that you go on a diet.
- You may need to change your workstation and avoid strenuous activities.
- In rare cases, surgery may be recommended if conservative treatment fails. The surgery involves dividing a muscle in the neck and removing a portion of the first rib.
If you have symptoms of TOS, avoid carrying heavy bags over your shoulder because this depresses the collarbone and increases pressure on the thoracic outlet. You could also do some simple exercises to keep your shoulder muscles strong. Here are four that you can try; do 10 repetitions of each exercise twice daily.
1. Corner Stretch: Stand in a corner (about one foot away from the corner) with your hands at shoulder height, one on each wall. Lean into the corner until you feel a gentle stretch across your chest. Hold for 5 seconds.
2. Neck Stretch: Put your left hand on your head, and your right hand behind your back. Pull your head toward your left shoulder until you feel a gentle stretch on the right side of your neck. Hold for 5 seconds. Switch hand positions and repeat the exercise in the opposite direction.
3. Shoulder Rolls: Shrug your shoulders up, back, and then down in a circular motion.
4. Neck Retraction: Pull your head straight back, keeping your jaw level. Hold for 5 seconds.
As with any exercise program, if you start to hurt-stop!