Shoulder pain. It doesn’t make the news like back pain, but it’s out there. You reach in the cupboard and feel a little pinch. Go to put the seat belt on and it grabs you as you pull the belt across your body. Lay on that shoulder at night, and the pain awakens you. That beautiful child or grandchild wants you to lift them, and you can’t because you know it will be painful. Tennis or softball? You might as well forget them as the overhead movement really hurts. Maybe the shoulder is a little stiff, and you men can’t reach back to tuck your shirt in, or women can’t reach behind your back and fasten a particular article of clothing. You may not seek treatment – it doesn’t bother you that much, you can live with it (but it sure is a nuisance), or maybe you are just fearful that the solution will include surgery. The pain may at the front of the shoulder, maybe at the side, or it may radiate all the way to the forearm. Sometimes the pain is felt in the arm or forearm, without pain at the shoulder. The problem is, you thought is would get better, or just simply go away, and it hasn’t. Maybe the fear of how miserable (painful) the treatment is imagined to be is enough to prevent you from seeking treatment. Hopefully, a little information on shoulders and shoulder pain will help you change your mind and seek the treatment that may just rid you of the problem, quickly and with relative ease.
The shoulder is a great joint. It’s a ball and socket joint, and it moves all over the place. With increased mobility, however, comes instability. You shoulder depends on connective tissue around the joint, as well as strong muscles, for support and stability. That makes the joint complex, and you might think of that complexity as the cause of many of your shoulder problems.
The first thing that comes to most minds is the rotator cuff. Yes, it is called the rotator cuff. I’ve heard a number of variations, most common would be the “rotary cup”. That’s okay, we know what you mean. The rotator cuff is made up of four muscles (supraspinatus, infraspinatus, teres minor and subscapularis). They are muscles that originate on the scapula (shoulder blade) and attach to the upper part of the humerus (the arm bone). The tendons come together to form a cuff, supporting the joint, aiding in preventing dislocation. The rotator cuff muscles help to stabilize the ball in the socket, and also initiate movement of the arm. You could develop tendonitis, suffer a tear of the tendon (thus “rotator cuff tear”), or develop weakness of the rotator cuff muscles – any of which might (or might not) cause your pain. Notice I said “might not”. There are a number of studies out there, having people with no shoulder pain receive an MRI, and finding that a large percentage of them have partial tears of the rotator cuff. Those of you that like to read about these things might want to look at http://ajs.sagepub.com/content/23/2/142.short, http://onlinelibrary.wiley.com/doi/10.1111/1756-185X.12476/abstract or http://www.bjj.boneandjoint.org.uk/content/91-B/2/196.abstract. If you have enough of the cuff torn, you may not be able to lift your arm away from your side, creating significant disability.
You may have heard of the “labrum”. It’s simply a rim around the socket that adds depth, and contributes to the stability of the shoulder. It can be torn, and you might have heard of a SLAP lesion, which is simply a tear (Superior Labrum Anterior to Posterior). A tear might lead to terrific instability and problems at the shoulder, or it might mean nothing – kind of like rotator cuff tears.
Impingement syndrome is another common diagnosis, and put most simply is pinching (impingement) of the rotator cuff tendons. It’s a diagnosis that is widely used, and in this day of tests, x-rays, scans and so on the term may fade as we can be more specific in the diagnosis. Simply put, impingement syndrome could be considered the “umbrella” under which many more specific diagnoses reside. Again, those with inquiring minds may want to read this – http://www.uhasselt.be/Documents/UHasselt/initiatieven/2012/schouderklachten/1-Overzichtsartikel-All%20in%20one/1-A4-Shoulder-Matsen-Evidence%20Relevant%20to%20the%20Diagnosis%20of%20Imping%20Syndr-JBJS-2011.pdf. Surgery may be required for impingement problems, but most are treated conservatively with physical therapy or perhaps injection. As we understand the various problems that live under that impingement “umbrella”, we are becoming more effective in treating the various problems with physical therapy, often with very simple exercise routines.
You may have noticed that even though we can see a lot of “things” on x-ray or MRI, that may or may not be the cause of the problem. Imaging is helpful, don’t get me wrong. It’s nice to know if there is a fracture, dislocation, bone tumor, advanced arthritis, bone spurs and all the rest that can be seen on these various pictures. However, they are only one part of the clinical picture. It is important to take a careful history of the problem, listening carefully for any details that may provide a clue to what treatment is going to be effective in treating the problem. It is also important to perform a careful examination. While these things take time, they are crucial to your care. If your health care provider doesn’t listen, give you adequate time, makes you feel rushed, or doesn’t take the time to adequately examine your shoulder (or any other part of you), or answer your questions, consider finding one that will. It’s not enough to just look at the pictures (imaging studies).
You may notice that we don’t try to name a specific tissue that is at fault. We could try, but chances are we would be wrong, or it wouldn’t be relevant. You may have a rotator cuff tear on MRI, but it may have nothing to do with your pain, for example. It is more important to identify the behavior of the problem, and develop a plan of treatment depending on the behavior. It’s not that complicated. What causes the pain? Is it loss of motion? Chances are simple stretching exercises can fix it. Does it relate to the muscles? Strengthening exercises will probably help – for one of two reasons actually. If it’s an injury to a tendon (commonly called tendonitis, but that name is changing quite often to tendinosis, but that’s a topic that deserves its own post), strengthening exercises will actually help to heal chronic changes in the tendon that have occurred as a result of tearing or other injury to the fibers of the tendon. If the muscles are weak, and certainly the rotator cuff muscles can be weakened from a variety of causes, strengthening may help. It’s the behavior of the problem that leads us to the solution.
Now, if you are feeling confused, please don’t be. You have a sore shoulder. It’s our job to help you. Most shoulder problems are going to get better with conservative care – meaning things that don’t involve surgery. There, now you can breathe easier. Most physical therapy treatments are relatively simple, typically involve exercise as their major component, and really aren’t painful (unless you consider all exercise to be a pain). As new research is being published constantly, we continually gain insight into better treatments, whether it is for shoulders or any other part of you. The term we use is “evidence based practice”. In other words, is there evidence (research) that supports your treatment approach, and if not, is there a better way to treat that problem that the evidence supports? Evidence based practice is a hot topic right now, and will be a good topic for another post.
Perhaps you have a massive rotator cuff tear, or a labrum tear that has created a marked instability of your shoulder. Maybe the impingement is so bad that physical therapy cannot help. These conditions create a significant disability and certainly diminish the quality of life. Surgery in these cases can definitely help. Most rotator cuff tears, as well as labrum tears, can be repaired. Bony problems causing impingement can be corrected. These procedures are typically done through the arthroscope, in an outpatient setting. Shoulder replacements can also be performed, however are a little more complicated. As one might imagine, surgery is a more painful solution, but one that corrects a disabling problem. Physical therapy is typically required after surgery to aid in restoring motion, strength and function.
Now, that’s a long-winded discussion of shoulder pain. It doesn’t address every shoulder problem – that would take a whole book. Hopefully it has helped you realize that your shoulder problem can be treated, it’s probably not all that complicated, probably won’t hurt more than a little if at all, and treatment can get you back to the things you enjoy, like throwing a ball, reaching into the cupboard, lifting your child or putting your arm around your sweetheart. If you don’t know your local physical therapists, ask around, find out where the best physical therapy office is in your area and give them a call (consider going to www.mckenziemdt.org and using the therapist finder for a McKenzie trained provider in your area, or www.apta.org for their therapist finder).