Your Guide to Shoulder Pain and Its Treatment

With more and more people trying to stay fit, shoulder problems are on the rise. Currently, shoulder pain or problems account for nearly 20 percent of visits to the orthopaedic specialists office. Most shoulder problems can be solved without surgery. But if shoulder pain is severe or movement is restricted, its time to seek help from an orthopaedic expert familiar with the full spectrum of shoulder problems and treatments.

The shoulder: a different joint

The shoulder is a complex joint made up of the humerus (upper arm bone), scapula (shoulder blade) and clavicle (collarbone), along with tendons, muscles and ligaments. These help us lift, carry, throw and reach up or backward. The shoulder is the most mobile and least stable joint in the body, because it is not anchored firmly to the skeleton by surrounding muscle.
Rotator cuff and related injuries The rotator cuff comprises four muscles and cord-like tendons, tightly enclosed within the shoulder joint. Rotator cuff injuries are the most common causes of shoulder pain and activity restriction at all ages. Rotator cuff tendonitis. The mildest rotator cuff injury is tendonitis (tendon inflammation). Tendonitis can develop with repetitive overhead activities such as playing tennis, pitching, raking, shoveling or painting. Tendonitis can also arise from joint degeneration due to osteoarthritis. It produces pain like a toothache radiating through the upper arm that can awaken you from sleep. Reaching overhead or behind your back is painful. Shoulder bursitis. Bursitis, which often accompanies rotator cuff tendonitis, involves painful inflammation of one or more bursa (fluid-filled sacs that surround our joints to provide lubrication and protection). Impingement syndrome. Swelling and inflammation of tendons and/ or bursa can place undue pressure on tendons as they pass between the upper arm bone and the shoulder tip, called the scapular acromion. In its cramped space, blood flow to the swollen tendon is reduced, and it begins to fray. The resulting pain intensifies when reaching overhead or backward. Ongoing impingement may produce a torn rotator cuff. Rotator cuff tears. A torn rotator cuff, sometimes called pitchers shoulder or tennis shoulder, is the most common cause of shoulder pain. The rotator cuff tendons can split or tear suddenly with injury, or slowly by rubbing bone spurs. Untreated tears can weaken the arm, inhibit its overhead elevation and visibly shrink muscles. Pain occurs during motion and also at night.

Labral tears The labrum, a cartilage cuff around the socket that encircles the head of the upper arm bone to hold it within its shallow bony socket, can tear with injury to the shoulder. It also becomes more brittle with age and thus susceptible to fraying. Aching in the shoulder, catches in the shoulder when moved, and pain with some activities may signal a torn labrum. Instability and dislocation When one of the shoulder bones moves or is pushed out of place due to injury, the shoulder becomes unstable and is at risk for partial or complete dislocation. Recurrent dislocations cause pain and unsteadiness when raising the arm or moving it away from the body, and a feeling that the shoulder is slipping out of place when reaching overhead. Frozen Shoulder Between ages 40 and 60, the joint capsule surrounding the shoulder can shrink, making movement painful and stiff. Reluctance to use the shoulder brings increasing stiffness, restricted motion and a persistent, dull aching. This condition is most frequently associated with diabetes, but in more than half the patients has no known cause. Pain fades after several months, but the shoulder becomes frozen and may take two to three years to thaw without treatment. Treatment is directed at pain relief until the acute phase passes, followed by therapy and even surgical intervention to regain motion if it does not return spontaneously. Fractures Shoulder fractures are usually caused by trauma: a fall while skiing, a collision during football, a car accident. A fracture of the ball at the top of the arm bone or its socket, or of the collarbone, can disable the shoulder. Bruising, pain and swelling, and pain or a deformed appearance can indicate a shoulder fracture. Most fractures are effectively treated by immobilizing the arm in a sling until the bone fragments knit together, which takes about six weeks. All fractures should be assessed; some require surgery.

To make an appointment with a Cleveland Clinic orthopaedic specialist, call 216.444.BONE (2663) or 800.890.2467. For information about our staff and services, visit clevelandclinic.org/ortho.

Arthritis Osteoarthritis is the wearing down of cartilage that allows bones to glide smoothly within the joints, and can occur with aging, trauma or overuse injury. The bones in the shoulder begin to rub against each other, and growths called bone spurs can develop. Stiffness, swelling, pain and reduced range of motion can occur, along with a catching sensation in the joint. Rheumatoid arthritis, a disorder of the immune system, produces chronic, painful inflammation of the joints lining, and eventual joint deterioration. Severe osteoarthritis or rheumatoid arthritis in the shoulder may necessitate joint replacement. Other causes Less common causes of shoulder pain include infection (osteomyelitis), soft-tissue or bone tumors and nerve problems. A shoulder specialist can help pinpoint the reason. When shoulder pain is intense, its important to seek help promptly. Evaluating shoulder pain Your doctor will thoroughly examine your shoulder, take your health history and order imaging. X-rays detail bone changes from arthritis and fractures. Magnetic resonance imaging (MRI) reveals soft-tissue injuries. Computed tomography shows 3-D images of bony abnormalities and tendon problems. Advanced centers will offer techniques such as ultra-fast, high-resolution CT to reveal the source of shoulder pain, and single-sequence MRI to confirm rotator cuff injuries.

Injections When other treatments dont help severe shoulder pain, cortisone (corticosteroid) injections may temporarily help to settle down inflamed tissues within the cramped joint, reducing pain. However, cortisone is a potent drug, and potential side effects should be discussed with your physician.

Surgical options
When shoulder problems do not respond to any conservative care, your orthopaedic specialist may recommend surgery. Options range from minimally invasive arthroscopic surgery to total shoulder replacement.
Arthroscopic Surgery In arthroscopic surgery, only a few small incisions are required, making recovery quicker and less painful. A viewing camera is inserted through one incision, and slender telescopic instruments are inserted through others. This allows surgeons to inspect and repair labral tears and rotator cuff tears, and remove spurs and bony growths to allow inflamed, cramped tendons to move more freely. They can also remove thickened, inflamed bursa and bone to create space around the rotator cuff and relieve painful impingement (arthroscopic decompression), and can cut through tight sections of the joint capsule to release a frozen shoulder. Arthroscopic surgery can be combined with standard open surgery when a larger incision is required to properly view and repair a more complex problem, or with forcible stretching of a tight joint capsule under anesthesia to free up frozen shoulder. Rotator cuff surgery Torn rotator cuffs do not heal by themselves and require surgery when pain persists. Repairing the torn muscle and tendon, and removing bone spurs restores comfort and function to the shoulder after several months of healing. Surgery for shoulder fractures Severe osteoarthritis or rheumatoid arthritis can cause painful, debilitating shoulder deformity. In these cases, or when trauma crushes the ball of the shoulder joint, then shoulder replacement surgery can relieve pain and improve quality of life. Any damaged cartilage or bone in the shoulders ball and socket are removed, and replaced with a metal ball and a plastic socket. This artificial shoulder always relieves pain and usually improves motion, strength and function. Recovery from surgery Physical therapy is essential to regaining your range of motion and strength, which relieves pain. Your surgeon will prescribe exercises that a physical therapist will tailor to your needs. Your therapist will ensure that you perform your exercises correctly, give you advice on body mechanics so that you avoid straining your shoulder, and check your progress.

Conservative care
Rest, ice and heat are essential. Fortunately, most shoulder problems do not require surgery, and respond to a directed physical therapy exercise program and anti-inflammatory medication. Rest When your shoulder hurts, its important to rest it, and refrain from reaching upward, carrying heavy objects and using heavy shoulder bags. Pain and inflammation will not subside if repetitive activities such as vacuuming, raking or car-washing continue to stress the sore shoulder. Keeping your elbow below shoulder-level is important. To prevent frozen shoulder after an injury, however, early movement is important. Ice and heat Icing the shoulder with cold packs (or bags of frozen peas or corn) when pain is severe reduces inflammation and swelling, and the discomfort they cause. Taking hot showers and doing recommended stretches first thing in the morning also help. Physical therapy Orthopaedic specialists prescribe physical therapy to help you recover from shoulder injury. Physical therapists tailor range-of-motion exercises to increase flexibility in the shoulder. They will also show you strengthening exercises that help prevent muscle shrinkage, and good body mechanics to help you avoid shoulder strain. Ultrasound or massage may be used for bursitis. In frozen shoulder, anesthesiologists can perform a nerve block to allow for more aggressive physical therapy. Anti-inflammatory medications Non-steroidal anti-inflammatory (NSAID) medication can be purchased over the counter to relieve shoulder pain. If aspirin, ibuprofen (Advil), naproxen (Aleve) and acetaminophen (Tylenol) do not provide adequate relief, prescription-strength NSAIDs can be prescribed. Supplements Glucosamine supplements, usually taken with chondroitin, may help ease pain from osteoarthritis.

To make an appointment with a Cleveland Clinic orthopaedic specialist, call 216.444.BONE (2663) or 800.890.2467. For information about our staff and services, visit clevelandclinic.org/ortho. Cleveland Clinics Department of Orthopaedic Surgery is consistently ranked among the top five programs in the nation by U.S.News & World Report.

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