How to conquer shoulder pain!

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Shoulder pain is exceedingly common affecting at least 20 per cent of the population at some point.

The shoulder is a partial ball and socket joint with the head of the humerus being held in place inside a shallow cup formed by the glenoid labrum of the shoulder blade. Stability is achieved by ligaments, tendons, and muscles of the rotator cuff. The shoulder joint is extremely mobile but it also less stable than other ball and socket joints such as the hip. That is because of the shallowness of the glenoid cup.

The shoulder is surrounded by a series of fluid-filled sacs (bursae) which cushion the joint.

So… it is easy to see that shoulder pain can arise from many different structures including the tendons, bursae, muscles, ligaments, and nerves.

Disorders of the rotator cuff are probably the most common cause of shoulder pain seen in clinical practice. Rotator cuff problems can run the gamut from tendonitis to tearing, to impingement syndrome (pinching of the rotator cuff between the acromion of the shoulder blade and the humeral head) to adhesive capsulitis (frozen shoulder).

Arthritis (degenerative or inflammatory) may attack the shoulder. Rheumatoid arthritis and pseudogout are the most common inflammatory types to do this..

Bone disease like fracture or avascular necrosis can also affect the shoulder.

Nerve entrapment disorders (brachial plexus injury) can present with shoulder pain.

Cervical spine arthritis can cause referred pain to the shoulder. Lung tumors, heart attacks, liver and gall bladder disease, and polymyalgia rheumatica can also lead to shoulder pain.

The history often provides valuable information. Primary shoulder pain is aggravated by movement. Night pain is common and patients often have difficulty finding a comfortable position in which to sleep.

A history of overuse (“weekend warrior syndrome”) may point towards a diagnosis of bursitis or tendinitis.

Trauma might indicate the presence of fracture, dislocation, or rotator cuff tear.

One cannot exclude the possibility of cancer, either primary or metastatic. Tumors such as hypernephroma (kidney cancer) and lung malignancies frequently metastasize to the shoulder.

Physical examination can determine range of motion as well as the possibility of rotator cuff dysfunction. Patients who have significant arthritis in any of the shoulder joints (glenohumeral=joint between the humerus and scapula; acromioclavicular=the joint between the scapula and the clavicle; sternoclavicular=joint between the sternum and the clavicle) will have tenderness and possible swelling localized to that joint. Patients with severe glenohumeral arthritis will have marked reduction in range of motion and even grinding with movement of the arm.

As noted earlier, a careful general physical exam is needed because of the possibility of pain referral from other areas.

Diagnostic testing is based on what is seen on exam and what is gleaned from history.

X-ray imaging is of value only for fracture or dislocation. Magnetic resonance imaging is the preferred method of imaging for diagnosis.

Treatment depends on the underlying diagnosis. For patients with impingement, bursitis, or rotator cuff syndrome, anti inflammatory drugs, rest with a sling, and physical therapy may be helpful. Glucocorticoid injection under ultrasound guidance can be helpful.

Recently, visco supplements (hyaluronan) injected into the joint have shown some beneficial effects.

Surgery is reserved for patients with severe impingement or rotator cuff problems unresponsive to conservative measures, large rotator cuff tears, or severe arthritis.

However, a newer treatment for tendonitis may be more effective and prevent the need for surgery. Percutaneous needle tenotomy is a technique where a small gauge needle is introduced using local anesthetic and ultrasound guidance. The needle is used to poke several small holes in the fascia. This procedure is called "tenotomy." Tenotomy induces an acute inflammatory response. Then, platelet rich plasma, obtained from a sample of the patient's whole blood is injected into the area where tenotomy has been performed. Platelets are cells that contain multiple healing and growth factors. The result? Normal good quality fascial tissue is stimulated to grow with natural healing.

For more information about this procedure, visit our sister site:
Tendonitis provides reliable, accurate, and useful information on tendonitis treatment written by a board-certified rheumatologist. Learn more about how to get tendonitis relief using the most up-to-date methods.

Surgical procedures- should it be absolutely needed- include removal of the clavicle in the area of rotator cuff impingement (acromioplasty), rotator cuff repair, removal of inflamed synovium, or joint replacement.

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