Shoulder Pain

Tendonitis

What is it? Shoulder tendinitis is a common overuse injury in sports (such as swimming, baseball and tennis) where the arm is used in an overhead motion. The pain – usually felt at the tip of the shoulder and referred or radiated down the arm – occurs when the arm is lifted overhead or twisted. In extreme cases, pain will be present all of the time and it may even wake you from a deep sleep.

Statistics: As per statistics, 6 out of 10 causes of shoulder pain are linked with supraspinatus tendonitis.

According to the survey, statistics show that while women only incurred only 33% of the total number of injuries at work, they incurred 65% of the tendonitis injuries and 61% of the repetitive motion injuries.

Important Facts: People at risk include carpenters, painters, welders, swimmers, tennis players and baseball players. The average patient is a male laborer older than 40, and the shoulder pain is on the same side as his dominant hand (for example, right shoulder pain in a right-handed person).

Volleyball players are particularly prone to shoulder tendonitis, inflammation of the tendons that support the shoulder.

If you have tendonitis, it’s very important to heal it quickly and completely. If you don’t, it may plague you forever.

Treatment Duration: Initial recovery is typically within 2 to 3 days and full recovery is within 4 to 6 weeks.

Do’s/Don’ts: Rest your shoulder initially, avoiding any movements that cause you pain. Start to do gentle movements as soon as possible to prevent any stiffness in your shoulder. Don’t push through pain. Only use your arm in ways that do not cause more pain. Do not attempt to strengthen the shoulder with push-ups. This has not been found to make a difference and may worsen the pain.

Common Myths: The issue we find with cortisone injections is that people get a false sense that they are healing because they are not experiencing the pain they once did. Some individuals even engage in activities they should not be doing because they “no longer feel pain”. Merely masking the pain is not a solution; it is just a temporary fix. Cortisone does not provide a permanent contribution to any stage of healing.

It is a myth that tendonitis injury heals completely back to 100% if you just give it time and rest. Tendonitis is really a process that is either going in a Downward Spiral or an Upward Spiral.

United States Food and Drug Administration has issued a special warning for all fluoroquinolones, including Cipro (ciprofloxacin), as these medications have an increased risk for tendonitis and tendon ruptures. If you are taking Cipro and experience tendon problems, such as difficulty walking, tendon pain, or weakness, contact your healthcare provider right away.

Bursitis

What is it? A bursa is a tiny fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body. The plural of bursa is bursae. There are 160 bursae in the body. Bursitis is inflammation of a bursa. When injury or inflammation of a bursa around the shoulder joint occurs, shoulder bursitis is present.

Statistics: The last statistic I looked at I think was from 2003 and there was at that time in the United States 14 million people who suffer from shoulder problems.

Important Facts:

You may have tendinitis (inflamed tendons) and bursitis in your shoulder at the same time. Your bursitis may be part of a problem called shoulder impingement (im-PINJ-ment).

Older age is associated with bursitis, and one of the most common places it strikes is in the shoulder, which has the greatest range of motion of all the body’s major joints. The pain is generally felt along the outside top of the shoulder. The discomfort of bursitis tends to be most severe after a night’s sleep and will typically subside somewhat with normal activity. Other places that are prone to bursitis are the elbows, hips, knees, and the base of the thumb.

Statistics: 8-13% of all sports injuries involve shoulder pain. 35% of elite swimmers reporting shoulder pain (swimmer’s shoulder). 52% of badminton players have past or present shoulder pain.

Treatment Duration: Two or three weeks should be enough to recover from mild or moderate shoulder bursitis.

Do’s/Don’ts: Take frequent breaks in sports that require repetitive overhead movements. Wear warm upper-body clothing in cold weather. Allow more warm-up time in cold weather. Wear sport-specific protective equipment to protect the shoulder against blunt forces.

Keep pressure off your shoulder. You may be told to avoid lying or sleeping on the shoulder with bursitis. You may be more comfortable sleeping on your back. Also avoid activities that make your shoulder pain worse, such as throwing and overhead reaching and lifting.

Keep your shoulder muscles strong by doing special exercises. Having strong arm, shoulder and back muscles can help support your shoulder. Your caregiver can help you plan an exercise program to build up your muscles and keep them strong.

Common Myths: Bursitis is the most common problem of the shoulder.

Reality: The term “bursitis” is often used incorrectly by physicians and patients to describe the most common cause of shoulder pain. Rotator cuff tendinitis is actually the most common cause of this complain.

Frozen Shoulder

What is it? Frozen shoulder (FS) is a fibrous contracture of the coracohumeral ligament and rotator interval coming on insidiously, or after minor trauma, and resulting in a global loss of active and passive movement especially in external rotation – and in the presence of a normal x-ray!

Statistics: Frozen shoulder is a painful, debilitating disorder reportedly affecting 2–5% of the general adult population (Lundberg, 1969) and 10–20% of people with diabetes (Miller et al., 1996).

This shoulder joint disorder affects roughly two-percent of the population and up to 20-percent of diabetics.

Important Facts: Primary frozen shoulder is classically described as having three stages, with stage I involving pain, stage II pain and restricted movement, and finally stage III, involving painless restriction (Reeves, 1975).

Left to its own devices the shoulder will start to thaw and slowly a near normal shoulder will come back.

Sadly FS is misdiagnosed some three times out of four. This is a particular error in the older age-group where I regularly find patients in their 70’s and older told they have FS when a simple x-ray would have revealed that they have Osteoarthritis (OA) or shoulder joint disease and really could do with a shoulder replacement. If you see a 70 year old with a stiff painful hip or knee, you would automatically and usually correctly, think arthritis. It is a myth to think that OA of the shoulder is rare.

Frozen shoulder (FS) is a fibrous contracture of the coracohumeral ligament and rotator interval coming on insidiously, or after minor trauma, and resulting in a global loss of active and passive movement especially in external rotation – and in the presence of a normal x-ray!

Treatment Duration: Most cases resolve over the course of 18–30 months. However, a minority of patients have a protracted course with ongoing restriction.

Do’s/Don’ts: It was only later when I read Doctor Cameron’s book that I discovered that exercises too early in the frozen shoulder situation can actually aggravate things. It seems that the best time to do exercises is near to the end of the business – when the frozen shoulder is in its thawing out stage. Of course, there was no way for me to know that so I just assumed that I must be making a meal of it and tried to just plod on as normal.

Once the diagnosis has been made – restricted passive external rotation and a normal x-ray – I offer my patients two alternatives: they can sit it out in the knowledge that it will all get better eventually or I can accelerate their recovery by doing an arthroscopic capsular release.

Common Myths: In the early stages FS and tendonitis can be indistinguishable. If the examining physician doesn’t actually try and move the arm themselves then they could believe that the shoulder doesn’t move but that is only because the patient doesn’t want to lift it any higher. Then a diagnosis of FS is made, a steroid injection is given and the symptoms all go away. Thus steroid injections cure FS!

Impingement Syndrome

What is it? Impingement Syndrome, which is sometimes called Swimmer’s shoulder or Thrower’s shoulder, is caused by the tendons of the rotator cuff becoming impinged as they pass through the shoulder joint.

Statistics: According to the Bureau of Labor Statistics (BLS) 2003 Survey of Injuries and Illnesses, in Texas, while back injuries are the most frequently reported on-the-job injury, shoulder injuries kept people out of work the longest—30 days compared to the back—12 days.

Published rates of the incidence and recurrence of shoulder pain are as high as 80% in competitive swimmers in the US.

Important Facts: In selected patients, chronic neck pain may be caused by shoulder impingement, which can be easily diagnosed with standard techniques. The difficulty in making this diagnosis is that the patient presents with neck pain rather than with the typical shoulder pain. The differential diagnosis of chronic lower neck pain should include shoulder impingement syndrome, which can be identified by classic physical and radiographic signs and can be treated with injection into the subacromial space and avoidance of the shoulder impingement position.

Treatment Duration: Conservative treatment (rest, ice packs, nonsteroidal anti-inflammatory drugs and physical therapy) is usually sufficient. Some patients benefit from steroid injection, and a few require surgery.

Do’s/Don’ts: TRY HARD TO STAY OUT OF STRESSFUL SITUATIONS! When your muscles tense up, your pain will increase! It’s a fact! A very sad fact, but a fact none the less!

I cannot stress how much you need to stretch in the morning as soon as your pain medication begins to work. Because if you don’t, when you don’t have any pain medicine, it will be harder to stretch the way you need to.

Don’t Wait To Go See a Doctor! I waited about 4 or so days before going to the doctor. THAT WAS TOO LONG! By then my right arm was basically useless, not to mention I was in such pain I was in tears. I was given some pain medication and it said take with food or milk.

Common Myths: Softball Pitching Myth Busted! For years, we’ve heard that the windmill pitching motion is natural and safe for the body unlike the overhead throwing motion that baseball players use. More and more research studies are showing that the incidence of pitching injuries in softball is pretty much the same as in baseball. In fact, the studies are showing that the windmill pitching motion is very tough on the body.

Myth: During a lat pull-down, you should pull the bar behind your head and to your upper back.
Reality: “This can lead to shoulder impingement syndrome, a painful condition that injures muscles, tendons and the shoulder joint. Pull the bar in front of your head to the top of your chest.”

Dislocation

What is it? If your shoulder is wrenched upward and backward, you may dislocate it out of its socket. This condition is both painful and incapacitating. The force required is often that of a fall or a collision with another person or object (both of which can occur during many sports).

Statistics: But even with physical therapy, for patients that are less than 25 years of age and are going back to high level sports, collision sports, contact sports, their chance of a recurrent dislocation is

Important Facts: The main symptom of a shoulder dislocation is severe pain at the shoulder joint.

The patient will have great difficulty moving their arm even a little bit.

If the shoulder is touched from the side, it feels mushy, as if the underlying bone is gone (usually the humeral head – top of the arm bone – is displaced below and toward the front).

Treatment Duration: Treatment may include medications to lessen pain. After a dislocation is confirmed by x-ray, many people require medicine to lessen pain and help relax the surrounding muscles during the reduction procedure (relocating the joint to its healthy alignment). The patient may require a mild sedative as well to allow the body to relax. Most people can have their dislocated shoulder relocated in the emergency department, but a few difficult cases require a general anesthetic in an operating room.

Do’s/Don’ts: If a sling is not available, rig one by tying a long piece of cloth in a circle (a bed sheet or towel may do nicely). A pillow placed between the arm and body may also help support the injured shoulder. Because an empty stomach is best during treatment, the patient should not eat more than ice chips before being examined by a doctor.

Common Myths: If you have dislocated your shoulder or another body part, a simple snap will not automatically put the joint back in place, regardless of what TV sitcoms suggest. Instead, ice the injury and seek emergency attention.

Subluxation Problems

What is it: A shoulder subluxation or instability involves a temporary, partial dislocation of the shoulder joint.

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 is all the way out of the socket. Both partial and complete dislocations cause pain and unsteadiness in the shoulder.

Statistics: Over 95% of shoulder dislocation cases are anterior.

Important Facts: A shoulder subluxation usually occurs in one of three types of patients: those with a prior injury to the shoulder, those who overuse their shoulder, and those who are double jointed.

What are the symptoms of shoulder subluxation?
Symptoms of a shoulder subluxation include the feeling that the shoulder has gone “in and out of joint”, “looseness” in the shoulder joint or, in some cases, pain, weakness or numbness in the shoulder or arm.

Treatment Duration: The doctor will place the ball of the upper arm bone (humerus) back into the joint socket. This process is called closed reduction. Severe pain stops almost immediately once the shoulder joint is back in place.

Do’s/Don’ts: Your doctor may immobilize the shoulder in a sling or other device for several weeks following treatment. Plenty of rest is needed. The sore area can be iced 3 to 4 times a day.

After the pain and swelling go down, the doctor will prescribe rehabilitation exercises for you. These help restore the shoulder’s range of motion and strengthen the muscles. Rehabilitation may also help prevent dislocating the shoulder again in the future. Rehabilitation will begin with gentle muscle toning exercises. Later, weight training can be added.

If shoulder dislocation becomes a chronic condition, a brace can sometimes help. However, if therapy and bracing fail, surgery may be needed to repair or tighten the torn or stretched ligaments that help hold the joint in place, particularly in young athletes.

Common Myths: If you have dislocated your shoulder or another body part, a simple snap will not automatically put the joint back in place, regardless of what TV sitcoms suggest. Instead, ice the injury and seek emergency attention.

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