Shoulder pain is the third most common musculoskeletal complaint, behind neck and back pain, seen in medical practices each year. The cause of shoulder pain can range from uncomplicated sprains to massive rotator cuff tears. During a 6 year span, there were over 5 million physician visits for shoulder pain attributed to rotator cuff problems. Research has indicated that the incidence of rotator cuff damage increases with age due to degeneration of the tendon. This suggests that as the current population ages, rotator cuff repair will also increase. Although the majority of these conditions are responsive to conservative treatment, some may require surgery.
Let’s go over some anatomy: The rotator cuff is a group of muscles and tendons that work together to stabilize the shoulder. The four muscles of the shoulder are the supraspinatus, infraspinatus, teres minor and subscapularis. The supraspinatus muscle is responsible for abduction (moving away from the body), the infraspinatus and teres minor provide external rotation (rotating away from the body), and the subscapularis provides internal rotation (rotating in towards the body). These muscles and tendons connect the humerus (upper arm), with your shoulder blade, or scapula. They also help hold the head of you upper arm bone firmly in your shoulder socket. This combination allows your shoulder to have the greatest range of motion (ROM) in the body.
Rotator Cuff Injuries
A rotator cuff injury includes any type of irritation or damage to your rotator cuff muscles or tendons. These injuries can range from Impingement Syndrome to Partial- and Full-Thickness rotator cuff tears. Impingement Syndrome is a chronic process that presents itself as shoulder pain. If left untreated, it can progress to permanent changes and eventual tearing of the rotator cuff. External impingement is the most common form of impingement syndrome and is caused by compression of the rotator cuff tendons as they pass through the coracoacromial arch. As this type of compression happens repetitively, it can cause inflammation of the bursa lining the joint and can narrow the space further. Other factors can contribute to the narrowing of this space as well, such as bone spurs and arthritic changes.
These changes and the progressive degeneration of the tendons can eventually lead to partial or full-thickness rotator cuff tears.
Common causes and risk factors of rotator cuff injuries may include:
- Trauma: Falling on the shoulder or outstretched arm, especially in the elderly, when attempting to break a fall.
- Normal wear and tear: After age 40, normal wear and tear on your rotator cuff can cause breakdown of collagen in the cuff’s tendon and muscles, which makes them more prone to degeneration and injury. You can also develop calcium deposits within the cuff or arthritic bone spurs that can pinch or irritate the rotator cuff.
- Lifting heavy objects
- Repetitive overhead activities (e.g. throwing a baseball, basketball, freestyle swimming, tennis)
- Occupational overuse (painting, carpentry, grocery clerking),
- Abnormally shaped acromion, which can make impingement of the rotator cuff tendons more likely.
- Poor Posture: Slouching causes your neck and shoulders take a forward position, which causes the space where the rotator cuff muscles are located in to narrow further and can impinge on the tendons.
Signs and symptoms may include:
- Pain and tenderness in your shoulder, especially when reaching overhead, reaching behind your back, reaching across your body, lifting/pulling or sleeping on the affected side.
- Shoulder weakness, especially in abduction or flexion. Many people frequently describe having significant difficulties combing hair, holding a hair dryer and removing. Immediate onset of weakness, especially associated with sudden trauma, can indicate an acute tear.
- Loss of range of motion.
- Inclination to keep your shoulder inactive.
A visit to your doctor is your next step. They’re likely to ask you several questions.
- Where is your pain located?
- Does your job or hobby aggravate your shoulder pain?
- When did the pain first occur?
- How severe is your pain?
- What specific movements aggravate or alleviate your pain?
- Do you have any weakness or numbness in your arm?
In the days before your doctor’s appointment, you can decrease your discomfort by trying some of the following:
- Rest your shoulder. Avoid movements that aggravate your shoulder and give you more pain.
- Apply cold packs. This can help reduce pain and inflammation.
- Taking over-the-counter pain medications, with the approval from your doctor. Nonsteroidal anti-inflammatory drugs (NSAIDS), such as aspirin, ibuprofen (Advil, Motrin, others) and naproxen (Aleve), to help reduce pain.
Tests and Diagnosis
After the doctor examines you, and if your injury appears to be severe or if they cannot determine the cause of your pain through physical examination, they will most likely order one or more diagnostic tests. These may include:
- Magnetic Resonance Imaging (MRI) scan
- An ultrasound scan
The main goal of any therapeutic intervention for shoulder pain is the return to pain-free function. A number of different factors can help determine the course of action that is taken when trying to reach this goal, such as age, pre-injury functional level and general health.
- Steroid Injections: Your doctor may use a corticosteroid injection to relieve inflammation and pain.
- Physical Therapy: This is the most conservative of all of the options. After modifying your activity and controlling pain, physical therapy can be begun. In the first active phase of therapy, gentle ROM exercises are started to prevent adhesions or scar tissue from forming followed by a strengthening program of the rotator cuff and scapular stabilizer muscles. Various modalities can used concurrently to aide in decreasing pain and inflammation such as ultrasound and electric stimulation.
- Surgery: If a large tear is present in your rotator cuff, you may need surgery to repair it. The surgery may be performed as an open repair with a 2 ½ to 4 inch incision or as an arthroscopic repair, which is less invasive.
- Arthroplasty: Severe, chronic rotator cuff tears may contribute to severe arthritis. Your doctor may want to perform a total shoulder replacement or arthroplasty.
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