Shoulder Pain

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Shoulder pain is a common complaint in the working and sporting adult. In most instances, the pain in the shoulder is transient and resolves spontaneously without treatment. However, in some individuals, this pain can become chronic and debilitating, limiting your ability to work, hindering your enjoyment in sports, or even disturbing your sleep at night.
The shoulder is a complex structure, made up of multiple tendons and muscles working together. The complexity of the shoulder anatomy allows a great degree of movement in the joint. However, it is also this mobility that makes it prone to degeneration and injury.
Some of the more common causes of shoulder pain are discussed here. An Orthopaedic surgeon is trained in the non-operative and surgical management of musculoskeletal disorders, and will be in a good position to advise you on your condition.

Shoulder Impingement Syndrome

In shoulder impingement syndrome, there is inflammation of the rotator cuff tendons and surrounding bursitis. This may sometimes be made worse with a bone spur on the underside of the acromion (shoulder blade bone).

Patients often complain of shoulder pain when trying to raise their arms, especially with lifting activities. They may have difficulty reaching for items placed on the top shelf, bending their arms to reach their back pockets, or putting on undergarments or clothing. They may have feelings of weakness in the arm. The pain can disturb sleep at night, making it difficult to find a comfortable position when lying in bed, or even waking them from sleep.

A visit to the doctor is important for him to understand the condition of your shoulder. Besides performing a clinical examination, he may arrange for an ultrasound or MRI of the shoulder to check on the integrity of the rotator cuff tendons.

Once the diagnosis is confirmed, your doctor will prescribe medications to improve the pain, and settle down the inflammation. Sometimes, your doctor may give an injection to the shoulder to help with the situation. Working closely with your therapist is important to prevent stiffness of the shoulder from developing, and also to promote strengthening of the cuff muscles. Most patients with shoulder impingement syndrome do get better with non-operative treatment.

In some situations, surgery may be required if the condition fails to improve. In the surgery, the inflammed bursal tissue will be removed, and the bone spur smoothened and leveled off. The rotator cuff will also be inspected to check for tears, and cleaned out or repaired.

Rotator Cuff Tears

The rotator cuff tendons surrounds the shoulder joint and is responsible for the strength and movement of the joint. These tendons can be damaged during a fall, when lifting too heavy a load, or simply because of overuse of the shoulder. When the tendons are damaged and torn, it will be painful to move the shoulder, and the shoulder will feel weak. The symptoms that you experience can be quite similar to that of shoulder impingement syndrome. However, it is important to distinguish one from another because the treatment of a torn cuff tendon is quite different. The torn tendon will usually need to be surgically repaired to restore function in the shoulder. A small tear that is repaired early will generally do better than a large tear that has been left neglected for a long time. So it makes sense to see your doctor early if you have any doubts.

Frozen Shoulder

This condition is also known as adhesive capsulitis. For reasons that are still not clearly understood, there is inflammation of the capsule that surrounds the joint. The joint capsule is thickened and inflammed, binding the joint tightly and preventing free movement of the shoulder. The shoulder generally feels stiff and painful. Depending on the degree of joint stiffness, this condition can seriously limit the function of the individual.

The initial treatment involves medication to settle the inflammation, and regular therapy sessions to regain flexibility of the shoulder joint. In most instances, this condition is self-limiting and it improves over time. However, progress is usually gradual, and it takes a lot of patience and perseverance on the part of the patient before improvements can be seen.
In certain situations whereby the condition is stagnant or worsening despite diligent efforts from the patient, surgery may be useful. During capsular release, the tight capsule of the joint is carefully divided to prevent injury to the other surrounding structures. Once the capsule is divided, the joint can be easily manipulated to regain motion and flexibility. Aggressive therapy usually follows to minimise the risks of recurrence of stiffness of the joint.

Acromio-clavicular Joint Osteoarthritis

The acromio-clavicular joint is located at the front of the shoulder, between the shoulder blade (acromion) and the collarbone (clavicle). The joint surface can undergo wear and tear, with thinning out of the joint cartilage. An arthritic joint will usually be painful, stiff and weak. This is especially so with movement of the arm above the chest level and when reaching across the chest.

Medications and injections to the joint can help with temporary relief of painful symptoms. In some situations, your doctor may propose surgery to resect the diseased joint for more permanent pain relief.

Recurrent Shoulder Dislocations

The shoulder joint is essentially a “ball-and-socket” joint consisting of the “ball” of the arm bone (humeral head) sitting in the “socket” of the shoulder blade bone (glenoid). This socket is deepened at the edges by a raised cartilage bumper called the labrum, thus preventing the humeral head from shifting out of the socket during shoulder movement.

The labrum can be damaged when the shoulder dislocates or shifts transiently out of joint. Once damaged, the restraint is lost and the shoulder becomes unstable. This feeling of instability can cause pain, especially when the arm is raised and put out to the side of the body.
Physiotherapy is generally useful to strengthen the surrounding muscles and regain some stability to the joint. With avoidance of certain risky maneuvers, most individuals are able to perform their daily activities without difficulties.
However, if you are a high-demand recreational or professional athlete, you may find that the shoulder is not stable enough to allow you to return to your sport of choice. In other instances, the shoulder is so unstable that it will dislocate even during simple actions such as reaching backwards with the outstretched arm, or even when sleeping! Under these circumstances, surgery can help to repair the labrum, and stabilize the shoulder joint.

Conclusion

Most shoulder surgeries nowadays can be performed using minimally-invasive techniques. Such “keyhole” procedures allow surgery in the shoulder to be carried out using multiple small skin incisions and specialized equipment. This technique gives the surgeon an excellent view of the structures in the joint, allowing the surgeon to make accurate diagnoses, before initiating the appropriate treatment. In addition, there is usually minimal injury to the surrounding tissue. Hence, recovery from surgery is often faster, and rehabilitation exercise can be started earlier.

In short, there are many conditions in and around the shoulder joint that can cause pain, stiffness, weakness, and limitation of arm function. So, visit your doctor early so that he can determine the cause of your problem, and help you make things better.

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Expert Author:
Dr Chong Kian Chun, Island Orthopaedic Consultants