The 5 Common Causes of Shoulder Pain and Treatment Options

by Gregory C. Mallo . M.D. 

 Shoulder Service, St. Charles Hospital

Shoulder pain is a common complaint in many elite athletes, weekend warriors and senior citizens and some typical factors that lead people to see treatment for it include: difficulty sleeping, trouble with accomplishing daily activities, or a significant decline in peak athletic performance. Though some cases of shoulder pain require only minimal intervention, or may resolve on their own completely, others may require surgery and it’s important to know how and why any given treatment option is recommended.

The first thing shoulder experts do when trying to determine initial treatment for a shoulder problem is attempt to separate the injury into one of two categories: 1. an injury that came on slowly and progressed over time or, 2. an injury that resulted from a significant traumatic event. In other words, is the shoulder pain being caused by an overuse type injury resulting from inflammation of the muscle, tendon, or bursa or is there a potentially serious traumatic injury such as a tendon or ligamentous tear? Three of what can be considered the five most common shoulder problems involve an overuse type injury or an injury that seemed to have developed overnight.

Cervical Spine or Neck Related (pinched nerve)

If you have ever slept wrong one night or passed out slumped over a stack of books while studying for finals, then you have probably experienced a stiff neck at some point in your life. Sometimes, in addition to limited movement from side to side, pain may actually radiate into the shoulders as well as down the arm. In this case, the shoulder pain that is being experienced is known as referred pain; although the pain may seem to be coming from the shoulder region, it is actually “referred” from an area in the neck where there is muscle spasm leading to a pinched, irritated nerve.

Pain of from a pinched nerve can be distinguished from other types of injury because it is often present at rest as well as with movement.  It is made worse by positioning of the neck and moving it from side to side, and often travels down the arm in tear hands or fingers.

The treatment for this includes heat, massage, and stretching exercises.  Appropriate use of anti-inflammatory medications, muscle relaxers and occasionally oral prednisone (steroid) can be beneficial.  If pain continues or weakness develops, an MRI and/or an EMG (nerve study) will be requested by a provider to identify the severity of the condition or injury.

Bursitis

You don’t have to be a doctor or a shoulder surgeon to be familiar with bursitis.  What actually is bursitis, what causes it, and how is it treated?

First, every joint in your body has a bursa involved in its function.  A normally functioning bursa is a thin sac or sheet, much like two-ply tissue paper, allowing the tendons above or below to glide smoothly. The bursa reduces friction between the rough, sharp bone and the softer, more delicate muscles and tendons. If the rotator cuff bursa becomes thickened and inflamed, it can become compressed against a bone spur above it, especially when raising the hand above shoulder height. This process is referred to as impingement.

Pain from bursitis/impingement is often felt in the deltoid region, or lateral side of the arm due to referred pain from the sensitive nerves in the bursa. Similar to other overuse conditions, treatment focuses on decreasing inflammation which will in turn decrease the size of the bursa. Ice, avoiding overhead activities, and anti-inflammatory medications are the mainstay of treatment. For severe cases, a cortisone injection can be provided in physical therapy to strengthen the rotator cuff tendon beneficial.

In the shoulder, the bursa resides above the rotator cuff and immediately below the bone on the top of your shoulder called the acromion. This is called the subacromial space. When you move her arm away from her body, especially when using her hand above her head, the space between the acromion and the rotator cuff decreases.

If the rotator cuff bursa becomes thickened and inflamed, it can become compressed against a bone spur above it, especially when raising the hand above shoulder height. This process is referred to as impingement.  Pain from bursitis/impingement is often felt in the deltoid region, or lateral side of the arm due to referred pain from the sensitive nerves in the bursa.

Similar to other overuse conditions, treatment focuses on decreasing inflammation which will in turn decrease the size of the bursa. Ice, avoiding overhead activities, and anti-inflammatory medications are the mainstay of treatment. For severe cases, a cortisone injection can be provided in physical therapy to strengthen the rotator cuff tendon beneficial.

Biceps Tendonitis of the Shoulder

Repetitive overhead activity such as volleyball, tenderness, or throwing a baseball, can lead to inflammation of this tendon known as the long head of the biceps tendon. Often pain is located in the front part of the shoulder, and is made worse with activities such as turning a steering well, tucking in a shirt, clasping a bra, or performing a wide grip exercises such as a pull-up.

Treatment involves activity modification by ensuring that any carrying or lifting is done with her hands close to her body.  This will decrease the amount of force on the tendon. Anti-inflammatory medications, ice, stretching, and massage can be very beneficial. A cortisone injection can be provided, usually under ultrasound guidance to eliminate pain.

Wait a second.  Isn’t the biceps the muscle that allows you to bend the elbow and look like Popeye? While this is partially true, this is only half of the story. One end of the biceps muscle is the tendon that attaches to the elbow and allows for a biceps curl, while the other half of the tendon travels up the arm in a narrow tunnel and attaches deep into the shoulder joint.

Rotator Cuff Tear

Switching gears a little bit, a tear typically results from a one-time, traumatic injury such as a fall from a ladder while changing a light bulb or from getting

gang-tackled on the 1 yard line during the final play of a football game. A serious rotator cuff tear is very rare in someone under the age of 40 and becomes very common after 50 years old.

When a person suffers from both significant pain and significant weakness, it is time to seek a professional opinion. Often an MRI is needed to determine the severity of the rotator cuff tear. A complete full-thickness tear, like a complete hole in the knee of your favorite jeans, will never return to its original state without surgical repair. A small partial tear, similar to the back pocket of your jeans thinning from the repetitive storage of your wallet, can actually return to a normal non-injured state in about 1 out of every 5 patients. Others are able to become pain and symptom free through exercise, medications, and activity modification.

Labrum Tear

Those of us who follow baseball are probably familiar with a tear of the labrum or labral tear. The labrum is a rim of tissue that formed a bumper around the flat, dish-like socket of the shoulder called the glenoid. The labrum helps keep the ball from sliding over the edge of the socket and dislocating. Shoulder surgeons liken the joint to a golf ball sitting on a golf tee. The labrum acts like a small bumper on the edge of a golf tee, which makes it more difficult for a stiff wind to blow the ball over and off of the tee.

When a shoulder dislocates, or forcefully gets pulled out of the socket, the labrum tears from the force of the ball pushing out against it. Other times, repetitive activity such as throwing a baseball can result in a labral tear too. A labral tear is often associated with a feeling of apprehension or fear that the ball will come out of the socket when attempting overhead activities.

Initial treatment of a torn labrum involves rest and anti-inflammatory medications. Typically, a sling is used for a period of 1-2 weeks to allow for the shoulder to heal. Then, physical therapy to strengthen the rotator cuff and shoulder blade muscles is carried out. One should always seek professional medical evaluation after a dislocation to determine the need for surgery.

Sources:

http://www.nba.com/article/2018/03/26/philadelphia-76ers-markelle-fultz-available-play

http://www.philly.com/philly/health/a-closer-look-at-76er-markelle-fultzs-shoulder-injury-20171101.html