Shoulder pain can come from more than one source. Your age, occupation and previous injuries may all play a role. Common causes include trauma, tendinitis, impingement syndrome, rotator cuff tear, arthritis, calcific tendonitis and frozen shoulder
Trauma means an injury. With shoulder pain, it means an injury to that joint – often from a direct blow. Any part of the shoulder can be injured. Broken bones, dislocations and shoulder separations are all common.
The most frequently broken bone in the human body is the clavicle (collar bone). This injury requires surgery only in special cases. It will first be treated with a sling to support the arm and prevent movement. Once it is less painful, physical therapy can be started. Those who suffer this injury are usually left with a bump over the collarbone.
The humerus (upper arm bone) can also be broken. This is more serious and sometimes requires surgery. The shoulder blade, or back part of the shoulder joint (scapula) can be fractured as well. This rarely requires surgery.
Keep in mind that other injuries may take place at the same time that a bone breaks. They may not show up on x-ray. If you still have pain after your shoulder should be better, another injury may have been missed. Since bones are sometimes slow to heal, surgery may be needed to speed up the process.
Shoulder dislocations and separations are two different injuries. The two terms do not mean the same thing and are often used incorrectly.
A shoulder dislocation involves the glenohumeral joint (see right). This is the connection between the ‘ball’ of the upper part of the arm bone and the ‘socket’ of the shoulder blade. It is important for movement of your arm. Several structures keep this joint together. A shoulder dislocation is an emergency that must be given immediate attention. Unless the joint is put back into the right position, permanent nerve damage may result. Depending on your work and activities, some surgeons may recommend surgical repair.
A shoulder separation is a separation of the acromioclavicular joint (see right). This is the connection between your collarbone and the top of the shoulder blade. Strong ligaments hold it together. These injuries are rarely emergencies and seldom require surgery. You may end up with your shoulder slightly out of line but you will have full use of it.
Impingement syndrome is probably the shoulder problem people understand least. The way that impingement syndrome develops is shown in the diagram above. Some tendons in the rotator cuff muscles pass through a very tight space in the shoulder. This space is actually an arch. Either the arch is too small or the tendons are inflamed or frayed. If they catch as they travel through the arch, it is called impingement. This condition usually starts slowly or may develop after a traumatic injury. Many arm movements are painful, especially those above shoulder level or behind your back (such as putting on a brassiere). The arm may ‘catch’ painfully with these movements.
The best way for a doctor to diagnose this condition is by examining the shoulder. An injection to freeze the tendons of the shoulder joint is an excellent test to confirm diagnosis. Usually this temporarily reduces pain.
Treating impingement syndrome is similar to that of tendinitis. It may include rest, ice or heat, anti-inflammatory medication and physical therapy.
If these treatments do not help, a cortisone injection can be useful. Many doctors will inject shoulders with cortisone before recommending surgery for impingement syndrome. If the injection does not help, surgery often gives excellent results.
This common injury involves a tear in the rotator cuff, a specific group of four shoulder muscles. If you have this type of injury, you may not even know what actually caused the tear. Most arise from the wear and tear of impingement syndrome rather than one specific injury. You may have pain and weakness. Sometimes your arm will even give out when you try to lift it.
Your doctor will first examine your shoulder. Diagnosis can be confirmed in one of two ways. The first uses a special x-ray such as an arthrogram, where the shoulder is injected with dye and x-rays are taken. The second method, diagnostic ultrasound, is now more commonly used to diagnose rotator cuff injuries. Not all rotator cuff tears cause pain, nor do they all require surgery. You may have a rotator cuff tear and not have any pain or weakness. Physical therapy sometimes makes the pain go away. For this reason, surgery is usually delayed when a rotator cuff tear is suspected.
Many types of arthritis exist, but the kind discussed here is osteoarthritis caused by wear and tear. Both the acromioclavicular and glenohumeral joints can be affected. Although X-rays sometimes show arthritis, seeing it on x-ray does not mean it is causing pain. If arthritis is the cause, physical therapy and medication may be recommended. If these fail, cortisone injections may work, or surgery in severe cases.
Tendons are the structures connecting muscles to bone. If they are overused or repeatedly injured, they can become inflamed and painful. The condition, called tendinitis, is a very common cause of shoulder pain. Usually tendinitis is associated with some activity such as heavy or repetitive lifting and the pain goes away with rest. If pain persists, the injury may be more serious. Treatment is rest, ice or heat, anti-inflammatory medication and sometimes physical therapy. Occasionally, a cortisone injection is needed.
This condition is a build up of calcium in the tendons of the shoulder. It is more common in people with diabetes. It may be a relief to learn that with calcific tendonitis the pain usually goes away in seven to ten days. On x-ray, calcium can often be seen long after the pain has gone. If x-rays are taken for a different reason and calcium is spotted, it just means calcific tendonitis was there in the past. The calcium may need to be removed surgically if it is still a problem.
This condition makes the shoulder stiff and painful. We don’t know why it happens, although it is more common in women, those with diabetes, thyroid problems or injuries to the shoulder. Frozen shoulder has three stages. The whole process can take up to three years. It first starts with pain lasting weeks to months, usually worse at night. Next is stiffness lasting four to 12 months. Finally the shoulder ‘thaws’ and becomes less stiff over weeks to months. With this condition, shoulder x-rays often appear normal. Physical therapy is usually used to treat it, although sometimes a cortisone injection will help.
Occasionally a surgeon will move the joint under general anaesthetic to reduce stiffness and speed recovery. This carries a small risk of a fracture.
What is the best test to diagnose shoulder pain? Believe it or not, the best test involves information you give to the doctor and a physical exam. Diagnosis can usually be based on this evaluation. If you have had an injury, either once or repeated, this may help narrow down the cause.
Sometimes x-rays and diagnostic ultrasound may confirm diagnosis. The publicity around magnetic resonance imaging (MRI) tests leads many to think this is the best method. In fact, MRI can be a poor way to assess many shoulder problems and is often unnecessary. It can miss things or even provide findings that are not causing symptoms.
Your shoulder may not even be the source of your pain. The neck contains several nerves that can cause pain in the shoulder. Your doctor may get x-rays or MRI of your neck to determine if a pinched nerve is involved.
If you suffer from a painful shoulder, you do not need to be told how much it can disrupt your life. Talk to your family doctor about it, and take heart – something can usually be done.