The Painful Shoulder
Deep persistant pain in the shoulder can affect young and old alike. The causes, however, can be very different and require a thorough diagnostic process to understand the underlying problem and lead to a solution.
Young, active patients often feel that there is an overuse syndrome. This may be the case, but it is important to understand why. Current exercise regimens usually emphasize strengthening the deltoid muscles, but the rotator cuff is largely ignored. This leads to an instability syndrome that can cause pain and even worse, a mechanical deficiency of the shoulder joint. If this is a chronic problem, with no history of a single traumatic event, the patient will usually respond to a strengthening therapy protocol that requires diligence on the part of the patient and therapist.
An acute injury, such as fall or impact on the raised arm, may lead to a discrete anatomic injury that may require repair. Because of this, it is critical to make a diagnosis and this is often dictated by the patient’s history of the problem. When acute injury leads to persistant pain, we often order an MRI which is a diagnostic study that best looks at the soft tissue structures deep in the shoulder. A plain xray only looks at the bony structures and is usually normal in people with painful shoulder syndromes. The MRI can often indicate the severity of the soft tissue injury and can dictate whether continued conservative treatment (anti-inflammatories, cortisone injection, and therapy) or surgical intervention is warranted. A true anatomic disruption, such as a torn cartilage rim or tendon rupture, will usually not get better on its own hence a mechanical solution may be necessary. In today’s modern age of medicine, we can fortunately solve many of these problems through arthroscopic surgery. This means that the joint is visualized through a small camera inserted through tiny holes in the skin outside the joint. This minimizes scarring, improves the surgeon’s visualization of the problem, and speeds the recovery. In certain cases, an open incision may be required depending on the severity and location of the problem.
Older patients often attribute their shoulder pain to “arthritis”. In fact, arthritis in the shoulder joint (particularly the ball and cup joint) is rather rare. Arthritis is when there is loss of cartilage in a joint and can lead to bone grinding against bone. This osteoarthritis condition is more commonly seen in the knee, hip or even the base of the thumb, but much less so in the shoulder.
The most common cause of shoulder pain in older people is known as impingement syndrome. Bursitis is often an element of this syndrome and this frequently used term is much more accurate in depicting the problem than the term “arthritis”. Impingement refers to the mechanical process where the overlying bony arch of the shoulder (acromion of scapula and clavicle) is pressing on or rubbing on the underlying rotator cuff tendons and bursa. With age, the blood supply to the rotator cuff is diminished, and small microtears in the tendon leads to tendonitis and bursitis and even larger tears. This situation may respond to conservative treatment including a cortisone injection to reduce the bursitis, and shoulder therapy to improve the strength of the intact rotator cuff. A complete rotator cuff tear implies that the torn tendon has pulled away from the bone and hence, cannot stabilize the head of the humerus against its cup joint (glenoid). The patient will either be unable to physically raise the arm or they can do this only with severe pain. This whole range of impingement problems is characterized by pain with elevation of the arm, pain worse at night, and inability to lie on the side of the affected shoulder.
Once the pain is severe enough and does not respond to therapy and other conservative means, then surgery is indicated. Some smaller tears can be repaired through arthroscopic means, but larger tears are usually repaired through a traditional incision. Most repairs require a one month period of immobilization in a sling and several months of postoperative therapy closely directed by the surgeon. The shoulder is a demanding joint and requires patience on the part of both patient and treating surgeon. The recovery is usually not rapid, but diligent adherence to the therapy protocol will in most cases yield a good result and a functional shoulder with minimal or no pain.
Alejandro Badia, MD Upper Extremity Surgeon Miami Hand Center
