Shoulder pain

One of the most common complaints I see in the clinic is shoulder pain.  The shoulder is one of the largest and most complex joints in the body.  Being a shallow ball-and-socket joint, it’s also the most mobile in your body. The ball is stabilized within the socket by a lip around the socket called the labrum (Latin for “lip”) and the rotator cuff.  The labrums primary function is to keep the shoulder ball inside its shallow socket.  The rotator cuff is four small muscles and tendons that help tether the ball into the socket and help lift and move your arm.  Keeping the ball of your upper arm in the shoulder socket is a tough job, with inevitable wear and tear.

You probably don’t think about your shoulders much, until you experience pain in one of them.  Shoulder pain, stiffness or weakness can make it difficult to carry out simple everyday activities, like brushing your hair, driving a car or reaching for something overhead.  Figuring out what’s wrong with your aching shoulder is the first step toward making it better. 

How to determine if shoulder pain is serious

Signs and symptoms of a shoulder injury:

• Sudden and sharp pain
• Decreased range of motion
• Pain associated with swelling, pressure or bruising
• Constant pain or pain that continues to worsen over time
• Pain that prevents you from falling asleep or wakes you up
• No pain relief after several days of rest, icing and over-the counter medications

Common conditions that cause shoulder pain

Rotator cuff impingement

Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the underlying soft tissues when the arm is lifted away from the body. As the arm is lifted, the acromion rubs, or "impinges", on the rotator cuff tendons and bursa. This can lead to bursitis and tendinitis, causing pain and limiting movement. 

Rotator cuff bursitis 

Bursae are small, fluid-filled sacs that are located in joints throughout the body, including the shoulder. They provide lubrication and act as cushions to reduce rubbing and friction between the gliding muscles and the bone.  Overuse of your shoulder or keeping the joint in an awkward position can aggravate the bursae, leading to swelling and inflammation of the bursa between the rotator cuff and part of the shoulder blade known as the acromion. The result is a condition known as subacromial bursitis which often occurs in association with rotator cuff tendinitis.

Tendinopathy 

Tendons are rope-like structures that connect your muscle to bone. Most tendinitis is a result of your tendons getting inflamed and irritated.  The pain is often associated with stiffness and usually present on the front and side of your shoulder.  The pain is usually aggravated by activities that involve using your arms overhead, like tennis, painting or brushing your hair. Often the pain will be worse at rest and improve with activity. 

Tendinopathy is one of two types:

• Acute (Tendinitis) - result from repetitive, forceful overhead activities such as throwing a ball, swimming or painting.
• Chronic (Tendinosis) - result from degenerative diseases like arthritis or repetitive wear and tear due to age.

Rotator cuff tears

Tearing or splitting of the rotator cuff will produce pain that is similar to impingement but has one additional differentiating feature. If the pain is associated with weakness, it is likely caused by a tear.  Tears can be partial thickness, whereby only part of the tendon is ripped away from the bone it’s attached to. Or there can be a full thickness tear, causing the tendon to completely separate from the bone. Although younger people can have rotator cuff tears, they become more common as we age, possibly because the interface between the tendon and the bone weakens and becomes more susceptible to injury. The prevalence rises with each decade of life.

Compared with impingement, a tear is more likely to be caused by an injury. Common causes include falling down on an outstretched arm, getting pulled by a dog on a leash, or tripping and landing on your shoulder. It may also deteriorate slowly over time due to a repeated motion (For example, a plumber or hair stylist who frequently raises their arms overhead). You may also experience pain when lifting your arm overhead (like brushing your teeth) or weakness when trying to lift anything above shoulder level.

Calcific Tendonitis

With calcific tendinitis, calcium deposits get embedded within the rotator cuff tendons. While it's unclear exactly what causes these deposits to form, some experts believe they may result from a healing process in the ligament gone awry. The condition can cause severe pain that often starts in the morning. It's more common in middle-aged and older adults and those who have diabetes or Parkinson’s disease.

Adhesive capsulitis

Commonly referred to as frozen shoulder, adhesive capsulitis is the painful condition where your shoulder becomes stiff and can’t move.  It’s caused by a thickening and stiffening of the tissues around the shoulder joint. It typically develops in people ages 40 to 60. Frozen shoulder is more common in women than in men and in people with certain medical conditions, such as diabetes, high cholesterol, or thyroid disorders.

Frozen shoulder can occur after a rotator cuff impingement, a tendon tear, or even minor injury. Why some people go on to develop a frozen shoulder is not clear. Someone with a shoulder injury may hesitate to move the arm as a result of the pain, which then leads to additional pain and stiffness. As a result, it may become virtually impossible to move the shoulder for weeks or months. The less you move your arm, the more the problem grows. Eventually, your shoulder feels frozen in place, hence, the name.  

Shoulder osteoarthritis

When people think of osteoarthritis, they may think of the knee or the hip, which are common sites for arthritis pain. But while osteoarthritis affects the shoulder less often, it's not uncommon. The condition develops when cartilage cushions between the bones in the shoulder erode, causing the bones to rub against one another.  It may be related to injury from sports (swimming, volleyball, baseball) or work.  Many people have no specific cause, it’s just “wear and tear” over time.

Symptoms such as deep aching pain in the back of your shoulder associated with swelling and stiffness, typically begin during middle age.  It develops slowly and the pain it causes worsens over time.  While you may be tempted to stop moving when you experience pain from osteoarthritis, doing so can make the problem worse.  Lack of movement allows the muscles to stiffen and shorten, resulting in a painful restriction of motion.  Ultimately, it may become even more difficult to move the way you want to, or result in a Frozen shoulder.

Other forms of shoulder arthritis include:

• Rheumatoid arthritis - this chronic autoimmune disease targets joints in your body, including your shoulder
• Post-traumatic arthritis - a shoulder injury may  heal, but there can be long-term damage that shows up later in the form of post-traumatic arthritis
• Rotator cuff tear arthropathy - count this form of arthritis among the potential after-effects of a rotator cuff tear.
• Avascular necrosis - this painful condition happens when something blocks the flow of blood to your bone.  It’s typically caused by fracture or disease.

Labral tear

The labrum is a cup-shaped rim of cartilage that lines and reinforces the ball-and-socket joint of the shoulder. It’s the “lip” of the socket that helps connect the shoulder socket on the scapula with the head of the humerus. It makes the socket deeper, creating space for the bones to move, and coats the surface of the socket area with soft cartilage, enabling the shoulder to move more freely and painlessly.

A shoulder labrum tear may be caused by a direct injury to the shoulder or be the result of prolonged wear and tear.  While labral tears can occur in big traumas, like a car crash or a serious fall, shoulder instability is a cause often missed.  Instability can slowly increase after an old injury or a seemingly less traumatic event.

Treatment

Treatment generally starts with rest, altering your activities, and physical therapy to help improve shoulder strength and flexibility.  Medications to reduce inflammation and pain may be beneficial, but they seldom are the solution to resolving your pain.  Failing simple treatment methods often leads to a surgical recommendation.  Certain types of shoulder problems, such as recurring dislocations, severe arthritis and large full thickness tears, may not benefit from conservative treatment and require surgical repair.  However, the vast majority of shoulder pathology will respond to Orhtobiologic injection in the form of Platelet-rich plasma (PRP) or stem cell therapy. 

Platelets are the part of the blood that allows the body to clot and initiate a healing response.  PRP is simply plasma obtained from your blood that contains a higher concentration of platelets than normal.  Studies have indicated that PRP is useful in treating tendon, ligament, muscle and joint injuries  The goal of treatment is to heal and repair injured tissue.  Adding PRP to a treatment regimen can help to stimulate the healing process, decrease pain and enable a return to activities sooner.

Stem cells are the body’s raw materials - cells from which all other cells with specialized functions are generated.  They are harvested from your bone marrow or fat (adipose).  Under the right conditions in the body they divide to form new stem cells or specialized cells such as blood, muscle, tendon, ligament or bone cells.  Stem cell therapy is generally used for more advanced pathology, such as full thickness rotator cuff tears or advanced arthritis. 

What to do if your shoulder hurts

As you age, you’re more likely to experience shoulder pain from a variety of common conditions.   The pain can come on gradually or abruptly, and range from mild to excruciating.  If you do have a problem, the much-used joint isn't shy about sharing the news.  However, the cause of the problem isn’t always obvious.  In general, if you’re experiencing a lot of pain or know you injured yourself, it’s best to see a doctor right away to have your shoulder condition diagnosed.  If you’ve had mild shoulder pain that’s gradually progressing, tried modifying your activities, over-the-counter medication, and performing gentle stretching exercises without benefit, it’s time to consult with a doctor.

Want to know what’s causing your shoulder pain and how to treat it?  Contact us to learn more about the best treatment options for you.