Shoulder Pain

The shoulder is formed of three bones- the scapula or the shoulder blade, the clavicle or the collarbone, and the humerus or the bone of the upper arm. The shoulder joint is a ball and socket joint that allows our arms to rotate freely in all directions.   

What is shoulder pain?

Our shoulders are made up of bones, tendons, and cartilage. They have a complex structure and can develop aches or pains due to a variety of reasons. Shoulder pain includes pain during a movement, lifting the arm above the head, trying to sleep on the affected shoulder, and weakness in the shoulder muscles.

Causes

Shoulder pain may occur due to many reasons. The most common causes of shoulder pain are as follows:

• Rotator cuff disorders
  Rotator cuff disorders are one of the most common causes of shoulder pain. The rotator cuff is the place where the four tendons that surround the shoulder ball meet. A rotator cuff injury can be in the form of tears in the rotator cuff. Most rotator cuff injuries are a result of wear and tear due to ageing and deterioration of the cuff, though they can also occur due to an accident.
• Shoulder fracture
  The shoulder bones can get injured due to an accident. A fracture in the clavicle bone (the collarbone) is the most common kind of fracture. Fractures of the humerus (the upper arm) are more common in the elderly, particularly people over 65 years of age.
• Dislocation of the shoulder
  A shoulder dislocation occurs when the ball of the shoulder joint is pushed out of the socket in which it rests. This generally occurs due to a fall or a sports injury. The soft tissues that surround the shoulder tend to tear. At times, the bones get injured as well. Shoulder dislocation can be partial or complete. In a partial dislocation, the ball of the arm comes out of the socket partially, while in a complete dislocation, the ball comes out of the socket completely. This condition is also known as chronic shoulder instability.
• Frozen shoulder
  A frozen shoulder is a condition in which there is no movement in the shoulder. This happens when there is inflammation in the inner lining of the shoulder or the capsule of the shoulder. The shoulder capsule becomes tight and rigid due to inflammation, causing pain.
• Arthritis of the shoulder
  • Arthritis of the shoulder can be of different types. The most common type is osteoarthritis. It occurs when the smooth cartilage that covers the ends of the shoulder bones wears away and the bones start rubbing against one another causing pain.
  • Another type of arthritis is rheumatoid arthritis, which is an autoimmune disease where the synovium (the lining that lubricates the joints) begins to swell leading to pain and stiffness.
  • Post-traumatic arthritis is a form of arthritis that develops after a physical injury.
  • Rotator cuff tear arthropathy can cause arthritis when the surface of the bones is damaged.
  • Avascular necrosis, an uncommon condition, where there is a loss of blood supply to the head of the arm bone, can ultimately lead to arthritis.
• Biceps tendinitis
  Biceps tendinitis is a condition where the tendons of the upper biceps get inflamed. This condition often occurs along with rotator cuff tendon damage. The condition can occur due to activities that require repetitive overhead motion.
• Biceps tendon tear
  Tendons attach the muscles to the shoulder bones. A bicep tendon tear may occur due to an injury or normal ageing processes that reduce the strength of the tendon with overuse.

Risk factors

• According to a study, the risk factors associated with shoulder injury are physical load and a poor psychosocial work environment. An increase in the muscular activity with little rest may lead to shoulder pain. A social work environment that is not conductive may also contribute to the development of shoulder pain.
• Another study has shown that risk factors associated with heart diseases such as high cholesterol, high blood pressure, and diabetes are linked to shoulder problems. People with most risk factors for heart diseases are five times more likely to develop shoulder problems as compared to people who do not have any risk factors.
• People over 40 years of age and those who tend to do repetitive lifting and overhead activities are at a greater risk of getting rotator cuff injuries. Therefore, painters, carpenters, tennis players, and swimmers have a higher risk of rotator cuff injury.
• Other risk factors for tendon injuries are
  • Ageing.
  • Overuse of shoulder muscles.
  • Smoking.
  • Certain medications that contribute to muscle and tendon weakness.

Aches and pain in the shoulders tend to occur mostly due to ageing and other related factors. Certain preventive measures go a long way in keeping shoulder related problems at bay. These include:

• Right posture
  Poor posture can lead to shoulder pain. When you slouch, the shoulder muscles on your back get overstretched and become weak. The shoulder blade squeeze is a simple exercise that can help to align your shoulders. Push your shoulder blades back and hold the position for a few seconds. Improving your posture is the first step to strong and healthy shoulders.
• Strengthening exercises
  Strengthening exercises focus on the shoulder blade muscles and the rotator cuff muscles. Stretch your arms out while standing or sitting to form the letter T. Hold this position for a few seconds and then lower your arms. Repeat the exercise three times and perform fifteen such repetitions. The muscles near the shoulders can be strengthened by the use of dumbbells, rowing machines, or resistance bands. Make sure that you do not strain yourself or hurt yourself while using workout gear. Begin with smaller weights and less resistance and increase as you get stronger.
• Stretching exercises
  The shoulder muscles that need to be stretched in adults and in the elderly are the pectoral muscles located in the chest area. These muscles are strong as they are constantly exercised when one drives or is sitting on the desk typing. To stretch these muscles, lay on your back and stretch your arms on your sides to make a T. Hold the position for about a minute and repeat twice.

Shoulder pain is diagnosed through a combination of the person’s symptoms and various investigative tests. These include:

• Medical history
  Your doctor will take your complete medical history to evaluate your general health and to determine the possible causes of shoulder pain. Certain activities are known to aggravate the symptoms of shoulder pain, whereas, other activities help to relieve the symptoms.
• Physical examination
  Your doctor will ask you a series of health-related questions to evaluate your condition. He/she will then conduct a physical examination to find out the range of motion of your shoulders and muscle strength. The doctor will also check for tender spots that cause pain on touch.
• Diagnostic tests
  In addition, your doctor may prescribe certain tests to help him/her identify the exact cause of pain:
  • X- rays
    X- rays pick up any deformities and injuries of the bones that form the shoulder joint and help to locate the site of injury or extent of bone damage.
  • MRI and ultrasound
    Magnetic Resonance Imaging (MRI) is useful to precisely understand the injuries of the soft tissues like muscles, tendons, and ligaments. Ultrasonography helps visualize soft tissue swelling and accumulation of fluid.
  • Investigations to rule out a heart problem
    If your doctor suspects that your shoulder pain is due to an underlying heart problem, he/she will carry out investigations to rule out any heart diseases. These include blood pressure monitoring, blood tests to check for cholesterol levels, ECG, Echocardiogram and coronary angiography.

The treatment of shoulder pain depends on the cause of the pain. Timely detection and treatment are essential to prevent further damage to the shoulder.

• Rotator cuff injury
  • A rotator cuff injury can be in the form of a rotator cuff tear. If the injury is not treated on time and one continues to use the shoulder despite increasing pain, the tear may get larger. Your doctor may suggest certain non-surgical alternatives depending upon the severity of pain.
  • Your shoulder may be immobilized with a sling to protect it and to prevent movement.
  • You may be asked to avoid certain activities that may cause shoulder pain.
• Oral medications and injectables
  Your doctor may prescribe certain medications that will provide relief from inflammation and swelling. When oral medicines do not improve the symptoms, your doctor may prescribe you steroid injections. These injections help to reduce the swelling in the shoulder joint and the surrounding tissues, thereby improving the symptoms. Such injections may not be suitable for everyone.
• Exercises
  Your doctor may recommend an exercise programme after a shoulder injury or a surgery. A well-designed exercise program will help to increase muscle strength and increase flexibility. Strong muscles relieve pain and increased flexibility helps to reduce muscle soreness and restores the range of motion.
• Surgery
  Surgery may be considered when other treatment options fail. There are different kinds of surgical options for shoulder pain depending on the kind of injury.
  • Total shoulder replacement surgery
    A total shoulder replacement surgery is generally recommended when other medical options have been exhausted or cannot be used. People with osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, rotator cuff tear arthropathy, and those who have severe fractures of certain kinds are advised to undergo this surgery.
  • Reverse total shoulder replacement surgery
    A reverse total shoulder replacement is a surgical procedure that is recommended when the conventional total shoulder replacement surgery will not be effective for the person with shoulder pain. This surgery is different from a conventional total shoulder replacement surgery as it relies on different muscles to move the arm instead of the rotator cuff muscles. A torn rotator cuff that cannot be repaired, a complex fracture of the shoulder, a tumour of the shoulder, and an unsuccessful conventional shoulder replacement may be treated by a reverse total shoulder replacement surgery. Your doctor will recommend the procedure depending upon your case.
  • Shoulder arthroscopy
    Shoulder arthroscopy is a minimally invasive surgery that uses very small incisions as opposed to the larger incisions that are required in an open surgery. A number of small incisions are made through which a small camera is inserted into the shoulder joint. The camera shows images on the screen. The surgeon uses these images to guide and move miniature surgical instruments and repair the shoulder joint. This type of surgical procedure dramatically shortens the recovery time of the patients.

Lifestyle management

Most problems of the shoulders tend to develop slowly. Lifestyle modifications such as adopting the correct posture, stretching, and strengthening the shoulders go a long way in preventing and even reversing shoulder pain. Stretching and warm-up exercises are especially beneficial in preventing acute shoulder injuries like dislocations.

Prognosis

Most people with shoulder pain find that their condition improves over time. Medication, certain lifestyle modifications such as improving posture help to relieve pain. Serious problems of the shoulder respond well to surgical interventions.

Complications

Most complications of the shoulder arise due to a physical injury, which requires immediate medical aid. Shoulder pain tends to develop over time and timely diagnosis and treatment help to avoid serious complications and speed up recovery. It should be noted that some kinds of shoulder pain that occur towards the front of the shoulders may indicate a heart attack. Get immediate medical help if you feel an ache, heaviness, or a pressure spreading from your chest to the shoulders.