Diagnosing and Treating Shoulder Problems

by Patrick O'Connell, M.D.

Diagnosing and Treating Shoulder Problems

Listening to patients discuss their symptoms is the first step in assessing common shoulder problems. We’re looking for the nature of the problem, and we’re often able to diagnose the problem from a patient's history.

  • Where is the pain?
  • Is it in the shoulder?
  • Is it the back, front, or side of the shoulder?
  • Does it radiate down the arm?
  • Does it go up into the neck?
  • Is there numbness or tingling?
  • Is the pain sharp or dull?
  • When does it occur? At night, in the morning, or during the day?
  • Does it keep you from sleeping?
  • Do you notice weakness in the shoulder when performing daily tasks such as lifting a gallon of milk out of the refrigerator?

The responses to these questions are all clues that give us an insight as to what the problem might be. When evaluating your shoulder, we also like to know what eases the pain and what aggravates it.

Equally important to a diagnosis is a good physical examination, and that starts with a simple inspection of the shoulder. We’ll be able to receive even more clues through this process.

  • Is there atrophy in the shoulder?
  • Is there significant swelling?
  • Is there bruising or discoloration of the skin (ecchymosis)?
  • Is there tenderness? And if so, where is the tenderness?
  • What is your shoulder’s range of motion?
  • What particular movements create pain?
  • How strong is the shoulder? Is there normal strength accompanied by pain? Or is there significant weakness in certain planes?
  • What direction does the shoulder feel loose in?

Once the physical evaluation is complete, we will take x-rays to identify if there is any arthritis or deformity within the shoulder.

The clues gathered from the symptoms discussion, physical evaluation, and imaging allow us to diagnose the problem and create a unique, individualized treatment plan. We start with more conservative treatment options such as physical therapy, medications, and injections.

If conservative options do not provide significant relief, we will move on to getting more extensive, advanced imaging done like an MRI. Unlike the x-ray, the MRI will provide a picture of what’s going on with the soft tissues in the shoulder. We’ll be able to identify rotator cuff tears, arthritis, labral tears, ligament tears, and much more. MRIs are particularly helpful if we feel that surgical treatment options may be the best route for your individual case.

What are some common shoulder problems?

Instability

Shoulder instability is common and can be caused by numerous situations and conditions. One category is traumatic unidirectional instability, which occurs when a patient falls or moves their arm incorrectly, and the shoulder dislocates.

Shoulders typically dislocate and shift forward, called anterior (from the front) dislocation, but they can sometimes dislocate and shift backwards, called posterior (from the back) dislocation. Posterior dislocations require a very different treatment plan, so identifying them is crucial.

A dislocated shoulder is easy to notice during a physical examination. Usually though, a patient will come see us after the shoulder has already been put back in place. From there, we then diagnose the direction of the instability and the appropriate treatment plan. Oftentimes for patients with a first-time dislocation, we will immobilize the shoulder for a period of time and follow that with physical therapy sessions. The younger a patient is when that first dislocation occurs, the higher the chances are it will reoccur. If dislocation happens again, we most likely will have to resort to surgical treatment.

The concern with patients who have reoccurring dislocations is the damage happening inside the shoulder. Every time the shoulder comes out of place, a little bit more of the inner shoulder is injured. Often some bone from the glenoid (socket of the shoulder) is lost during this process because the humerus (head of shoulder) hits the socket when it dislocates. If a patient loses enough bone, the shoulder becomes extremely unstable and will require a different operation where we will need to put some bone in the front of the glenoid.

Atraumatic instability is another common type of instability where the shoulder is slipping part of the way out, instead of being completely dislocated. This condition can also be called multidi-rectional instability and is often associated with people who are hyper-flexible or have certain connective tissue diseases such as Ehlers-Danlos syndrome or Marfans. Just like any other shoulder problem, resolving it with physical therapy and conservative treatment options is the goal. But again, if that does not work, surgery is most likely the route that will need to be taken.

Rotator cuff

Rotator cuff conditions are also very prevalent. Conditions can range from rotator cuff tendonitis to partial thickness tears to full thickness tears. These tears can be small, medium, large, or massive. Just like all patients, rotator cuff tears tend to be unique and require individualized treatment plans. Personalized physical therapy routines accompanied by something to diminish the inflammation in the shoulder (anti-inflammatory medications or injections) is the treatment plan we often try first. Even patients with full thickness tears can receive significant relief from physical therapy and anti-inflammatory medication alone.

For those rotator cuff patients that don’t make significant progress in physical therapy or have large tears that require more extensive treatment, the most common procedure we will perform is an arthroscopic repair. When repairing your rotator cuff, we will also look at the quality of the tissue. Is it healthy tissue that happened to tear, or is there a more chronic problem that needs to be addressed?

Most patients with rotator cuff tears don’t remember a specific incident where they hurt their shoulder. The shoulder just started becoming sore due to chronic wear and tear. That being said, some patients can have a traumatic event that results in a rotator cuff tear.

In some cases, the rotator cuff is completely torn and has been for some time. The rotator cuff is retracted and scarred in, making it impossible to pull it back to its original location. In those cases, we perform a superior capsular reconstruction where we put a graft on top of the shoulder, similar to restoring the roof of a home. I have found that to be very effective at eliminating patients’ pain and improving the function of the shoulder in instances where we are unable to do a full rotator cuff repair.

With chronic rotator cuff tears, we often see the head of the humerus riding up on the socket, creating an accompanying arthritis called rotator cuff arthropathy. Patients with the combination of arthritis and rotator cuff tear will most likely need reverse total shoulder replacement where the ball and socket of the shoulder switch positions. Their natural positions are reversed, which can make up for the deficient rotator cuff.

Arthritis

Arthritis can also occur in a shoulder that is perfectly intact. We will initially treat it conservatively, whether that be medications or injections to diminish the inflammation and reduce pain. While these treatments will not cure the arthritis, they will hopefully make it tolerable for as long as possible.

When the arthritis reaches a point where it is no longer tolerable, a shoulder replacement is the next treatment option. If the patient has a perfectly healthy rotator cuff, we will consider perform-ing an anatomic shoulder replacement where we restore the anatomy of the shoulder by replacing only the worn out parts.

In younger patients, we also can consider looking at the shoulder arthroscopically and “cleaning out” the joint. This procedure won’t restore the shoulder to 100% function, but it will increase the range of motion, diminish pain, and hopefully make the shoulder last for a longer period of time before more extensive procedures need to take place.

Frozen shoulder

Adhesive capsulitis, commonly known as frozen shoulder, is also quite common. Patients will often complain about a history of pain in their shoulder and that they are progressively losing range of motion. We often see this condition in middle-aged females or patients with diabetes, but a patient of any demographic can develop it.

The first treatment plan is to diminish inflammation in the shoulder by either medications or injections and physical therapy. Occasionally, a patient will have persistent pain or restriction of their range of motion that will need to be address arthroscopically.

Frequently asked questions

Can a rotator cuff tear heal itself?

A tear can heal itself, but what typically happens is the rotator cuff tears and pulls back from its original position. If the tear does not pull back, then yes it can heal properly on its own. How-ever, when it’s pulled back, it’s going to be a much more difficult process.

A common problem that occurs with rotator cuff tears is the blood supply doesn’t function properly, making it harder for the body to heal the injury on its own. Then over time, it tears more and more.

What are your thoughts regarding platelet rich plasma (PRP) and prolotherapy for rotator cuff issues?

PRP is the process of taking some blood from the patient and spinning it in a centrifuge, result-ing in a layer of platelets and growth factors we inject into the injury site. PRP may help in the healing process.

There have been a number of studies performed looking at PRP injections for rotator cuff tears. PRP injections cannot fix tears that are pulled back, but may offer some pain relief.

Prolotherapy is a treatment option to help improve the motion and strength of the shoulder. It certainly can be helpful, but again, it won’t heal the rotator cuff tear. However, some patients receive enough relief and return of function with physical therapy that surgery is not required.

If you have had one or more rotator cuff tears surgically repaired, is it more likely for that tissue to tear again?

Every patient is different and has their own set of unique circumstances. It varies from tear to tear.

If it's a healthy rotator cuff with a small tear, the risk for re-tear is probably small. If it’s a bigger or chronic tear with a poor blood supply, those patients would be at a higher risk for re-tear.