Shoulders come into play in all walks of life. Athletes need their shoulders for serving, for throwing, for swinging, for swimming, for lifting. Laborers need their shoulders for heavy lifting, pushing, pulling, and reaching. And everyone needs their shoulders for day-to-day activities at home, whether it’s raking and gardening, reaching for the dishes, vacuuming, or anything you do on a repetitive basis. If you start to experience a problem with your shoulder you may lose the ability to do these things. In this blog post, I’ll explain the causes of shoulder pain and describe how I’ll diagnose and treat you in the office.

Shoulder Anatomy

The shoulder is made up of three bones: the scapula (shoulder blade), the acromion, and the clavicle (collarbone). The scapula has a cavity in it called the glenoid. The glenoid is the socket part of the “ball and socket” of your shoulder joint. The top of your upper arm bone, called your humerus, is shaped like a ball and fits into the glenoid. The acromion is on top of the scapula, and the clavicle is on top of the acromion. Where the acromion and the clavicle meet is the AC joint.

Fibrous tissues called ligaments surround the shoulder and provide the support and stability for your joints so they don’t slip out of place. Your shoulder has a series of muscles surrounding it, called the rotator cuff, that attach to various points on your humerus. The rotator cuff muscles provide much of the power and the strength of your arm in certain directions, including raising forwards and backwards, across the chest, out to the side, and rotating in and out.

Causes and Treatment of Shoulder Pain

Some shoulder injuries occur suddenly, such as after a fall. Landing with your hand out in front of you or with your arm pulled behind you can both cause shoulder injuries.

Other shoulder problems occur gradually over the course of time from repetitive use and repetitive stress. The long-term use can lead to wear-and-tear issues and overdue conditions.

Finally, other issues can occur from degeneration over time – shoulder arthritis, with the chronic symptoms of pain, stiffness and weakness.

AC Joint/Collarbone Injuries

If you land on your shoulder and separate your clavicle from your acromion, it’s a separated shoulder. The separated shoulder comes in different grades of severity, from slightly out of place to very out of place. You may also break your clavicle, either at the joint or in the middle of the bone.  

In many cases, we can treat you with a simple sling for support, rest, pain medication, and physical therapy when the injury has healed sufficiently. Occasionally there are severe cases that require surgery to repair them.

Arthritis is the other condition we see in the AC joint. In arthritis, the cartilage between the two surfaces starts to wear away. The bones become closer together and they start to hurt. Arthritis of the AC joint can be treated with medicines, with injections, and, if it’s painful enough, with surgery.

Rotator Cuff Injuries

The rotator cuff is underneath the acromion bone. On top of the rotator cuff is a tissue called the bursa.

You may fall and tear your rotator cuff away from the bone. The tear may be large or small. Typical symptoms of a rotator cuff tear include pain, the inability to elevate your arm, and weakness that can lead to stiffness.

Not as severe but still annoying can be rotator cuff tendonitis or bursitis, which typically occurs more gradually over the course of time. As you get older, your rotator cuff tissues start to degenerate and become more susceptible to injury when doing motions you wouldn’t think twice about when you were younger. Tendonitis or bursitis can also lead to symptoms of pain, stiffness, and occasionally weakness.

Shoulder Joint Injuries

Underneath your rotator cuff is your shoulder joint. If you fall a certain way on your shoulder, your shoulder can dislocate, or your upper arm bone can slip out of the socket of your shoulder blade. A dislocation may occur once or multiple times. If it happens multiple times, your shoulder has become unstable.

You can try to treat an unstable shoulder without surgery, resting and bracing it, but with multiple dislocations we’ll usually recommend an operation to re-tighten those ligaments and reconstruct your shoulder.

You can also get arthritis of your shoulder joint, where the cartilage covering the surfaces wears away and eventually the bones touch. The bones touching is very painful and causes the joint to be stiff. Like with hips and knees, first try medications, injections and physical therapy. If those don’t work, we’ll replace your shoulder joint.

Frozen shoulder, or capsulitis, is another insidious condition. With frozen shoulder, the lining around your shoulder joints can become inflamed, thickened, and painful when you move your arm. There are some medical conditions that make you more likely to get frozen shoulder, but most of the time there is no single cause we can point to. It’s a long, drawn-out process, but it usually resolves with physical therapy, medications, and injections. Occasionally a surgery is needed.

Finally, you may break your arm. It’s may seem dramatic if you fall, but it’s common in the wintertime when people slip on ice and don’t have time to react. Many times you can wear a cast and your arm can heal if the bones are in the right position, but sometimes surgery is needed.

How We Diagnose You

After you make an appointment and come into the office, I’ll examine you to find out what is wrong with your shoulder and figure out the correct treatment plan.

The first thing we’re going to do is take a history. I’m going to ask you questions.

  • When did the pain or discomfort start? Has it been there just a couple of days? Several weeks? Months? Years?
  • Is this a continuous pain or does it come and go?
  • Is it a positional pain? Are there certain positions that make your shoulder hurt more than others?
  • Have you lost motion? Does it feel stiffer?
  • Does it hurt at night? (Night pain is often a rotator cuff symptom.)
  • Have you had an injury?
  • Have you been treated in the past?
  • What makes you feel better? What have you tried?
  • What makes it feel worse?

The answers to the questions are a key element for me to determine what your diagnosis is.

Your age also matters in diagnosing your issue. Younger people are probably going to have more ligament issues, middle-aged people are more likely to have rotator cuff issues, and older people are more likely to have arthritis issues.

After the history is the physical exam. I’ll look at your neck and both of your shoulders for comparison. I look at your neck because sometimes issues in the neck can show up with symptoms in your shoulders. For example, a pinched nerve in your neck might cause pain on the inside of your shoulder blade and cause your arm to fall asleep when you tilt your head.

When I examine you, I’m going to look for areas of swelling or tenderness or a difference in the shape of the muscles. I’m going to check your ranges of motion. Are they normal? Are they similar between your shoulders? Or are they restricted somehow? I’m going to check for strength to see if you have weakness, which can indicate a rotator cuff problem. I’m going to check your stability to see if your shoulder is too loose – maybe there’s a ligament or a cartilage problem.

After the physical exam you’ll have an X-ray. Even a normal X-ray helps rule out certain problems. X-rays can be very helpful in determining if you have arthritis, if you have an injury, if you have bone spurs, and other things going on in your shoulder.

After the X-ray I’ll decide if I have enough information to create a treatment plan and if so, tell you what it is. Your treatment plan might include physical therapy, which can be very helpful to strengthen muscles, stabilize joints and recover stiff joints. I may recommend anti-inflammatory medications. For certain conditions, such as frozen shoulder, I may recommend a cortisone shot.

If I don’t think I have enough information I’ll suggest more tests. The typical next test is an MRI scan, which can provide a much more detailed picture of your shoulder. It can tell me, for example, if you have a torn cartilage from a dislocated shoulder, if you have a fracture that’s healing, or if you’ve torn the rotator cuff. This information can be valuable in making decisions such as whether or not to operate on an injured rotator cuff.

Whether surgery is recommended depends on your specific circumstances. There are certain cases where we’ll recommend surgery because we think you’re going to be better off in the long run fixing it than leaving it alone. There are other cases where we’ll say that you don’t need to do surgery unless none of the other treatments work well enough.

Helpful Tips

  • Don’t do everything all at once, especially if you’re starting something new. If you’re going to start a fitness program, you need to make sure that you do so gradually. Spend enough time stretching and make sure that you don’t just work on the big shoulder muscle groups; also work on strengthening your rotator cuff muscles and the muscles around your scapula. Everything works in unison. Don’t do a lot of sudden changes.
  • If it hurts, it’s telling you a reason why it’s hurting. Before trying to push through shoulder pain that doesn’t resolve easily, come see an orthopedist or check with your primary care doctor. We can help you a lot if issues are caught early.
  • Don’t sit and suffer forever. For example, many people with frozen shoulder delay getting help until it’s really bad, and we can help you earlier on.

FAQs

What is impingement of the shoulder?

Some people have less space in their shoulders than usual due to bone spurs coming down from the acromion or collarbone. When you have less space in your shoulder and raise your arm, the bone spurs rub the bursa tissue on top of your rotator cuff and compress the bursa. Impingement syndrome leads to the symptoms of bursitis (inflammation of the bursa) and tendonitis (inflammation of the tendons). Treatment includes changing how you move your arm so you’re not repeatedly rubbing the bursa, anti-inflammatory medications, and possibly a cortisone shot.

What are the symptoms of shoulder arthritis?

The typical symptom of shoulder arthritis is that your shoulder has been hurting for several years. Eventually, people start to notice the lack of motion and stiffness in the shoulder. After years of the shoulder being inflamed due to arthritis, the lining of the shoulder joint kind of becomes like a chronic frozen shoulder and it restricts motion and becomes painful to move it. People will report that they can’t get their arm out to the side or overhead. The shoulder also becomes noisy, makes grinding sounds and becomes painful not just when you’re using it but also at rest or at night.

When should you consider a shoulder replacement?

When you've tried everything else and you can't take it anymore. Ultimately, it’s a matter of your quality of life, just like a hip or a knee replacement. When you can’t sleep, when you can’t function during the day, when you can’t do much of anything with it and you’ve failed conservative treatments, then it’s time to consider a shoulder replacement operation.