Shoulder Pain: Causes and Treatment
The shoulder joint is a complex joint with a large range of motion in different planes. It is vulnerable to injury through many different causes. In this article I’m going to explain the different disorders that can occur and how to treat them.
Rotator cuff injury
The rotator cuff are a group of 4 muscles that surround the shoulder joint which stabilise the shoulder. Supraspinatus, infraspinatus and teres minor externally rotate (supraspinatus also abducts the shoulder) and subscapularis internally rotates the shoulder joint.
External rotation means the movement which turns the palm up. Abduction is the movement of the arm away from the body. Internal rotation means turning the palm down when it is facing up.
There are three categories of rotator cuff injury. These are tears or sprains, bursitis and tendinitis.
Tendinitis (also called impingement syndrome) is where the attachment of one of the rotator cuff muscles becomes inflamed and is usually due to overuse. The tendon and surrounding areas can become tender, swollen and painful with movement.
In a rotator cuff tear, there may be bleeding in the muscle which will usually look like a purple bruise further down the arm. There will be limited movement, sometimes no initiation of movement altogether. With a strain there will usually be pain during movement and restriction.
Bursitis is an inflammation of the fluid filled sacks (the bursa) which lie in between muscles and bone, and between some muscles. There will usually be swelling and tenderness when touched.
Not all injuries are caused by rotator cuff strain. It can be caused by degeneration within the joint. The shoulder can be damaged for months or years before symptoms start to appear. Sometimes degenerated joints don’t cause any pain at all.
Common rotator cuff injury symptoms include:
- avoiding certain activities because they cause pain
- difficulty achieving full range of shoulder motion
- difficulty sleeping on the affected shoulder
- pain or tenderness when reaching overhead
- pain in the shoulder, especially at night
- progressive weakness of the shoulder
- trouble reaching behind the back
Rotator cuff injuries can be acute or degenerative.
Acute injuries usually occur from one particular incident. These can be caused by lifting objects that are too heavy, falling, or having the shoulder forced into an awkward position. Young people are more likely to experience this type of rotator cuff injury.
Degenerative injuries are due to long-term overuse. People most at risk for these injuries include:
- athletes, particularly tennis players, baseball players, rowers, and wrestlers
- people with jobs that require repetitive lifting, such as painters and carpenters
- people above 40 years of age
Sometimes you may require surgery for your rotator cuff injury. However, according to the mayo clinic, half of patients with rotator cuff can recover without surgery by doing exercises at home.
Home Care for Your Shoulder
There are several things you can do to help reduce pain from rotator cuff tendinitis. These techniques can also help prevent rotator cuff tendinitis or another flare-up of pain.
Shoulder self-care includes:
- using good posture while sitting
- avoiding lifting your arms repetitively over your head
- taking breaks from repetitive activities
- avoiding sleeping on the same side every night
- avoiding carrying a bag on only one shoulder
- carrying things close to your body
Frozen shoulder
Frozen shoulder is the common name for adhesive capsulitis, a condition which limits the joint rage of motion. The tissues in the joint can sometimes become thicker and scar tissue can occur. The shoulder may not have space to move as a consequence. Common symptoms are pain, swelling and stiffness.
Frozen shoulder begins when your shoulder starts to hurt. This results in you moving the shoulder less and less. Stiffness then occurs. Brushing your hair and reaching can be difficult.
If you have a weakened immune system, diabetes or a muscular imbalance you could be susceptible to frozen shoulder. A long period of immobility due to depression, or post surgery may also make you more prone to adhesions which are bands of stiffness in the joint tissue. It can take 2-9 months to develop.
If you don’t get frozen shoulder treated, the pain can stay for 3 years. Physical therapy from an osteopath or another health practitioner reduce this to 6 months.
The goal is to stretch your shoulder joint and regain the lost motion. It can take anywhere from a few weeks to nine months to see progress. A home exercise program of gentle range of motion exercises is important. If you don’t see progress after six months of daily exercises, speak to your therapist or doctor about other options.
Medications
To treat the pain and reduce your joint inflammation, your doctor may recommend an anti- inflammatory medication like aspirin, ibuprofen, or naproxen sodium. A steroid injection may be offered.
Ice treatment
Placing an ice pack on your shoulder for 20 minutes at a time several times per day can help to decrease pain.
Exercise
Your therapist will provide instructions on the types of exercises you must do, how often to do them, and when to push yourself harder. Most people with a frozen shoulder can improve their condition without surgery.
If physical therapy doesn’t improve your condition, surgery is an option. Your options are: to manipulate the shoulder and put it through a full range of motion under a general anesthetic to help break up any adhesions OR arthroscopic surgery. This type of surgery involves making a small cut in your shoulder and using a camera called an “arthroscope” to remove scar tissue. This allows the shoulder to move better.
Postoperative therapy is usually required as well. Many patients have their full range of motion back within three months if they are compliant with exercises.
Thoracic outlet syndrome
This is a condition which describes compression of the nerves and/or vessels that pass in the thoracic outlet which is a space between the first rib and clavicle (collarbone). Compression may result in chest pain, shoulder pain, neck pain, and arm or hand pain, numbness or tingling. Severe compression may result in weakness of the arm or hand.
The compression can result from a number of factors. Tight muscles such as the pectorals, particularly pec minor, scalenus medius and posterior. A cervical rib, a genetic anomaly, can also cause compression.
Causes of the condition can be chest breathing, stress, forward head posture, desk work, muscular overuse, injury, excessive exercise (running) or an apical lung tumour.
How Can Thoracic Outlet Syndrome Be Prevented?
If the condition develops, you can take steps to reduce symptoms and to prevent it from recurring. These include:
- practicing proper posture when sitting or standing
- taking breaks at work or school to stretch and move around
- maintaining a healthy weight
- performing strengthening and dynamic stretching exercises
- avoiding activities that make your symptoms worse
- avoiding lifting heavy objects
- avoiding carrying heavy bags on the shoulders
- avoiding making repetitive movements
If you do get TOS, prognosis is generally very good. You may want to receive therapy from a physiotherapist, chiropractor or osteopath, sports masseuse and/or acupuncturist. Surgery is an option if none of the the above therapists work. Angioplasty is a type of surgery which open up blood vessels. A cervical rib may be removed if there is one.
Osteoarthritis
Osteoarthritis (OA) is the process of wear and tear in the body. This means that it’s a condition of overuse which leads to a degeneration in the cartilage, tissues, synovial fluid and other structures in joints. OA can cause pain and inflammation in more than one joint in the body. It usually starts at the age of 30, even if it’s symptomless at this point. It can lead to deformity and altered gait.
The synovium is a tissue in a joint which produces thick fluid which keeps the joint healthy. If this becomes inflamed, often extra fluid is produced and the joint swells. As cartilage deteriorates, often there isn’t enough synovial fluid which result in more pain and uneasy movement. There also isn’t enough cushioning. As bones scrape together, they can also grow thicker and produce osteophytes which are boney spurs.
The joints most commonly affected by OA are in the hands, feet, spine, and weight-bearing joints, such as the hips and knees.
- Excess weight. Being obese or overweight puts additional stress on joints, cartilage, and bones, especially those in the knees. It also means you’re less likely to be physically active.
- Family history. Genetics may make a person more likely to develop OA. If you have family members with the disease, you may be at an increased risk of developing OA, too.
- Gender. Before age 45, men are more likely to develop osteoarthritis. After 50, women are more likely to develop OA than men. The difference becomes almost even around age 80.
- Occupation. Certain occupations, such as those in construction, agriculture, cleaning, and retail, increase a person’s risk for developing OA. Their bodies are used more rigorously as part of their job, which means their joints are worked more and likely age faster than people who have a desk job.
Younger, more active people can also develop osteoarthritis. However, it’s often the result of a trauma, such as a sport injury or accident. A history of physical injuries or accidents can increase a person’s chance of later developing osteoarthritis.
Treatments
Osteoarthritis does not have a cure. Instead, the goal of treatment is to manage pain, then reduce contributing causes that make the symptoms of OA worse. The first step is to reduce pain. This is often initially done with a combination of medicines, exercise, and physical therapy from an osteopath, chiropractor or physiotherapist.
Secondly, lifestyle changes may be warranted to slow down the progression of OA. Incorporating low-impact exercise and getting more rest can often extend the life of knees and joints without resorting to more invasive treatments.
Exercise
Low-impact exercise such as playing golf, walking, swimming, yoga, and cycling help strengthen muscles and keep bones strong. Exercise also improves joint mobility.
Heat/cold therapy
Apply warm compresses and cold packs to joints when they are sore or painful. This can help relieve pain and reduce inflammation.
Weight loss
Losing as little as 5 pounds can help decrease the symptoms of osteoarthritis, especially in large joints, such as the hips and knees.
Fibromyalgia
Fibromyalgia is a widespread pain disorder of unknown origin. It is characterised by fatigue, pain and tenderness around the muscles and bones of the whole body and depression. There are no tests for fibromyalgia so it’s often misdiagnosed. Some medics say it doesn’t exist which can lead to further depression in individuals suffering already. Findings include pain on light touching of at least 11 of 18 trigger points mainly around the shoulders, chest, outer elbows, hips, base of head and knees.
Researchers are getting closer to understanding fibromyalgia so some stigma is being lifted. Many doctors are prescribing lifestyle changes instead of medication as they think this will make the most difference to peoples’ health.
The pain caused by these trigger points can also be described as a consistent dull ache affecting many areas of your body. If you were to experience this pain for at least three months, doctors may consider this a symptom of fibromyalgia. People with this disorder may also experience:
- fatigue
- trouble sleeping
- sleeping for long periods of time without feeling rested
- headaches
- depression
- anxiety
- inability to focus or difficulty paying attention
- pain or dull aching in the lower abdomen
Symptoms may be a result of the brain and nerves misinterpreting or overreacting to normal pain signals. This may be due to a chemical imbalance in the brain.
The following things can help with treatment of fibromyalgia:
- physical therapy such as therapy from an osteopath, chiropractor or physiotherapist
- acupuncture
- meditation
- yoga
- regular exercise
- getting enough sleep at night
- massage therapy
- a balanced, healthy diet
Therapy can help those with fibromyalgia, as it can reduce stress and anxiety, particularly group therapy as you can meet others that are going through similar symptoms.
Ankylosis spondylitis
Ankylosing spondylitis is a form of arthritis that primarily affects your spine. It causes severe inflammation of the vertebrae that might eventually lead to chronic pain and disability. In more advanced cases, the inflammation can cause new bone to form on the spine, which may lead to deformity.
Ankylosing spondylitis can also cause pain and stiffness in other parts of your body. Other large joints such as the shoulders, hips, and knees can be involved as well.
The cause of ankylosing spondylitis is unknown. The disorder does tend to run in families, so genetics probably play a role. If your parents or siblings have ankylosing spondylitis, you are 10 to 20 times more likely to be diagnosed with the disease than someone with no family history.
What Are The Symptoms Of Ankylosing Spondylitis?
The symptoms of ankylosing spondylitis vary. It is often characterized by mild to moderate flare-ups of inflammation that alternate with periods of almost no symptoms. The most common symptom is back pain in the morning and at night.
Other symptoms may include:
- early morning stiffness
- loss of appetite
- low grade fever
- weight loss
- fatigue
- anemia or low iron
Because ankylosing spondylitis involves inflammation, other parts of your body can be affected as well. Patients may also experience:
- inflammation of the bowels
- mild eye inflammation
- heart valve inflammation
- Achilles tendonitis
A rheumatologist, a doctor who specializes in arthritis, is often consulted to help diagnose ankylosing spondylitis. The first step will be a thorough physical exam. A doctor will ask you for details about the pain and the history of your symptoms.
An X-ray of your spine and any painful joints will show erosion. The erosion may not be detected if the disease is in the early stages. An MRI study may also be done, but the results are often difficult to interpret.
A blood test called an erythrocyte sedimentation rate may be done to gauge the presence of any inflammation. A blood test for a protein HLA-B27 may be done. However, the HLA-B27 test does not mean that you have ankylosing spondylitis, only that you have the gene that produces this protein.
How Is Ankylosing Spondylitis Treated?
Because there is no cure for ankylosing spondylitis, your treatment will be focused on managing pain and preventing disability.
Activity
Daily exercise is encouraged to help you maintain flexibility and range of motion. Physical therapy may be prescribed for treatment.
Posture
Practicing good posture is promoted in order to prevent the deformity of the spine that can occur in later stages.
Heat/Cold
Applying heat to stiff joints can help reduce pain and soreness. Applying cold helps to reduce swelling.
Surgery
If you have severe damage or deformity to your knee or hip joints, surgery may be necessary.
It is not known how you can prevent ankylosing spondylitis because no one knows what causes it in the first place. However, if you have the disease, you can focus on preventing disability by staying active, eating healthily, and maintaining a normal body weight.
Dislocations
A dislocation is when a joint moves out of its usual place. For example, if your humerus was to move out of the glenoid fossa of the scapula, that would be a dislocation of the shoulder. A dislocation should be treated as an emergency. If it is untreated, it can cause damage to the nerves, blood vessels and surround structures of the joint.
Treatment
Initial treatment for a dislocation may be RICE (rest, ice, compression and elevation. The joint may go back into place after this. If it doesn’t, a doctor may put the joint back into place for you while you’re under anaesthetic. You may then be asked to wear a sling for 6 weeks until the joint has healed.
Polymyalgia rheumatica
This is an inflammatory disorder which causes pain and stiffness around the shoulder and pelvic girdles. If left untreated, mobility issues can occur.
The disorder is often sudden and worse in the morning. It usually effects women over 65 and the disorder is rare under 50.
A disorder called temporal arthritis is often linked to polymyalgia rheumatica. Diagnosis of his disease is important as it can cause blindness. Other symptoms are head aches, jaw pain and scalp tenderness. Other symptoms of the disorder are fatigue, depression, malaise, sudden unexplained weight loss, loss of motion, a low grade fever and loss of appetite.
If your doctors suspects you have this condition they may do a blood test to see if your c reactive protein and erythrocytes sedimentation rate is high as this indicates inflammation. A biopsy from your temporal artery to test for temporal arteritis may be carried out also.
PMR is often treated with corticosteroids such as prednisone. These medications have some uncomfortable side effects which should be made known to you.
Tendon sheath inflammation (Tenosynovitis)
The tendons in the body have a tunnel like covering called a sheath and sometimes these can become inflamed. Repetitive movements and overuse can cause this. Tenosynovitis is most common in hands, wrists, shoulders and feet. It can often cause a fever due to infection of the the sheath. There is also often stiffness in nearby joints, swelling, pain, redness and tenderness. The biceps muscles has a long head which has a sheath. When this getting inflamed,
anterior shoulder pain may occur.
An MRI is sometimes carried out to diagnose tenosynovitis. A course of antibiotics may be used if there is an infection.
Muscular strain or ligamentous sprain
Muscles and ligaments around the shoulder girdle sometimes get overstretched which leads to strains and sprains. This can happen when you overwork the upper body at the gym, if you have a desk job and have poor seated posture or if you have a job which involves a lot of overarm movements such as a painter and decorator or plasterer. Injuries and accidents can also cause strains and sprains, such as road traffic accidents with associated whiplash. Muscles which are commonly strained in the shoulder are the trapezius, the biceps long head, the rotator cuff (as previously mentioned) and the pectoral muscles.
Ligaments attach bone to bone and these can become sprained when a joint is taken past its end range of motion. There are 3 grades of sprain. Grade 1 is a minimal, grade two is partial and grade 3 is a complete. Common ligaments sprained in the shoulder are coracoacromial ligament, the glenohumeral ligaments, coracoclavicular ligaments and the ligament of the long head of biceps (the humeral ligament).
Lung cancer
Lung cancer can result in shoulder pain. Other symptoms are a hoarse voice, a cough which contains blood, chest pain which gets worse on breathing deeply, wheezing, shortness of breath, fever, weight loss, night sweats and malaise. Lung cancer can go misdiagnosed as it can have a similar presentation to a common cold.
Fracture
A fracture may be the cause of shoulder pain. It can present as tenderness of a local area and may be due to a fall on an outstretched hand, which is particularly likely if an individual has osteoporosis. Tests may include palpation, tap test, vibration testing and/or an x ray. Sometimes if a tendon is pulled away from its bony origin or insertion it can pull bone away with it; this is called an avulsion fracture.
Rheumatoid arthritis
Rheumatoid arthritis is an autoimmune inflammatory condition which symptoms are joint pain, skin, eye, lung and heart problems. It may be caused by genetic, environmental, microbial, chemical, immunological or hormonal factors. It’s a disorder of destruction, remodelling and deformity.
Rheumatoid arthritis, unlike osteo, attacks the joint lining causing pain, swelling and eventually erosion. The ligaments and tendons become over stretched and lax which is what causes the deformity.
Joint stiffness is usually worse in the morning for an hour after waking and after inactivity. Fatigue, fever and weight loss are also symptoms. It tends to effect smaller joints first, particularly the joints that attach your finger to your hands and toes to your feet (the metocarpophalangeal joints). As it progresses, knees, hips, elbows and shoulder can become involved. In most cases, it effects joints on both sides of your body.
In 40 percent of cases, other structures are effected. These can be the skin, eyes, kidneys, bone marrow, blood vessels, heart, lungs, salivary glands and nervous tissue.
Your sex, age, whether you smoke or drink, are obese, exposure to asbestos or silica, or have any family history can increase the likelihood of development of RA.
Treatment
Fish oils, plant oils such as black currant, borage and primrose have been shown to help. Small studies have shown tai chi to benefit people with RA.
Liver cancer
Liver cancer can cause right shoulder pain because of what is called “referred pain”. It is thought that the neural pathways to the spine for the shoulder and liver converge.
Other symptoms of liver cancer usually come much later in the disease process and they include, fatigue, itching, unexplained weight loss, jaundice, abdominal pain particularly on the right side, a swollen abdomen, vomiting, back pain and nausea.
Gout
Gout is a form of arthritis which can be caused by a diet high in rich foods such a meat, fish, cheese and alcohol. Some water medications such as diuretics can bring on gout. It’s caused by a build up of uric acid which crystallised and become attached to joints causing sudden, extreme burning discomfort, swelling and stiffness. The typical presentation is a large, purple, painful toe which throbs. You can get gout in your knees, ankles, shoulders and elbows or any joint.
Treatment
Medications are prescribed and advice on the diet is usually given.
SLE
Systemic lupus erythematosus is a multi system autoimmune disorder. It can cause arthritis in two or more joints with pain, tenderness, swelling and effusion. The criteria for diagnosing SLE is when a patient has 4 or more of the following: arthritis, renal problems, autoantigens, antinuclear antibodies, serositis (lung problems), haematological signs, photosensitivity, oral ulcers, immunological disorder, neurological disorder and/or a rash.
Juvenile rheumatoid arthritis
Juvenile idiopathic arthritis is the most common childhood illness. Symptom are persistent joint pain for 6 weeks or more, fevers, missing school recurrently, morning stiffness and aching joints throughout the day. A rash on the trunk or extremities is also common.
Treatment of juvenile rheumatoid arthritis may involve medication, psychosocial interventions, measures to enhance school performance, improved nutrition, physical therapy from an osteopath, chiropractor or physiotherapist and occupational therapy.
Summary
As you can see from the above, there are many causes of shoulder pain. If you have shoulder pain or would like advice on preventing it, please seek advice from a qualified physical therapist such as an osteopath, physiotherapist, sports therapist or chiropractor as well as a GP.
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