The Painful Shoulder

By Philip R. Hardy, MD

The Painful Shoulder by Dr. Philip Hardy

The Painful Shoulder

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The shoulder complex joint which not only
has the greatest amount
of motion of any joint in
the body, but which in
reality is made up of four
separate gliding surfaces.
The ball and socket part
is made up of the round
end of the upper arm
bone, called the humerus, and the socket part, which is a part of the shoulder blade, called the
glenoid. The incredible amount of motion is due to the relatively large ball, approximately the
size of an egg, articulating with the small socket, approximately the size of a teaspoon. This
arrangement provides little stability, however, and so this amount of motion comes at the cost
of the shoulder being that joint of the body most likely to dislocate. The shoulder will often
become painful without an actual injury, or dislocation, however, and it is the development of
pain in the shoulder, without an identifiable injury, which is the topic of this article.
This design of the shoulder which allows the arm to be used overhead, requires a lubrication
sac, called the bursa, to be interposed between the muscles and tendons of the shoulder,
called the rotator cuff, and the overlying bone, called the acromion. – See diagram.
If someone performs a lot of overhead activity that they are not accustomed to, such as chopping
a lot of wood with an ax, the bursa becomes inflamed, and the condition is known as ‘bursitis’.
This will usually get better by itself over time, as long as no actual structural damage has
occurred to the rotator cuff tendons themselves. If this process continues, eventually the rotator
cuff tendons become inflamed as well, and this condition is called rotator cuff tendonitis.
As the years go by, the rotator cuff wears against the underside of the acromion causing the
cuff to get roughened, and thinner. Eventually, a ‘partial thickness tear’ develops. This is similar
to when a piece of material becomes threadbare, but without an actual hole appearing in it.
If this process continues, eventually a hole will appear in it, and this is then called a ‘complete
rotator cuff tear’. In reality, this means that some of the important muscles of the rotator cuff
have become detached from the end of the humerus and so can no longer serve to control the
motion of the ball in the socket, nor to add their power to the movement of the shoulder.

Rotator Cuff Rehab

The ability of the shoulder to recover function in this situation depends on the extent to which
it is possible to strengthen those rotator cuff muscles which remain attached. This involves
very specific exercises which must selectively strengthen the rotator cuff without allowing
them to become more inflamed. Additionally, these exercises must strengthen the muscles of
the rotator cuff without strengthening the other muscles around the shoulder. This is because,
as in the illustration above, if the other muscles, such as the deltoid, overpower the rotator
cuff, they cause the rotator cuff to be banged into the acromion, causing further damage.
This process of causing injury to the rotator cuff, by banging it into the acromion is called ‘impingement
syndrome’ or simply ‘impingement’. This produces pain, further inflames the bursa
and the tendons of the cuff and is therefore another cause of ‘bursitis’ and of ‘rotator cuff
tendonitis. This commonly not only bothers patients attempting to do such normal activities
as putting on a shirt or jacket, but also is more often bothersome at night when they lie down.
As the process of the roughened rotator cuff rubbing against the acromion continues, spurs
form on the underside of the acromion, further aggravating the problem. Treatment of this
condition includes the use of anti-inflammatory medications, exercise and physical therapy.
If this is unsuccessful, the use of a cortisone shot into the bursa sac may sometimes permanently
improve this condition. This is because the inflammation of the bursa and the tendons
is decreased by the use of the cortisone, which shrinks the inflamed tissues, allowing the cuff
muscles to function better, and literally pull themselves out of trouble. If none of the above
measures work, then arthroscopic surgery is the next option.

Shoulder Arthroscopic Surgery

Arthroscopic surgery is typically performed on an outpatient basis, meaning the patient gets
to go home the same day as the surgery. Its advantages are that the extent of the damage to
the tissues can be accurately assessed by means of nothing more than puncture wounds, 1/4
to 1/2 inch in size. As techniques and instrumentation have improved, it is now often possible
to correct all of the problems found at the time of the surgery through these same puncture
sites, including removing the spurs from the bone, and stitching the rotator cuff back where
it came from. This makes the surgical repair of the painful shoulder a much more reasonable
option for patients than before arthroscopic repair was feasible.

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