The Painful Shoulder
By Dr. Philip Hardy
The Painful Shoulder by Dr. Philip Hardy
The shoulder complex joint has the greatest amount of motion of any joint in the body. The shoulder is actually made up of four separate gliding surfaces.
The ball and socket part is made up of the round end of the upper arm bone, the humerus, and the socket part, which is a part of the shoulder blade or the glenoid. The incredible amount of motion is due to the relatively large ball. It is approximately the size of an egg, articulating with the small socket. The small socket is approximately the size of a teaspoon. This arrangement provides little stability. However, 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. 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 use of the arm overhead, requires a lubrication sac, called the bursa. The bursa lubricates in-between the muscles and tendons of the shoulder, know as the rotator cuff, and the overlying bone, known as the acromion.
If someone performs a lot of overhead activity, such as chopping a lot of wood with an ax, there is inflammation of the bursa. Bursitis is the name of this condition or the inflammation of the bursa. This will usually get better by itself over time. As long as no actual structural damage occurs to the rotator cuff tendons themselves. If this process continues, eventually the inflammation of the rotator cuff tendons becomes rotator cuff tendonitis.
Rotator Cuff Tears
With age, the rotator cuff wears against the underside of the acromion causing the cuff to roughen and get 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 and this is a ‘complete rotator cuff tear’. In reality, this means that some of the important muscles of the rotator cuff detach from the end of the humerus. It 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 of the injury. Is it possible to strengthen those rotator cuff muscles which remain attached to provide function? 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. If the other muscles, such as the deltoid, overpower the rotator cuff, they cause the rotator cuff to impinge into the acromion, causing further damage.
This process of causing injury to the rotator cuff, by banging it into the acromion is known as ‘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 going down by the using the cortisone. This shrinks the inflammation in the tissues, allowing the cuff muscles to function better. It 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 occurs in an outpatient surgery center. 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 seen by means of nothing more than puncture wounds, 1/4 to 1/2 inch in size. As techniques and instrumentation evolve, 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.
Physical Therapy for the Shoulder
Physical therapy is so important to recover from any of the shoulder conditions. The conservative approach to care and treatment can be a great first step. Here are some examples of exercises for the shoulder.
If you have recently had a shoulder surgery please watch this helpful video: Dressing the Upper Body After an Injury or Surgery
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- Please read this article on Proximal Humerus Fractures.
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