Shoulder Pain.

Shoulder problems that cause pain, loss of movement, and power , are one of the more common reasons to visit the Doctor for musculoskeletal problems.

The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion that is allows. This instability increases the likelihood of joint injury, this often slowly leads to a degenerative process in which tissues break down and no longer function well.

The shoulder joint is composed of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone) .

The glenohumeral joint, to which the term "shoulder joint" commonly refers, is a ball-and-socket joint that allows the arm to rotate in a circular fashion or to hinge out and up away from the body.

The "ball" is the top, rounded portion of the upper arm bone or humerus; the "socket," is a dish-shaped part of the outer edge of the scapula into which the ball fits.
The bones of the shoulder are held in place by muscles, tendons, and ligaments. The ligaments attach the shoulder bones to each other, providing stability.The rotator cuff is a structure composed of tendons that, with associated muscles, holds the ball at the top of the humerus in the shoulder socket and provides mobility and strength to the shoulder joint.


Most common causes of shoulder pain
:

Dislocation / instability; the shoulder may dislocate after a fall or forceful blow to the shoulder. The ligaments and/or tendons that hold the joint together may be stretched or torn when the shoulder dislocates thus causing future instability of the joint. Dislocation of the shoulder can also result in fractures in or around the socket joint.

Fractures of / or around the shoulder; Fractures of the head of humerus can result commonly after in fall in the elderly. Fractures can also result in or around the socket joint.

Rotator cuff tendonitis / Impingement Syndrome; the Most Common Cause of shoulder joint pain is rotator cuff tendonitis (injury and inflammation of the tendons, rotator cuff tendons) the tendons that surround the shoulder joint. The most common cause of rotator cuff tendonitis is overuse of the shoulder, though the rotator cuff tendons may be injured suddenly as a result of a fall or accident.

There is a small space between the head of the upper arm bone and the acromion (a bony projection from the top of the shoulder blade) that the rotator cuff passes through. If the rotator cuff becomes inflamed (tendonitis), it may not have enough room and may get squeezed and compressed. This is called Impingement syndrome. This causes further irritation to the tendon.

This condition causes severe pain when reaching overhead constant or sudden during an activity, it is associated with loss of movement and weakness, which may worsen over time.

Rotator cuff rupture full and partial; if any of the rotator cuff muscles are weak, the humerus may not be kept centered in the socket of the shoulder blade. Age-related changes in the tendons leave them weaker, less elastic, and more susceptible to injury. These tendons may tear or break. The main symptoms of rotator cuff injuries are severe shoulder pain and weakness, a full rupture leads to serious lack of power.

Symptoms worsen when lifting the arm above shoulder level or a complete inability to raise the arm. A rotator cuff tear will cause more weakness than rotator cuff tendonitis but the symptoms are similar. Symptoms may occur suddenly if the rotator cuff in injured by a traumatic injury, such as an accident or fall.


Osteoarthritis; is caused by gradual degeneration of the smooth cartilage that coats the ends of the bones in a joint. The ends of the bones in a joint are coated with smooth articular cartilage, which allows the bones to glide smoothly against each other. When the cartilage breaks down and becomes rough, friction occurs between moving bones. Irritation and damage to the bones result. In severe cases, cartilage is totally worn away and bone rubs against bone. This causes the ends of the bones to thicken, and bones spurs may form. Arthritis of the shoulder causes over a period of time worsening pain and gradual loss of movement.

Calcification tendonitis; this condition is caused by a gradual build up of calcium deposit in the shoulder tendons or muscles. This causes inflammation and pain in the surrounding tissues. The symptoms develop rapidly. It may be too painful to move the shoulder, yet resting the shoulder does not relieve the pain. It may be difficult to sleep because of the pain.
There may be intermittent pain or discomfort when a large calcium deposit in a rotator cuff tendon becomes pinched between bones of the shoulder joint when raising the arm overhead.

Frozen shoulde
r; the frozen shoulder (adhesive capsulitis) starts with inflammation of the shoulder joint or the muscles/tendons surrounding it.

The inflammation may be the result of an injury (such as a rotator cuff tear) but may occur for no apparent reason. Not using the shoulder for a prolonged period of time can lead to frozen shoulder.

Having diabetes or thyroid problems increases the risk of developing frozen shoulder.

Referred pain to the shoulder; Shoulder pain in some cases may not actually originate from the shoulder but may be reflected from another part of the body. I.e.: Pain often is reflected from the nerves in the neck, or from other trapped nerves.

Also, cardiac pain is felt in the left arm and shoulder and back.

It may also originate from a gastric source, or from accumulated abdominal gases.



When to seek specialist treatment
;
If you experience a sudden onset of severe shoulder pain without having an accident see your Doctor immediately to rule out more life threatening causes.

See your specialist if you have reduced of movement or power in your shoulder that develops over a period of time. Or if you have shoulder pain that does not improve after resting.

Seek advice urgently if you have shoulder pain that keeps you awake at night and interferes with your normal daily activities. Also if you have an accident that leaves you with severe shoulder pain, or if your over the counter pain medicine stops taking effect.

The diagnosis.
The specialist will take your full medical history and examine you. He may ask for investigations, including an X-ray or an MRI scan to confirm your diagnosis. Once your Specialist has the results he will explain what they mean and what treatments are available for you.


Treatments
:
Conservative/ non surgical treatments; Depending on your diagnosis your specialist may recommend one of several conservative treatments. Some treatments include instructions to avoid overhead activities and any activity that causes pain, rehabilitative exercises, treatment with the physiotherapist under Doctors guidance, anti-inflammatory medications, applying ice, applying heat, stretching exercises to prevent frozen shoulder, sometimes a cortisone injection, and finally possible shoulder surgery.

Shoulder Decompression/ Acromiaplasty; to repair a rotator cuff injury surgery may be needed to repair the full or partial thickness rotator cuff tears. The aim of the surgery is to open more space for the tendons of the rotator cuff t o pass, making more space by shaving the bits of bone (spurs or tightness) that impinge upon the tendons. Also, it allows evaluation of the rotator cuff, and if necessary the repair of the tendons. This procedure could be performed by key hole or open surgery, and aims to restore function and power to the shoulder.


Shoulder replacement
; Used to treat end stage arthritis of the shoulder. A metal prosthesis is used to replace the diseased head and socket joint. Relieving pain and restoring function.

Removal of calcium deposits; under image guidance sometimes the deposits can be broken up with a hypodermic needle and sucked out with a syringe. This procedure often relieves pressure on the tendon and brings quick relief. Normal function is often restored within days.

Surgical repair for instability; Patients with repeated dislocations of the shoulder may usually require surgery. This is a repair operation in which the surgeon will tighten and reattach the tendons and muscles supporting the joint. It may be carried out using arthroscopic or open surgery. This procedure will prevent future dislocations of the shoulder.

Surgical repair of fractures of the shoulder; A fractured head of the humerus is a very common injury resulting from falls on to an outstretched arm. It is particularly common in older people with osteoporosis. If fragmented or displaced, the fracture may require open surgical repair and possibly replacement with an artificial joint (prosthesis).