Why does my shoulder hurt and what can I do about it?
Hi. My name is Gavin Jennings. I’m an Orthopaedic Surgeon based in Bath, UK and I specialise in the shoulder. I’d like to talk to you today about why you may have shoulder pain and what can be done about it.
The shoulder is a complicated joint and not surprisingly there a number of reasons for shoulder pain. Despite this complexity we can simplify the reasons for pain by placing them into broad groups.
So the biggest of these groups involves problems with the deep tendons in the shoulder known as the rotator cuff and about 70% of the patient’s in a shoulder surgeons clinic will be in this category.
The next most common area to cause issues is within the ball and socket joint itself glenohumeral joint. There is another joint which is part of the shoulder “girdle” which is formed where the collarbone meets the front of the shoulder blade This is called the acromioclavicular or AC joint and this can also be the root of some problems.
What can make it even more tricky for a sufferer to work out where their pain is coming from is the fact that pain from the joint and pain from the tendons are often felt in exactly the same place. So I will go will explain some of the characteristics of the pain which give us a very good idea as to where that pain is actually arising from and then talk about what we can do about it.
The first thing we need to think about is whether someone’s shoulder pain is genuinely arising from the shoulder. Problems with the neck can also give rise to pain felt in the shoulder. This type of pain however is often associated with numbness, tingling and sometimes weakness down the arm and may be improved or made worse by changing the position of the head.
Genuine shoulder pain is usually felt at the upper outer part of the arm (overlying the deltoid muscle). The exceptions to this are problems arising from the joint at the end of the collarbone, the AC joint. This is the one area where the pain is perceived right at the point of the problem.
The tendons of the rotator cuff can be prone to developing inflammation or even tearing. This type of problem gives pain in the upper arm particularly when the person lift the arm up from the side. Activities such as reaching back to put a coat on, lifting objects into cupboards and reaching back for a seat belt in the car can often cause pain. If the person lift their arm to the side they tend to get pain as the arm reaches about shoulder height and sometimes this can get a little bit easier as the arm is taken overhead. This is known as a painful arc.
If the problem gets really bad however the person may struggle to lift the arm above shoulder height at all.
Treatment of rotator cuff problems will initially involve physiotherapy and steroid injections. Physiotherapy aims to progressively strengthen the muscles of the rotator cuff and address issues which may lead to ongoing problems to the tendons such as poor posture. Steroid injections aim to reduce the inflammation and swelling in the tendons. Sometimes the tendons can develop tears and in some instances these may require surgical repair to resolve the problem.This can usually be done with a keyhole operation.
The commonest problems that occur within the shoulder joint itself are frozen shoulder and arthritis. Also the shoulder joint is very mobile and the payoff for this is it is prone to be unstable.
Frozen shoulder is a poorly understood condition where the lining of the joint becomes inflamed and then thickened. What this means further the person suffering with this condition is a progressively worsening pain and loss of movement in the shoulder. The shoulder is often extremely painful particularly if the person reaches out suddenly or jolts the shoulder. Reaching behind the back can become very difficult.
The first treatment that is recommended for frozen shoulder is usually a steroid injection. In addition physiotherapy can help reduce some of the symptoms. If these measures fail to improve the shoulder adequately a keyhole release of the shoulder to restore movement and reduce pain can be considered.
Arthritis can occur in the shoulder just as it can in other joints such as the hip and knee. People with shoulder arthritis tend to suffer from pain which can be present to a degree at rest but is usually worse with movement the shoulder gets stiff and can crunch in great as the joint surfaces get rough and irregular steroid injections are often effective at least in the medium term in improving symptoms. If nonoperative measures become ineffective a joint replacement may be needed.
Instability can occur at almost any age but it is certainly much more common in the under 30 age group.People are often very aware of instability in the shoulder for example if they have had a significant injury and following this the shoulder comes out of joint recurrently. Instability however can sometimes be much more subtle. The shoulder may fully dislocate but may just partly slip out of joint, which is known as a subluxation.
Instability can occur as a result of a specific injury and if this results in structural damage to the shoulder surgical repair may be needed. In other types of instability physiotherapy may provide a solution.
Problems of arthritis and instability can also affect the AC joint.
The pain arising from AC joint wear and tear or arthritis is felt on top of the shoulder right at the site of the joint. Sometimes the pain will radiate up that side of the neck. The shoulder is often uncomfortable to lie on and exercises such as press ups and shoulder press which force the joint surfaces together can be painful. Again initial treatment may involve a steroid injection and if nonoperative measures again fail to give adequate relief a keyhole operation to tidy up and restore space in the joint may be needed.
Instability in the AC joint is usually obvious as this results from a significant injury such as falling off a bike onto the side of the shoulder. The person will be immediately aware of the injury due to significant acute pain and they will often also notice a deformity at the end of the collarbone which appears to be sticking up higher than on the normal side. In many cases AC joint injuries will settle sometimes with the need for physiotherapy. Occasionally however surgery is required to reconstruct and stabilise the joint.
The conditions mentioned will cover about 90% of shoulder joint problems. If you require any further information please do not hesitate to contact me.