The rotator cuff is the most common cause of shoulder pain in patients over the age of 40. Impingement, bursitis, tendonitis are commonly used terms to describe an inflamed rotator cuff.
There are four rotator cuff muscles that stabilize the shoulder while the larger muscles(deltoid) raise the arm. The biceps tendon and labrum are other important structures in the shoulder.
When the rotator is inflamed or torn, certain movements can become very painful. Patients may experience pain with overhead work, lifting or even just laying in bed at night.
X-rays rule out associated conditions: arthritis, calcific tendonitis or loose bodies in the joint. If conservative treatments are ineffective, then magnetic resonance imaging (MRI) provides visualization of the rotator cuff and determines if there is a tear.
Initial treatment consists of physical therapy, rest, oral anti-inflammatory medications and possibly cortisone injections. Sometimes a single cortisone injection can be enough to reduce the inflammation enough for the symptoms to resolve.
If the symptoms fail to resolve and an MRI demonstrates a rotator cuff tear, surgery can be indicated. We do know that tears that are less than 1 cm tend to be stable over time with less risk of tear progression. Large tears may progress over time and become irrepairable. Rotator cuff repair is performed arthroscopically with anchors that attach the tendon back to the bone.
Surgery is performed as an outpatient procedure. A nerve block is often performed by the anesthesiologist to help with the pain for the first day after surgery. A sling is worn for 6 weeks and physical therapy is continued for 3 months after surgery. Heavy lifting must be avoided for several months, depending on the size of the tear.
This is usually caused by either a traction or compression injury to the shoulder. This condition typically causes a deep “toothache” type of shoulder pain. The “SL” stands for superior labrum, where the biceps tendon attaches above the shoulder socket. Typically there is pain with outstretched arm activities. The diagnosis may be made clinically, and isn’t always visible on MRI examinations.
If therapy treatments are unsuccessful and pain limits function, shoulder arthroscopy is an option. During surgery, the two main options involve cutting the tendon free, or cutting and repairing it to another location (called a ‘tenodesis’). Cutting the tendon free creates a higher risk of a biceps prominence in the arm, along with some cramping. If I can repair it, I typically tell the patient to limit elbow bending for six weeks, and no overhead strength activities for four to six months.
Shoulder degenerative arthritis typically causes pain and/or catching and clicking of the shoulder. Symptoms are caused by loss of the cartilage surface on the ball and socket joint, along with loose bone fragments that may float around. Anti-inflammatory medications may be helpful (along with intermittent steroid injections).
If these treatments are ineffective, shoulder replacement is an option. If rotator cuff muscles around the shoulder are torn, sometimes a different type of replacement must be done, called a ‘reverse’ shoulder replacement. I usually restrict my shoulder replacement patients to no more than 10 to 15 pounds lifting with that arm for the rest of their lives. This helps reduce the chance of loosening and further surgery down the road.
Before surgery, a three-dimensional map of the shoulder socket is created with imaging that allows the surgeon to plan out the precise placement of the implants before the day of surgery. During the surgery itself, the computer navigation guides are used to position the implants more accurately.
Pain in the front of the shoulder can result from an inflamed biceps tendon where it enters the shoulder joint. There is a groove the biceps tendon lives in and biceps tendonitis usually involves tenderness in that area. It can be worsened with outstretched arm activities (due to tension on the biceps tendon). Physical therapy and anti-inflammatory medications may prove helpful. Steroid injectoin into the sheath around the biceps to can help to resolve the symptoms.
During a direct injury to the shoulder, the ball and socket can sometimes become separated. If the ball stays out of the joint, this dislocation sometimes has to be put back into place in the hospital with anesthesia. In younger persons, there is a much higher chance that there will be another dislocation in the future. Non-surgical rehabilitation involves functional therapy with a sling initially, and a brace for sport. If there are recurrent dislocations, or the patient is at high risk for re-injuring (due to sports participation), then surgery is considered. I perform an arthroscopic repair of the torn structures, and follow with six weeks in a sling followed by gradual sport-specific rehab. It is a minimum of six months before returning to sports after surgery.
Does your shoulder hurt if your arm is outstretched?