Shoulder Education

Shoulder Joint Health

Shoulder Education

The shoulder is made up of three bones - the upper arm bone (humerus), the shoulder blade (scapula) and collarbone (clavicle). And these three bones are joint together by two joints in the shoulder.

The joint where the head of the upper arm bone fits into the rounded socket of the shoulder shoulder blade is called the glenohumeral joint. A combination of muscles and tendons called the rotator cuff keeps the arm bone centered into the shoulder socket. The other joint is the acromioclavicular (AC) joint, where the collar bone meets the tip of the shoulder blade at the acromion.

What you need to know:
Arthritis of the Shoulder

Arthritis is the inflammation of one or more of the joints in our body. According to the National Health Interview Survey held in 2011, more than 50 million people in the US reported that they had been diagnosed with some form of arthritis. Similar with arthritis of other parts of the body, arthritis in a diseased shoulder causes unbearable pain and stiffness.

Causes
Shoulder arthritis like osteoarthritis is caused by wear-and-tear that is often associated with old age,  most common in patients over 50 years of age. An autoimmune disease that causes the immune system to attack its own tissues , causing bones to soften and pain to the shoulder joints. Prolonged injuries may also result in disruption of blood supply to the bones, weakening the bones and causing arthritic pain.

Symptoms
A patient with any type of shoulder arthritis will experience great pain, which may be aggravated by activity and may worsen progressively. Pain in different areas of the back and shoulders indicate different arthritis locations and conditions; if the glenohumeral shoulder joint is affected, a deep ache or pain that is centered in the back of the shoulder that may intensify with weather changes is the usual complaint. Pain in the top of the shoulder that sometimes radiate to the side of the neck indicates acromioclavicular (AC) joint arthritis, and rheumatoid arthritis may cause pain throughout the shoulder if both glenohumeral and AC joints are affected.

Patients may also experience limited range of motion, such as increased difficulty to raise an arm to comb hair or reach up to a shelf. There may be grinding, clicking or snapping sounds as the shoulder is moved. With shoulder arthritis, night pain is common and may cause difficulty sleeping.

Diagnosis
The diagnosis of shoulder arthritis can be made by an X-Ray imaging of the shoulder and neck area. An arthritic shoulder will show a narrowing of the joint space, changes in the bone, and the formation of bone spurs (osteophytes).


X-ray showing severe osteoarthritis of the glenohumeral joint

The doctor may inject a local anesthetic into the suspected arthritic joint; if it temporarily relieves the pain, the diagnosis of arthritis is supported and confirmed

Types of Shoulder Arthritis?
There are five major types of arthritis that typically affects the shoulder.

  • Osteoarthritis
    Osteoarthritis is a condition that destroys the smooth outer covering (articular cartilage) of bone. It is known as a ‘wear-and-tear’ arthritis; the cartilage becomes frayed and rough as it wears away with age, resulting in decreased protective space between the bones, causing pain during movements as the bones of the joints rub against each other.
    An illustration of a damaged cartilage in the glenohumeral joint (left) and a shoulder X-ray showing osteoarthritis and decreased joint space (right).
  • Rheumatoid Arthritis
    Rheumatoid arthritis is a chronic autoimmune disease that attacks multiple joints throughout the body; it is symmetrical, affecting the same joints on both sides of the body. In autoimmune diseases such as rheumatoid arthritis, the defenses that protect the body from infection damages the normal tissues (eg. cartilage and ligaments) and soften bones instead. In rheumatoid arthritis, the synovium lining that lubricates joints swell up, causing joint pain and stiffness.
  • Post-traumatic Arthritis
    As its name suggest, post-traumatic arthritis is a form of osteoarthritis that develops after an injury such as a shoulder fracture or dislocation.
  • Rotator Cuff Tear Arthropathy
    A large, long-standing rotator cuff tendon tear can develop into arthritis, as the rotator cuff can no longer hold the head of the humerus in the glenoid socket, the humerus can move upwards and rub against the acromion, damaging the surfaces of the bones. The combination of large rotator cuff tear and advanced arthritis can lead to severe pain and weakness, eventually the patient may not be able to lift the arm away from the body’s side.

    Rotator cuff arthropathy
  • Avascular Necrosis (AVN)
    Avascular necrosis of the shoulder is a painful condition that occurs when the blood supply to the head of the humerus is disrupted, causing blood cells to die and ultimately destruction of the shoulder joint and arthritis.AVN develops in stages, initially affecting only the head of the humerus, but as it gradually progresses, the dead bone gradually collapses, damaging the articular cartilage covering the bone and the glenoid socket, leading to arthritis.

Treatments
As with all treatments of arthritis, the patient’s overall health, medical condition and severity of the disease will be evaluated before making and recommendation for treatments. For arthritis of the shoulder, non-surgical and surgical methods of treatments are effective for different stages of the disease.

  • Non-surgical treatment
    Initial treatment of arthritis of the shoulder is usually non-surgical. The doctor may recommend resting or a change in activities to avoid provoking pain or physical therapy exercises to improve the shoulder’s range of motion. NSAIDs such as aspirin or ibuprofen and/or corticosteroid injections may also be recommended to reduce any inflammation and pain. In the case of rheumatoid arthritis, the doctor may prescribe a disease-modifying drug, such as methotrexate.Other therapies such as application of moist heat and ice may also help alleviate inflammation and pain. Dietary supplements such as glucosamine and chondroitin sulfate may also help relieve pain.
  • Surgical treatment
    Surgery may be considered if the pain causes disability and is not successfully relieved with non-surgical methods. The surgeon will recommend the best surgical method to treat the diagnosed condition.Before any surgery is undertaken, appropriate blood tests, chest X-rays, electrocardiograms and urine samples will be obtained to ensure that the patient has no underlying condition that may complicate the surgery.
Rotator Cuff Tears

The arm is kept connected to the shoulder by the rotator cuff, it is a group of four muscles that come together as tendons to form a covering around the head of the humerus, attaching the humerus to the shoulder blade and help lifts and rotates the arm.

The bursa (lubricating sac) between the rotator cuff and the bone on top of the shoulder (acromion) allows the rotator cuff tendons to glide freely when the arm is moved. When the rotator cuff tendons are injured, the tendon no longer fully attaches to the head of the humerus, weakening the shoulder and making daily activities such as combing hair or getting dressed to become painful or difficult.bursa can also become inflamed and painful. When one or more rotator cuff tendons is torn, the

In most rotator cuff tears, the tendon is torn away from the bone.

In many cases, torn tendons begin by fraying and can completely tear, sometimes with lifting a heavy object. Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be involved.

Causes
There are two main causes to rotator cuff tears – injury and degeneration. Acute tears may happen from injuries such as falling down on an outstretched arm, or lifting something that is too heavy with a jerking motion; it can also occur with other shoulder injuries such as a broken collarbone or dislocated shoulder.

Degenerative tears are the result of wearing down of the tendon that occurs slowly over time as we age. Rotator cuff tears are more common in the dominant shoulder, yet there is also a greater likelihood of a tear in the opposite shoulder, even if the patient does not experience pain in the latter shoulder. Repetitive stress or overuse on the same shoulder can put excessive stress on the rotator cuff muscles and tendons, lack of blood supply to the tendons can also lead to a tear. As we age, bone spurs or overgrowth often develop in the underside of the acromion bone, causing the spurs to rub on the rotator cuff tendon causing shoulder impingement that will weaken the tendon over time, making it risk for tears.

Symptoms
Some rotator cuff tears are not painful, but may result in arm weakness and other symptoms. The most common symptoms of rotator cuff tears include:

  • Pain at rest and at night, especially if lying on the affected shoulder
  • Pain or weakness when lifting or lowering the arm or with specific movements
  • Crackling sensation when moving the shoulder in certain positions

Tears that happen suddenly usually cause intense pain and immediate weakness in the upper arm, and may be accompanied by a snapping sensation. Tears that develop progressively due to overuse also cause pain and arm weakness which at first may be mild and only present when lifting the arm over the head. Over time, the pain may become more noticeable and no longer goes away with OTC medications or painkillers.

Diagnosis
The doctor will examine the shoulders after discussing the patient’s symptoms and medical history. The doctor will have the patient move their arms in several different directions and also test arm strength to determine the range of motion and check for any problems with the shoulder joint. He or she may also examine the neck to make sure the pain is not caused by a ‘pinched nerve’, and to rule out other conditions such as arthritis.

Imaging tests such as X-rays also help the doctor confirm the diagnosis, yet, X-rays do not show the soft tissues like the rotator cuff, though it may show a small bone spur. MRIs or ultrasounds can better show soft tissues like rotator cuff tendons, showing the rotator cuff tear, as well as the location and size of the tear. It can give the doctor a better idea of the age of the tear as it can show the quality of the rotator cuff muscles.

Treatments
A rotator cuff tear can worsen over time without appropriate treatment; early treatment can prevent symptoms from getting worse. The goal of the treatments is to reduce pain and also restore function, and treatment options vary according to every individual depending on the patient’s age, activity level, general health and the type of tear. Many doctors recommend management of rotator cuff tears with physical therapy and non-invasive treatments.

  • Non-surgical treatment
    In about 80% of patients with rotator cuff tears, non-surgical treatments manages to alleviate the pain and improve shoulder joint function. Treatment methods include resting the shoulder or a sling to help protect the shoulder and to keep it still, besides avoiding activities that may cause shoulder pain. Strengthening exercises and physical therapy such as stretching exercises to improve flexibility and range of motion will also be programmed according to individual condition. Non-steroidal anti-inflammatory medications like ibuprofen or naproxen may be prescribed to reduce any swelling or pain. Last resort of non-surgical methods include steroid injections such as cortisone to relieve painful symptoms.
  • Surgical treatment
    Surgery will be recommended by the doctor if the pain is not relieved by non-surgical treatment, experience continued pain, or are very active and need the use of arms for overhead work or sports. Other signs that surgery may be a good option include:
    • Symptoms have lasted 6 – 12 months
    • Patient has large tear (>3cm) and the quality of the surrounding tissue is good
    • There is significant weakness and loss of function in the shoulder
    • The tear was caused by a recent, acute injury

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of the upper arm bone, and there are a few options on how to repair it, which will be discussed in detail by the surgeon based on individual health and condition needs.

Shoulder Impingement / Rotator Cuff Tendinitis

Rotator cuff tendinitis is the irritation or damage of the rotator cuff tendons whereas shoulder impingement refers to the rubbing of tendons (hence the ‘impinging’ on) and the bursa when patients raise their arms to shoulder height, causing irritation and pain. Bursitis refers to the inflammation and swelling with more fluid causing increased pain.

Causes
Rotator cuff tendinitis is common in both middle-aged patients, young athletes such as basketballers, swimmers who may perform overhead activities and those who do repetitive lifting such as construction or painting.

Symptoms
Rotator cuff pain commonly causes local swelling and tenderness in front of the shoulder, patient may experience pain and stiffness when the arm is lifted, or lowered from an elevated position. Initial symptoms may be mild and thus patients may not have sought treatment in the early stages. These symptoms may include:

  • Minor pain during activity and at rest
  • Pain radiating from the front of the shoulder to the side of the arm
  • Sudden pain with lifting and reaching upwards movements
  • Athletes in overhead sports may have pain when throwing or serving a tennis ball.

Symptoms may progress over time, such as having pain at night, loss of strength and motion, difficulty doing activities that require placing the arm behind the back, such as buttoning. If the pain comes suddenly, the shoulder may be severely tender, all movement may be limited and extremely painful.

Diagnosis
The doctor will examine the shoulders to see whether it is tender in any area or whether there is any deformity after discussing the patient’s symptoms and medical history. The doctor will have the patient move their arms in several different directions and also test arm strength to determine the range of motion and check for any problems with the shoulder joint. He or she may also examine the neck to make sure the pain is not caused by a ‘pinched nerve’, and to rule out other conditions such as arthritis.

Imaging tests such as X-rays also help the doctor confirm the diagnosis, yet, X-rays do not show the soft tissues like the rotator cuff, though it may show a small bone spur. MRIs or ultrasounds can better show soft tissues like rotator cuff tendons, showing the rotator cuff tear, as well as the location and size of the tear. It can give the doctor a better idea of the age of the tear as it can show the quality of the rotator cuff muscles.

Treatments
The goal of treatments for this condition is to reduce pain and also restore function. Treatment options vary according to every individual depending on the patient’s age, activity level and general health.

  • Non-surgical treatment
    Initial treatment for shoulder impingement is non-surgical methods, although it may take several weeks to months, many patients experience a gradual improvement and function restoration. Treatment methods include resting the shoulder and undergoing activity modification to avoid overhead activities that may cause shoulder pain. Physical therapies will also be recommended to focus on restoring normal motion to the shoulder, such as stretching exercises to improve the range of motions. Once the pain improves, the therapist can start on a strengthening programme for the rotator cuff muscles.Non-steroidal anti-inflammatory medications like ibuprofen or naproxen may be prescribed to reduce any swelling or pain. Last resort of non-surgical methods include steroid injections such as local anaesthetic and cortisone into the bursa beneath the acromion to relieve painful symptoms.

    A cortisone injection may relieve painful symptoms.
  • Surgical treatment
    When the pain is not relieved by non-surgical treatment, surgery will be recommended by the doctor.  With surgery, the goal is to create more space for the rotator cuff, such as removing the inflamed portion of the bursa, or part of the acromion.

Recovery
Post surgery, the arm may be placed in a sling for a short period of time to allow for early healing. As soon as it is comfortable for the patient, the sling will be removed to begin exercise the use of the arm. The doctor will provide a rehabilitation programme based on patient needs and the findings at surgery; this will include exercises to regain range of motion of the shoulder and strength of the arm, and will typically takes 2-4 months to achieve complete relief of pain, but some may take up to a year

Shoulder Joint Tear (Glenoid Labrum Tear)

The shoulder joint is made of three bones: the head of the upper arm bone (humeral head) rests in a shallow socket in the shoulder blade (glenoid); the head of the humerus is usually much larger than the socket, and is surrounded by a soft fibrous tissue rim called the labrum. The labrum helps stabilise the joint and deepens the socket by up to 50% so that the head of the humerus fits better and stronger. In addition, it serves as an attachment site for several ligaments.


Tears can be located either above or below the middle of the glenoid socket

  • A SLAP lesion (superior labrum, anterior to posterior lesion) is a tear of the rim above the middle of the socket that may also involve the biceps tendon
  • A Bankart lesion is a tear of the rim below the middle of the glenoid socket that also involves the inferior glenohumeral ligament

Glenoid rim tears often occur with other shoulder injuries, such as a dislocated shoulder (full or partial).

Causes
Injuries to the glenoid labrum can occur from acute trauma or repetitive shoulder motion, such as sudden fall on outstretched arm, a direct blow to the shoulder, a violent overhead reach etc. Throwing athletes or weightlifters can experience glenoid labrum tears as a result of repetitive shoulder motion.

Symptoms
The symptoms of glenoid labrum tear are very similar to other shoulder injuries, these symptoms include:

  • A sense of instability in the shoulder
  • Shoulder dislocations
  • Pain that is usually associated with overhead activities
  • A sense of shoulder joint ‘catching’, locking, popping or grinding
  • Occasional night pain or pain with daily activities
  • Decreased range of motion and loss of strength

Diagnosis
The doctor will ask for history of any experienced injury that led to the shoulder pain, such as a specific incident or that the pain have gradually increased. The doctor will also conduct several physical tests to check the range of motion, stability and level of pain. X-rays may also be requested to determine the reason for the problem.

However, X-rays will not show damage to the rum of the shoulder socket, thus the doctor may order a CT scan or MRI scan. A contrast medium may be injected to help detect any tears, ultimately the diagnosis will be made with arthroscopic surgery.

Treatments
The physician may prescribe anti-inflammatory medication and rest to relieve the symptoms, until the final diagnosis is made. Rehabilitation exercises to strengthen the rotator cuff muscles may also be recommended.

Depending on the injury, the doctor may perform a traditional, open procedure or an anthroscopic procedure, in which small incisions and miniature instruments are used to examine the rim and biceps tendon.

Recovery
Post surgery, the operated shoulder will need to be kept in a sling for 3-6 weeks, depending on the doctor’s recommendation. The doctor will also prescribe gentle, passive and pain-free range of motion exercises. When the sling is removed, the patient will gradually start to do motion and flexibility exercises to strengthen the shoulder. Although it will take about 4-6 months before the shoulder is fully healed, athletes usually can begin to do sport-specific exercises 12 weeks post-surgery.

Clavicle Fracture (Broken Collarbone)

The clavicle is located between the ribcage (sternum) and the shoulder blade (scapula), connecting the arm to the body.

A clavicle fracture is a break in the collarbone that occurs when a fall onto the shoulder or an outstretched arm puts enough pressure on the bone that it snaps or breaks. Most fractures occur in the middle portion (or shaft) of the bone. Occasionally it will break where it attaches at the ribcage or shoulder blade; it may break just slightly, or it may break into many pieces (comminuted fracture), the broken pieces may line up straight, or may be far out of place (displaced fracture).

The clavicle lies above several important nerves and blood vessels, yet when a fracture occurs, these vital structures are rarely injured.

Causes
Clavicle fractures are most often caused by a direct blow to the shoulder that can happen during a fall onto the shoulder, such as in a car collision, or falling onto an outstretched arm. In a baby, clavicle fracture can occur while passing through the birth canal.

Symptoms
A clavicle fracture can be very painful and makes it hard to move the arm. Other symptoms include:

  • Sagging of the shoulder downward and forward
  • Inability to lift the arm because of the pain
  • A grinding sensation when attempting to raise the arm
  • Bruising, swelling and/or tenderness over the collarbone
  • A bump or deformity (‘tenting’ of the skin) over the fracture site


The broken ends of the bone may cause tenting of the skin over the fracture site

Diagnosis
The doctor will ask for any symptoms or the occurrence of injury as he or she carefully examines the shoulder. Certain tests will be performed to ensure that no nerves or blood vessels were damaged when the fracture occurred. X-rays may also be requested to help pinpoint the fracture site and determine the severity of the break. If other bones are broken, a CT scan may be ordered to see the fracture in better detail.

shows a fracture in the middle of the clavicle. Note how far out of place (displaced) the broken ends of the bones are.

Treatments
If the broken ends of the bones have not significantly shifted out of place, surgery may not be needed; most broken collarbones can heal without surgery.

  • Non-surgical treatment
    Non-surgical methods to heal broken collarbones may include:
    – Arm support or sling to keep the arm and shoulder in position while the injury heals
    – Physical therapy to maintain arm motion and prevent stiffness
    – Gentle exercises during the initial healing stage, with more strenuous exercises introduced gradually once the fracture is completely healed.
    – Pain medication including acetaminophen can help relieve pain as the fracture healsA ‘malunion’ happens if the fracture fragments do move out of place and the bone heals in that position. Treatments for this condition is determined by how far out of place the bones are and how much this affects arm movement
  • Surgical treatment
    Surgery will be recommended for bones that have broken and significantly shifted out of place. Surgery typically involves putting the broken pieces of bones back into position and preventing them from moving out of place again as they heal, to improve shoulder strength post-recovery. For this purpose, plates and screws or pins may be used to reposition the bone fragments. Pain medication may also be prescribed to relief the pain post-surgery.As with any other type of surgery, there may be complications involved, such as infections, bleeding, blood clots, blood vessel damage or problems that complicate wound healing. Risks that are specific to clavicle fractures include difficulty with bone healing, lung injury and hardware irritation. Rest assured that the doctor will discuss each of the risk in detail and take specific measures to avoid complications.

Recovery
The collarbone may take several months to heal from a clavicle fracture; it may be longer in diabetic patients or those who smoke or use tobacco products. Most patients return to regular activities within 3 months of the injury, and the doctor will inform when the injury is stable enough to do so. Thus it is important to follow up with the doctor as scheduled to make sure the bone heals correctly and stays in position.

Dislocated Shoulder

The shoulder joint is the body’s most mobile joint that can turn in many directions, but this advantage also makes the shoulder an easy joint to dislocate. Patients may experience partial dislocation (subluxation) – the head of the upper arm bone is partially out of the socket, or complete dislocation all the way out of the socket. Both types of dislocations cause pain and unsteadiness in the shoulder.


Shoulder instability.

Causes
Shoulder joints can dislocate forward, backward, or downward. A common type of shoulder dislocation is when the shoulder slips forward (anterior instability), where the upper arm bone moved forward and out of its socket. It may happen when the arm is put in a throwing position.

Symptoms
Symptoms of shoulder dislocation include:

  • Deformity, bruising or swelling in the shoulder joint
  • Numbness or weakness

Sometimes a dislocation may tear ligaments or tendons in the shoulder, or even damage any nerves. The muscles may have spasms from the dislocation, causing it to hurt more. When the shoulder repeatedly dislocates, there is recurrent shoulder instability.

Diagnosis
The doctor will examine the shoulder, and an x-ray may be ordered. He or she may also ask about how the dislocation happened or whether the shoulder had ever been dislocated prior.

Treatments
The doctor will place the ball of the upper arm bone (humerus) back into the joint socket in a process called ‘closed reduction’. Any severe pain will stop almost immediately once the shoulder joint is back in place.

If shoulder dislocation becomes a recurrent problem, surgery may be needed to repair or tighten the torn or stretched ligaments that help to hold the joint in place, especially in young athletes. Sometimes, the recurrently dislocating shoulder can result in some bone damage to the humerus or shoulder socket. If the surgeon identifies bone damage, a bone transfer type of surgery may be recommended.

Recovery
Post-surgery, the doctor may immobilise the shoulder in a sling or other device for several weeks following treatment, and will prescribe plenty of rest. The sore area can be iced 3 – 4 times a day. Rehabilitation exercises to help restore the shoulder’s range of motion and strengthen the muscles may be prescribed after the pain and swelling subside. Weight training may be added later on.

Rehabilitation is important to prevent future dislocations. If shoulder dislocation becomes a recurrent problem, a brace can sometimes help.