Shoulder Pain: Causes and Treatment
Why does my shoulder hurt when I lift my arm? How do I relieve shoulder pain?
What is shoulder pain that radiates down the arm? Why are my shoulder and arm paining?
How long will my injured rotator cuff take to heal?
Is my shoulder hurting because of a pinched nerve?
These are just some of the questions that our team of physiotherapists across ReLiva Physiotherapy clinics answers frequently. This is because painful shoulder conditions are a relatively common occurrence nowadays.
A study reports that shoulder pain affects 18-26% of adults at any point in time. Symptoms can be persistent and disabling in terms of an individual’s ability to carry out daily activities both at home and in the workplace. Shoulder pain, therefore has large health care costs and a major impact on the health of affected individuals, including absence from work and disability.
That is why in this post, we have collated answers to questions about common shoulder problems and what can be done to treat them for pain relief.
Let's begin by understanding the shoulder. Shoulder joint is the most movable joint in the body. It is also one of the most potentially unstable joints allowing an individual to place the hand in numerous positions. As a result, it is the site of many common problems.
What are the most common causes for Shoulder Pain?
Apart from sprain and strains, they most common causes for shoulder pain include the following:
- Shoulder dislocation
- Rotator Cuff Disease: Tendinitis and Bursitis
- Torn Rotator Cuff
- Frozen Shoulder (Adhesive Capsulitis)
- Arthritis of the Shoulder
- Other much less common causes are tumors, infection, and nerve-related problems
We discuss each these specific shoulder problems one after the other, along with the treatment guidance.
To better understand shoulder problems and how they occur, it helps to begin with an explanation of the structure of the shoulder and how it functions.
What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion in the arm — from scratching your back to throwing the perfect ball.
[Continue reading or scroll to the bottom to understand the structure of Shoulder.]
Now let’s us address the different shoulder conditions including their symptoms and treatment.
1) Shoulder Dislocation
The shoulder joint is the most frequently dislocated major joint of the body. In a typical case of dislocated shoulder, either a strong force pulls the shoulder outward (abduction) or extreme rotation of the joint pops the ball of the humerus out of shoulder socket.
Dislocation commonly occurs when there is a backward pull on the arm that either catches the muscles unprepared to resist or overwhelms the muscles. It could be of 2 types
- When a shoulder dislocates frequently, the condition is referred to as shoulder instability.
- A partial dislocation in which the upper arm bone is partially in and partially out of the socket is called a called a subluxation.
- Read more about Shoulder dislocation and its treatment here.
2) Rotator Cuff Disease: Tendinitis and Bursitis
Tendinitis and Bursitis are closely related conditions and may occur alone or in combination.
Rotator Cuff Tendinitis :
Tendinitis is inflammation (redness, soreness, and swelling) of a tendon. In tendinitis of the shoulder, the rotator cuff and/or biceps tendon become inflamed, usually as a result of being pinched by surrounding structures. The injury may vary from mild inflammation to involvement of most of the rotator cuff. When the rotator cuff tendon becomes inflamed and thickened, it may get trapped under the acromion. Squeezing of the rotator cuff is called impingement syndrome.
Rotator Cuff Bursitis:
Bursitis or inflammation of the bursa sacs that protect the shoulder, may accompany tendinitis and impingement syndrome.
What causes Rotator Cuff Tendinitis and Bursitis ?
- Inflammation caused by a disease such as rheumatoid arthritis may cause rotator cuff tendinitis and bursitis.
- Sports involving overuse of the shoulder and occupations requiring frequent overhead reaching are other potential causes of irritation to the rotator cuff or bursa and may lead to inflammation and impingement.
- Repeated motion involving the arms, or
- The effects of the aging process on shoulder movement over many years, may also irritate and wear down the tendons, muscles, and surrounding structures.
What are the symptoms of Rotator Cuff Tendinitis and Bursitis ?
Signs of these conditions include :
- Slow onset of discomfort and pain in the upper shoulder or upper third of the arm
- Difficulty sleeping on the shoulder.
- Pain when the arm is lifted away from the body or overhead.
- Pain in the front or side of the shoulder that may travel down to the elbow and forearm, if tendinitis involves the biceps tendon (the tendon located in front of the shoulder that helps bend the elbow and turn the forearm)
- Pain may also occur when the arm is forcefully pushed upward overhead.
How are Rotator Cuff Tendinitis and Bursitis diagnosed?
Diagnosis of tendinitis and bursitis begins with a medical history and physical examination. X rays do not show tendons or the bursae but may be helpful in ruling out bony abnormalities or arthritis. The doctor may remove and test fluid from the inflamed area to rule out infection. Impingement syndrome may be confirmed when injection of a small amount of anesthetic into the space under the acromion relieves pain.
What is the treatment for Rotator Cuff Tendinitis and Bursitis?
Once diagnosed, Rotator cuff problems are usually treated with the following:
- The first step is to reduce pain and inflammation with rest, ice, and anti inflammatory medicines. [Read more about RICE protocol here]
- After the first 2-3 days of RICE, ReLiva Physiotherapist will use ultrasound modality in most cases, to warm deep tissues and improve blood flow.
- Gentle stretching and strengthening exercises are added gradually. These may be preceded or followed by use of an ice pack.
- As pain reduces, physiotherapist will add basic exercises like joint mobility, strengthening.
- If there is no improvement, your orthopedic doctor may inject a corticosteroid medicine into the space under the acromion. While steroid injections are a common treatment, they must be used with caution because they may lead to tendon rupture.
- If there is still no improvement after 6 to 12 months, the doctor may recommend either arthroscopic or open surgery to repair damage and relieve pressure on the tendons and bursae.
3) Torn Rotator Cuff
Rotator cuff tendons often become inflamed from overuse, aging, or a fall on an outstretched hand or another traumatic cause. Sports or occupations requiring repetitive overhead motion or heavy lifting can also place a significant strain on rotator cuff muscles and tendons. Over time, as a function of aging, tendons become weaker and degenerate. Eventually, this degeneration can lead to complete tears of both muscles and tendons. These tears are surprisingly common.
In fact, a tear of the rotator cuff is not necessarily an abnormal situation in older individuals if there is no significant pain or disability. Fortunately, these tears do not lead to any pain or disability in most people. However, some individuals can develop very significant pain as a result of these tears and they may require treatment.
What are the symptoms of Rotator Cuff tear?
When there is a torn rotator cuff, following symptoms may be observed:
- The patient feels pain over the deltoid muscle at the top and outer side of the shoulder, especially when the arm is raised or extended out from the side of the body.
- Motions like those involved in getting dressed can be painful.
- The shoulder may feel weak, especially when trying to lift the arm into a horizontal position.
- A person may also feel or hear a click or pop when the shoulder is moved.
- Pain or weakness on outward or inward rotation of the arm may indicate a tear in a rotator cuff tendon.
- The patient also feels pain when lowering the arm to the side after the shoulder is moved backward and the arm is raised.
How is Rotator Cuff Tear diagnosed?
The doctor may diagnose the tear with history and physical examination. However, it may not be able to locate the tear with just physical examination. Hence tests like MRI or ultrasonography help to determine the location as well as the severity (partial or full) of the tear.
What is the treatment for torn Rotator Cuff?
The treatment protocol for torn Rotator cuff usually includes the following:
- Rest is advised to the patients.
- Heat or cold application to the area also helps to relieve pain.
- Medications can be given to reduce the pain and inflammation.
- Physiotherapy treatment includes electrical stimulation of muscles and nerves, ultrasound, IFT or TENS.
- A cortisone injection near the inflamed area of the rotator cuff can be given in case of severe pain.
- If surgery is not an immediate consideration, exercises are added to the treatment program to build flexibility and strength and restore the shoulder’s function. If there is no improvement with these flexibility and strength and restore the shoulder’s function.
- If there is no improvement with these conservative treatments and functional impairment persists, the doctor may perform arthroscopic or open surgical repair of the torn rotator cuff.
Patients with rotator cuff tendinitis or bursitis that does not include a complete tear of the tendon can usually be treated without surgery with rehabilitative rotator cuff strengthening exercises. They are very effective.
4) Frozen Shoulder (Adhesive Capsulitis)
As the name implies, movement of the shoulder is severely restricted in people with a “frozen shoulder.” This condition, which doctors call adhesive capsulitis, is frequently caused by injury that leads to lack of use due to pain. Rheumatic disease progression and recent shoulder surgery can also cause frozen shoulder. Intermittent periods of use may cause inflammation. Adhesions (abnormal bands of tissue) grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally lubricates the gap between the arm bone and socket to help the shoulder joint move.
Interesting Facts about Frozen Shoulder:
- People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or those who have been in an accident, are at a higher risk for frozen shoulder.
- Frozen shoulder is more common among women than men.
- People between the ages of 40 and 70 are most likely to experience it.
[Read more about Frozen Shoulder, its causes and treatment here]
5) Shoulder Fracture
A fracture involves a partial or total crack through a bone. The break in a bone usually occurs as a result of an impact injury, such as a fall or blow to the shoulder. A fracture usually involves the clavicle or the neck (area below the ball) of the humerus or the shaft.
How is Shoulder fracture treated?
When a fracture occurs, the doctor tries to bring the bones into normal alignment that will promote healing and restore arm movement. If someone’s clavicle is fractured,
- Patient must initially wear a strap and sling around the chest to keep the clavicle in place.
- After removal of the strap and sling, the doctor will prescribe exercises to strengthen the shoulder and restore movement.
- Surgery is occasionally needed for certain clavicle fractures.
Fracture of the neck of the humerus is usually treated with a sling or shoulder stabilizer. If the bones are out of position, surgery may be necessary to reset them. Exercises become a major part for restoring shoulder strength and motion along with mobilisations after a certain period.
[Read more about recovering from fracture here]
6) Arthritis of the Shoulder
Arthritis is a degenerative disease caused by either wear and tear of the cartilage (osteoarthritis) or an inflammation (rheumatoid arthritis) of one or more joints (glenohumeral / acromioclavicular). Arthritis not only affects joints, but may also affect supporting structures such as muscles, tendons, and ligaments.
[ Related Reading : Arthritis – Do your Joints Pain? ]
- Diagnosis: A doctor may suspect the patient has arthritis when there is both pain and swelling in the joint. The diagnosis may be confirmed by a physical examination and x rays. Blood tests may be helpful for diagnosing rheumatoid arthritis.
How is Shoulder Arthritis treated?
Treatment of shoulder arthritis depends in part, on the type of arthritis.
- Osteoarthritis of the shoulder is usually treated with 2 pronged approach:
- Nonsteroidal anti-inflammatory drugs
- Along with physiotherapy to restore normal functions
- Rheumatoid arthritis requires :
- Physiotherapy as the 1st line of treatment to maintain and regain the muscle strength, joint mobility and
- Additional medications such as corticosteroids may or may not be given.
- In case of failure of the non-operative treatment, surgery is opted where surgeon replaces the shoulder joint with an artificial ball for the top of the humerus and a cap (glenoid) for the scapula. Physiotherapy is a MUST post surgery for full recovery.
Structure of Shoulder:
Your shoulder is made up of three bones:
- Your upper arm bone (humerus),
- Your shoulder blade (scapula), and
- Your collarbone (clavicle)
The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.
The bones of the shoulder are held in place by muscles, tendons, and ligaments.
- Tendons assist the muscles in moving the shoulder.
- Ligaments provide stability.
- Bursae (two sac-like structures) permit smooth gliding between bones, muscles, and tendons. They cushion and protect the rotator cuff from the bony arch of the acromion.
The shoulder joint can be compared to a golf ball and tee, in which the ball can easily slip off the flat tee. Because the bones provide little inherent stability to the shoulder joint, it is highly dependent on surrounding soft tissues such as capsule ligaments and the muscles surrounding the rotator cuff to hold the ball in place.
What are the Origins and Causes of Shoulder Problems?
The shoulder is easily injured because the ball of the upper arm is larger than the shoulder socket that holds it. To remain stable, the shoulder must be anchored by its muscles, tendons, and ligaments.
Although the shoulder is easily injured during sporting activities and manual labor, the primary source of shoulder problems appears to be the natural age-related degeneration of the surrounding soft tissues such as those found in the rotator cuff. The incidence of rotator cuff problems rises dramatically as a function of age and is generally seen among individuals who are more than 60 years old. Often, the dominant and non-dominant arm will be affected to a similar degree. Overuse of the shoulder can lead to more rapid age-related deterioration.
Shoulder pain may be localized or may be felt in areas around the shoulder or down the arm. Systemic diseases involving gall bladder, liver, heart or cervical spine can also generate referred pain to the shoulder, scapula and arm. However, these factors must be ruled out before concluding to any diagnosis.
This article is based on inputs from Dr Swapnaja Joshi (PT).
Dr Swapnaja is a Masters in Musculoskeletal Physiotherapy. She is very popular among her patients for her positive demeanor and effective treatment. She can be found at one of the ReLiva clinics.