Treatment of Shoulder Pain

Common Causes of Shoulder Pain

• rotator cuff disorders including
• impingement
• tendinosis
• full or partial thickness tears
• calcific tendinitis
• frozen shoulder (adhesive capsulitis)
• biceps tendinitis
• shoulder joint osteoarthritis
• shoulder instability
• acromio-clavicular joint pathology
  

Patient Age

• Young patient
  Instability, AC joint separation, dislocation
• Middle-aged patient
  Impingement syndrome, RCT, adhesive capsulitis (female)
• Older patient
  Rotator Cuff Tear, degenerative arthritis, adhesive capsulitis
  

Shoulder Impingement

• The pain is due to irritation of the rotator cuff tendon (supraspinatus tendon)
• The clinical features are; onset usually insidious but can be sudden after overuse, painful lateral aspect of upper arm, worse at night, can not lie on affected arm
  
• Commonly caused by repeated overhead movements which cause pinching of the tendon
  
  

Outlet impingement

• In older athletes
  Tendinopathy followed by acromial changes and compression of the cuff under the arch
• In younger athletes
  Subtle glenohumeral laxity leading to muscle imbalance and subacromial space impingement
  
  

“Supraspinatus Outlet”

• Space between the anterior acromion, coracoacromial ligament, and acromioclavicular joint
• Supraspinatus muscle tendon
• Narrowing causes impingement
  

Neer’s Impingement Sign

• Patient seated
• Forcibly flex arm to overhead position
• Pain => humerus impinges against CA arch

Hawkin’s Impingement Sign

• Throwing position
• Flex forward 30 deg
• Forcibly int. rotate
• Pain => impingement of supraspinatous against CA ligament
  

Athletic Impingement

• In younger athletes, the impingement may be related to eccentric overload and microtrauma to the cuff or to subtle glenohumeral instability
  
• This may lead to secondary CA ligament impingement

Pathology of Outlet Impingement (Neer)

• Stage I: Edema and Hemorrhage
• Stage II: Fibrosis and Tendonitis
• Stage III: Bone Spurs and Tendon Rupture
  

Stages of Rotator Cuff Impingement

• Stage I
  Younger patients
  <25 y/o (can occur at any age)
  -Clinical features
  -Edema
  -Hemorrhage
  -Pain worse with >90 degrees abd.
  -Reversible lesion
  
• Stage II
  Middle age patients
  25-40 y/o
  -Pain with ADL’s
  -Night pain
  -Fibrotic changes of
  -Supraspinatus tendon
  -Biceps tendon
  -Subacromial bursa
  -Irreversible because of long term repeated stress
  

Treatment

• Treatment is rest in the younger patient, modification of activity (i.e. not playing golf/ racket sports)
• In chronic cases physiotherapy, analgesics and sometimes steroid and local anaesthetic injections become necessary
• Surgery
  

Treatment of calcifying tendinitis

• Non-operative: rest, NSAIDS, stretching, PROM, steroid injection
• Extracorporeal Shock Wave treatment
• Needle aspiration & lavage (Harmon 79% good; DePalma 61%)
• Operative: Arthroscopic lavage & debridement

Rupture of the Rotator Cuff (Stage III Impingement)

• End stage result of prolonged impingement
• Occasionally secondary to trauma
• Expected to progress if not treated
  

Frozen Shoulder

• Painful/Freezing StageMost painful stage.
• Motion is restricted, but the shoulder is not as stiff as the frozen stage. Typically lasts 6-12 weeks.
• Frozen Stage- Pain usually eases up, but the stiffness worsens. The frozen stage can last 4-6 months.
• Thawing Stage- The thawing stage is gradual, and motion steadily improves over a lengthy period of time. The thawing stage can last more than a year
  
  

Biceps Tendinitis

• Swelling and inflammation in biceps tendon
• Pain with shoulder and elbow flexion
• Pain with lifting
• Weakness due to pain


Treatment

• Rest
• Anti-inflammatory drugs
• Cortisone injection
• Physiotherapy
• Arthroscopic biceps tenodesis
  

Please note that the information contained herein is for general medical information only.
If you have any specific medical condition or queries, please consult your medical doctor.

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