SHOULDER PAIN

Shoulder Pain

Shoulder pain may present itself as stiffness of the shoulders, pulling pain, or sharp jabbing pain. The severity of the shoulder pain differs amongst patients, some may find that it interferes with mobility and daily activities, while others are unable to raise their arms completely.

What Causes Shoulder Pain?

The shoulder consists of three bones – the humerus, scapula, and collarbone. The head of the humerus is inserted into the scapula, while the scapula is surrounded by a set of muscles and tendons. These tissues are called rotation muscles or rotator cuffs.

Rotary muscles are composed of 4 muscles and tendons. Whenever a muscle or tendon is abnormally stimulated or damaged, the rotation muscle function will be affected, and patients will feel pain.

Broadly speaking, shoulder pain can be due to bony problems, joint problems, or surrounding muscles and tendons issues. Bony pain may include fracture of the humerus, scapula, or collar bone. Shoulder joint typically would include rheumatoid arthritis or wear and tear osteoarthritis of the shoulder as well as dislocation of joint. The last category of muscles and tendon pathology forms a large proportion of painful shoulder conditions eg. Tendinitis, bursitis, muscle or tendon tear.

Types of Shoulder Injuries

TENDINITIS
Tendinitis is the inflammation or irritation of the tendons, usually caused by some strenuous exercises such as throwing balls and lifting weights. It may also be related to carrying heavy objects frequently. Tendinitis can either be acute or chronic.

BURSITIS
Bursitis is the inflammation of the bursa, which is a soft tissue that cushions the bones, tendons, and muscles near your shoulder joints. A normal bursa allows for smooth gliding of the muscles and tendons against each other when activated. Symptoms of bursitis are like tendinitis and can be caused by it. Once the bursa is inflamed, it can cause severe pain when the tendon or muscle is gliding over the bursa.

ARTHRITIS
There are many types of arthritis, the most common of which is osteoarthritis. Osteoarthritis is joint swelling and stiffness caused by prolonged wear and tear, possibly caused by sports or labour injuries. The shoulder joint can have early degeneration due to overuse of the shoulder such as baseball players, acrobatic gymnasts and racket games.
Degeneration does not equal arthritis and it can be worn out without any pain. When the shoulder is arthritic, it means that the joint is inflamed and patients will naturally reduce the movement of the shoulder. Over time, the soft tissue of the joints will be further locked and stiffened, and the range of motion of the shoulder will be reduced further.

SHOULDER SPRAIN
A shoulder sprain is an injury to the rotator cuff muscle or ligament of the shoulder joint. Some injuries may be minor due to overuse or overstretched or overstrained. Other injuries may be severe including a tear of the ligaments. Small sprains are usually not as noticeable; however, a complete tear causes persistent and sharp pain, accompanied by weakness. This is usually caused by trauma directly to the shoulder such as car accidents or a fall onto an outstretched arm. This type of injury cannot be detected by X-ray and needs an MRI to evaluate the severity of the sprain.

SHOULDER GIRDLE SYNDROME/PERSONAGE-TURNER SYNDROME
Shoulder Girdle syndrome (brachial neuritis) is a neurological disorder that causes sudden and severe pain in the upper arm and shoulder. Weakness in the muscles of the shoulder, arm, forearm, or hand follows the pain, which lasts from days to a few weeks.

It is likely that there is damage or inflammation to the network of nerves that go from the spine through the neck, into each of the armpits, and then down the arms. This network is called the brachial plexus. Damage to those nerves causes muscle weakness.

Parsonage-Turner syndrome is frequently misdiagnosed as cervical radiculopathy or cervical spondylosis. A relatively uncommon condition, current studies have not identified an underlying cause.

SHOULDER IMPINGEMENT SYNDROME
Shoulder movement is dependent on the smooth gliding function of all the tendons and muscles over the shoulder joint. Whenever the tendons are impinged by surrounding structures such as bone spur, this will cause pain. The pain is described as sharp, transient, and episodic whenever lifting the shoulder or lowering the arm. Patients have also described feeling weakness and loss of shoulder mobility and movement of the shoulder. The most common cause of impingement is the overgrowth of bony spur of the acromion and its related joint due to overuse of the shoulder, narrowing the path of the supraspinatus tendon gliding through the sub-acromial space. This tendon often starts as tendinitis due to constant irritation of bony friction over the tendon and may end up as tendon tear and edematous swelling.

Symptoms Of Shoulder Pain

PAIN
You may feel pain when pressing on the area of injury (lying on the affected shoulder) or with movement (lifting the arm or removal of clothes). Depending on the severity and location, the shoulder pain may be mild to intense/ present in one arm or both.

SWELLING AND TENDERNESS
The injured area may be very tender, there may also be bruising or changes in skin colour, if it is caused by sudden trauma or impact such as in a car accident or a fall, the swelling will develop rapidly, this may require further treatment if it is severe. Severe swelling may render the shoulder shiny and warm with loss of skin ceases.

INSTABILITY
Some instances of severe shoulder sprain will also cause instability in the shoulder joints, degenerative conditions such as osteoarthritis may also result in instances of shoulder instability and general shoulder weakness. Instability of the shoulder joint will increase the likelihood of dislocation, accelerated degeneration and painful movement.

RESTRICTED MOVEMENT
If shoulder injuries and pain is aggravated, it can result in loss of strength and mobility, you may feel difficulties in tasks that require reaching behind the back. The shoulder movement may be restricted to the extent of being “frozen” and contracted.

A Message About Shoulder Pain

Shoulder pain is a symptom of something that has gone wrong. There are many different reasons for the causes of shoulder pain. If shoulder pain is not treated adequately, it can progress to restriction of movement such as “Frozen Shoulder”. Once it has reached this stage, it is harder to treat. Conservatively, only 20% of patients recover from this “frozen phase” to thawing stage, with others ending up with permanent contracture of the shoulder.

Shoulder pain is not always about bone spur. Sometimes a simple sprain can be the start of persistent shoulder pain, starting on the slippery slope of deconditioning and worsening of shoulder condition, ending in contracture and stricture.

Diagnosing Shoulder Pain

Here at Singapore Paincare, our team of experienced primary care physicians and pain care specialists together with an orthopedic surgeon will evaluate your condition. This includes a physical exam, questions about your symptoms, and an evaluation of your medical history. In cases of referred pain from the cervical spine, additional tests are also carried out such as nerve conduction or electromyography, these tests help to identify characteristic symptoms to eliminate other forms of disease or injuries such as slipped disc of the neck spine causing nerve impingement. In persistent shoulder pain, An X-ray or MRI scan may be needed to investigate the causes of your shoulder pain. The MRI scan is needed to evaluate the soft tissues, tendons, and muscles of the shoulder joint.

What Treatments Are Available for Shoulder Pain?

Depending on the severity of the shoulder injury, medication or surgery may be required to treat the damaged bone, ligament, or muscles.

Non-surgical Treatments for Shoulder Pain

Conservative treatment of shoulder pain would include rest, support, and ice. Often, simple painkillers such as Panadol or Anti-inflammatory medications can reduce the inflammatory pain of simple injuries and sprains. Some of the treatments for shoulder pain may benefit from physiotherapy, which can help to reduce stiffness in the affected areas and help to accelerate the restoration of rotator cuff function.

When pain has persisted beyond 6 weeks, it would need additional medical attention to assist in the healing of the shoulder pain. Generally, some specialised injections would be needed to help with the healing of painful conditions.

CORTISONE INJECTION
Cortisone is used to treat tendon ligament or inflammation. It is a form of anti-inflammatory which can reduce pain. This is useful as the first approach to giving a targeted treatment for active inflammation.

PRP INJECTION
Platelet-rich plasma is used to stimulate the natural healing of human tissues, usually used to speed up the process of recovery if cortisone/steroids show little or no effect. This form of prolotherapy is the proliferation of fibrosis and improves the healing of the underlying injuries.

Surgical Treatments for Shoulder Pain

Short-term shoulder injuries can be resolved with conservative treatments. However, severe injuries may require surgery, this is usually discussed with our doctors to see if patients are suitable candidates.
If you choose to have surgery, your options may include:
ARTHROSCOPY
Arthroscopy is an alternative minimally invasive procedure to access and treat the joints in the shoulder. The process uses a camera to view the affected region, allowing the doctors to make precise removal of ligaments or fluid as necessary. Through the scope, repair of tendons may be possible without the need for large surgical wound.

SHOULDER JOINT REPLACEMENT SURGERY
If all other options did not provide relief, doctors may recommend a replacement of the damaged sections of the shoulder with an artificial component. However, this is only done as the last resort or if the patient is a suitable candidate for surgery.

How Can I Prevent Shoulder Pain?

The key to preventing shoulder pain is by listening to your body. It is best to seek professional help if the pain doesn’t go away. It’s also important to do a proper warm-up before doing any type of exercise or sport. Having a healthy diet and staying in shape also helps.