by | Aug 26, 2019 | Health

Understanding Shoulder Pain

by | Aug 26, 2019 | Health

Understanding Shoulder Pain

The shoulder is a complex ball-and-socket joint. Multiple structures are involved in permitting a wide range of movements: bone, cartilage, tendons, ligaments, muscles, bursae.

These structures may have an underlaying disease which can be mild to debilitating in nature. Traumatic causes: bone fractures, joint damage and tendon tears; Non-traumatic causes: tendinitis, bursitis, impingement, arthritis.

Important structures in the mobile shoulder joint

The glenoid labrum is a cartilaginous structure that deepens the concavity of the bony glenoid joint and supports the humeral head (ball) as it articulates in the glenoid joint (socket).
These deeply located structures include glenohumeral ligaments which support the joint and provide stability.

The joint capsule is a sac-like structure with relative laxity which encloses the joint, protecting intrinsic and deeply located structures and allowing wide mobility.

Rotator cuff tendons include the subscapularis-, supraspinatus-, infraspinatus- and teres minor tendons. These tendons are vital in actions such as raising the arm above the head (abduction); bringing the arm towards the body (adduction); lifting the arm forward or backwards (flexion or extension) and rotating the arm inwards or outwards (internal /external rotation).

Types of shoulder pain

Pain can be acute or chronic. Acute pain is the sudden onset of pain mostly resulting from trauma. Chronic pain is a longstanding condition often due to impingement or a neglected injury.

Conditions

Acute

Tendon tears

can occur partially or completely. Tendon fibres are delicate structures which tear from overload or high tension.

Bone fractures

are well known as a broken bone. This ranges from a hairline fracture, simple or complex fracture, depending on the severity.

Acromioclavicular 

joint is located on the top of the shoulder that is often injured due to the impact of a direct fall on the shoulder or with an outstretched hand. The small ligaments supporting this joint may tear or become inflamed.

Subacute

Effusion

is the swelling of a joint due to abnormal accumulation of fluid. This result from trauma, arthritis or infection and causes joint pain and stiffness.

Bursitis

A bursa provides cushioning between bones, tendons, joints and muscles. Inflammation of this sac-like structure causes swelling with fluid accumulation.

A hypermobile and unstable joint

happens when the humeral head moves within the joint socket (chronic instability); moves out partially (subluxation) or completely (dislocation). This occurs when the tendons, joint capsule, ligaments or cartilage labrum become stretched, torn or detached. An imbalance in the protagonist and antagonist muscle groups may also be a cause. It can be present from birth or acquired with repetitive movements and exercise.

Chronic

Tendinitis
(acute or chronic)

describes the state of an enlarged tendon resulting from inflammation, trauma or impingement. This can have increased blood supply and calcification formation due to the natural healing process that the body adapts in the case of injury or impairment.

Osteoarthritis

refers to the process of ageing where the cartilage between bones wears off.

Impingement

occurs when soft tissue structures (tendon, bursa) compress between bony structures upon arm movements, which often results in thinning of tendon fibres. This can progress to tendon tears. Bursitis also often occur as a result of continuous friction.

Bone spurs
(bony projections)

are formed by arthritis and is associated with impingement of the tendon or bursa in closest relation.

Interlinked shoulder conditions

Diagnosis

X-rays

Gives information on the coracoacromial arch (bony structures) most commonly involved in impingement. Narrowing of the joint space is demonstrated. Shoulder dislocation and bone spur formation can be confirmed. Bone fractures can be identified.

Ultrasound

Dynamic evaluation of soft tissue structures (tendons, bursae, blood vessels, muscle and bone surfaces) to identify impingement, tears, bursitis or tendinitis. While all other modalities provide static images, ultrasound provides a live dynamic evaluation of structures as the arm is moved in various directions and positions. Therefore, the entire rotator cuff can be visualized.

Arthrogram

To identify rotator cuff tears by means of injecting a fluid and taking an X-ray of the shoulder, to demonstrate communication between normally isolated cavities around the joint.

Computed Tomography (CT)

Superior to X-rays, allows visualization of fractures that are not visible on X-rays. Muscle, tendons, bursae and cartilage can also be seen which is not visible on X-rays.

Magnetic resonance imaging (MRI)

Best imaging modality. This uses a magnetic field to assess bone and soft tissue structures. The joint can be visualized from various perspectives allowing intra-articular (deeply located) anatomy (like cartilage) to be evaluated allowing one of a kind shoulder assessment. Intra-articular cartilage can be well visualized, not possible with any other modality.

Treatment

As prescribed by your doctor: Oral anti-inflammatory medication or antibiotics in the case of an infection.

Physical therapy by means of stretching and strengthening of shoulder structures. Ultrasound therapy, heat therapy or massage techniques may also be used.

In the case of persistent symptoms your doctor may consider a corticosteroid injection.

Surgery: for drainage of bursitis, repairing of tendon tears or shoulder replacements in more severe cases. This is usually prompted by a degenerative arthritic joint.

Where to start?

An appointment to your general practitioner. Your GP may prescribe medication or send you for an X-ray and/or ultrasound to identify the problem. Thereafter, you may be referred to a physiotherapist or surgeon depending on the degree of injury.

Visiting a physiotherapist may also be of benefit for conservative treatment. The physiotherapist will refer you for an X-ray and/or ultrasound if therapy appears ineffective or if a more focused approach is required.

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