Painful Shoulder

Normal Anatomy
Definition
Shoulder pain involves any pain in or around
the shoulder joint.

Considerations 
The shoulder is the most mobile joint in the
human body. The joint includes four tendons.
The purpose of a tendon is
to hold muscle to bone. Together,
these four "rotator cuff" tendons
stabilize the upper arm bone to the
shoulder socket and allow a wide
range of motion in the shoulder.
 Mechanism of the pain

Any swelling, inflammation, tearing, or bony

changes around these tendons causes pain when a
person tries to move the arm above the head,
behind the back, or straight out in front.
Reasons beyond that pain
Because of its high level of mobility, the shoulder
has heavy reliance on the muscles around the
shoulder to act as dynamic stabilisers during
movement of the arm. Dysfunction of the stabilising
mechanics, either at the shoulder joint itself or around
the shoulder blade, combined with or without
abnormalities in the anatomical arrangement of the
structures around the joint, or biomechanical faults
make the shoulder particularly prone to pain and
injury.
 How common are these
conditions?

Around 11 patients out every 1000 visit their GPs

with shoulder complaints each year.
Most Common Causes:

Frozen Shoulder. (Idiopathic Adhesive Capsulitis).

Painful Arc Syndrome.

 Frozen shoulder
• Frozen shoulder is clinical syndrome charachterized by gross
restriction of shoulder movement associated with contraction
and thickening of the joint capsule.affect middle age.

• Also associated with severe pain disturb sleeping,

• There is frequently history of a minor trauma lead to shoulder

cuff tearing, initiating prolonged inflammatory changes and
contraction of shoulder cuff responsible of symptoms.

• If there is no improvement with appropriate treatment for 4

monthes , manipulation of the shoulder under general
anasthesia.
 Other Causes

Bursitis / Rotator Cuff Tendonitis

The most common diagnosis in patients with shoulder pain is
bursitis or tendonitis of the rotator cuff.

Rotator Cuff Tear

Rotator cuff tears occur when the tendons of the rotator cuff
separate from the bone. Surgery is sometimes necessary for
this condition.

Calcific Tendonitis
Calcific tendonitis is a condition of calcium deposits within a
tendon -- most commonly within the rotator cuff tendons.
Treatment of calcific tendonitis depends on the extent of
symptoms.
Shoulder Instability
Instability is a problem that causes a loose joint. Instability can
be caused by a traumatic injury (dislocation), or may be a
developed condition.

Shoulder Dislocation
A dislocation is an injury that occurs when the top of the arm
bone becomes disconnected from the scapula.

Shoulder Separation
Also called an AC separation, these injuries are the result of a
disruption of the acromioclavicular joint. This is a very
different injury from a dislocation!

Labral Tear
A Bankart lesion is a type of labral tear most commonly due to
dislocation of the joint. Bankart lesions cause problems of
persistent instability.
SLAP Lesion
The SLAP lesion is also a type of labral tear. The most
common cause is a fall onto an outstretched hand.

Arthritis
Shoulder arthritis is less common than knee and hip arthritis,
but when severe may require a joint replacement surgery.

Biceps Tendon Rupture

A proximal biceps tendon rupture occurs when the tendon of
the biceps muscle ruptures near the joint.
 Referred shoulder pain
• Whiplash
• Fractured humerus
• Ruptured bicep tendon
• Disc conditions
• Thoracic outlet syndrome
• Ectopic pregnancy
• Diaphragm irritation
• Diaphragm conditions
• Liver abscess
• Referred gallbladder pain
 Referred shoulder pain
• Gallbladder conditions - usually right shoulder pain.
• Gallstones
• Cholangitis
• Cholecystitis
• Internal bleeding (see Bleeding symptoms) - often
causing shoulder-tip pain
• Referred heart pain
• Angina
• Heart attack
• Polymyalgia rheumatica
 Diagnosis

Determining the source of the problem in the shoulder is

essential to recommending the right method of
treatment.

The first step is a thorough medical history.

Next, perform a physical examination including the

movements
Shoulder movements
 Investigation:
Plain X-ray of the shoulder:
- Antro-posterior.
- Lateral.
CT.Scan; provides a more detailed view of the shoulder area

MRI and ultrasound are other valuable diagnostic tools because

they provide images of the soft tissues without using
radiation .

Special investigations.
If you suspect infections :
WBC Blood culture
Chest x-ray Aspiration of joint

EMG (electromyogram), which can indicate nerve damage

an arthrogram, an X-ray study in which dye is injected into

the shoulder to allow the orthopaedist to better see the joint
and its surrounding muscles and tendons

Arthroscopy : is a surgical procedure in which the

orthopaedist looks inside the joint with a lighted telescope.
It is sometimes used to diagnose causes of shoulder pain
and indicate soft tissue injuries that are not apparent in the
physical examination, X-rays and other tests.
Normal Antro-posterior view
Normal Lateral View
 Treatment
• It depends entirely on the cause of the problem.

• Shoulder Pain Treatment Basics :

Rest:
– The first treatment for many common conditions is to rest
the joint, and allow the acute inflammation to subside.
– Acute rotator cuff tears require immobilization in a sling.
But It is important to use caution when resting the joint,
because prolonged immobilization can cause a frozen
shoulder.

Ice and Heat Application:

Ice packs and heat pads are among the most commonly
used treatments for shoulder pain.
Stretching: Stretching the muscles and tendons
that surround the joint can help with some
causes of shoulder pain.

Physical Therapy: Physical therapy is an

important aspect of treatment of almost all
orthopedic conditions. Physical therapists
use different modalities to increase strength,
regain mobility, and help return patients to
their pre-injury level of activity. Some
specific exercises may help you stregthen the
muscles around the joint and relieve some of
the pain associated with many conditions.
Treatment Medications :

Anti-Inflammatory Medication

Cortisone injections
 Common Causes of Pain and 
Dysfunction of the Shoulder
• rotator cuff strains/tears 
• rotator cuff tendinitis 
• glenohumeral (shoulder joint) instability 
• glenohumeral dislocation/subluxation 
• acromioclavicular joint injury 
• fractures of the clavicle (collar bone), or scapula (shoulder blade) 
• adhesive capsulitis (frozen shoulder) 
• biceps tendinitis 
• referred pain from the cervical or thoracic spine 
• referred pain from soft tissues 
• nerve entrapments (eg suprascapular, long thoracic) or brachial 
plexus injury 
• levator scapula syndrome 
 Prevention

• If you have had shoulder pain in the past,

use ice and ibuprofen after exercising.

• Learn proper exercises to stretch and

strengthen your rotator cuff tendons and
shoulder muscles. A doctor or physical
therapist can help.
• If you are recovering from tendinitis,
continue to perform range-of-motion
exercises to avoid "frozen shoulder."

• In sports-related activities, learn proper

technique to prevent painful and
expensive shoulder problems.
 References
• Clinical Orthopaedic Examination McRae
• AAOS: American Academy of Orthopaedic 
Surgeons
• Essential orthopedics and trauma