“A pain in the shoulder”

swollen shoulder bursa causing bursitisTHE SHOULDER is a ball and socket joint with a large range of motion, which allows us to use our hands effectively. A thick fibrous capsule that helps to contain it and keep the parts in place surrounds the joint.

There is a second joint formed between the end of the collarbone (clavicle) and the shoulder blade (scapula). A group of four muscles, called the rotator cuff, surround the joint and are responsible for helping to move the joint as well as stabilise it.

Many conditions can result in a painful shoulder, which may result in minor discomfort or serious disability. In addition, pain in the shoulder may actually be pain originating somewhere else that is referred to the shoulder. Left shoulder pain is a
complaint in people experiencing a heart attack.

Commonly, neck pain is often referred to the shoulder also. The first step in addressing shoulder pain then is to make an accurate diagnosis. This requires a detailed and directed interview of the patient, expert physical examination and appropriate imaging.

One of the more common complaints is pain with overhead activities, or a painful arc of motion. This is common in people who consistently perform activities at and above shoulder level, and in athletes competing in overhead sports like tennis, golf, and swimming.

These symptoms are often related to inflammation of the tissue overlying the rotator cuff (bursitis) or the tendons of the rotator cuff (tendinitis) themselves. This constellation of symptoms is referred to as impingement syndrome.

Similar symptoms in patients over 40 years old may indicate a tear in the rotator cuff tendon, with the risk increasing with increasing age. A detailed discussion on the treatment of these conditions is beyond the scope of this article.

Anti-inflammatory medications can be used by mouth or via injection into the shoulder. This is coupled with activity modification and directed exercise therapy with a physiotherapist.

Adhesive capsulitis (frozen shoulder) is a common painful shoulder condition. It is characterised by gradual loss of shoulder range of motion. Patients are usually females older than 40 and are often diabetic or have thyroid problems.

This condition is usually treated with physical therapy and a home exercise programme. Corticosteroid injections may be used to help speed recovery. If no improvement is seen after six months of therapy, then surgery may be considered.

Forcefully putting the shoulder through a range of motion with the patient asleep (manipulation under anaesthesia) was the traditional treatment. Since the introduction of shoulder arthroscopy, treatment has been extended to include cutting of
the capsule for more severe cases. Results are generally better with arthroscopy and incision of the capsule under direct vision using the arthroscope. Either treatment must be followed by early directed physical therapy.

Arthritis affects the shoulder joint just as it does in the hip or knee joints. This is more common in people who do heavy manual labour and in weight lifters. Typically these patients are 50 years or older. The options for treatment are similar to the options for knee osteoarthritis. Treatment typically begins with non-surgical options including painkillers, physical therapy, steroid injections and viscosupplementation. Surgical management typically consists of some form of
shoulder replacement, and may be partial or total.

If the patient also has a deficient rotator cuff, a special type of replacement called a reverse shoulder replacement is needed. This is by no means a complete list of painful shoulder conditions, but it includes many of the more common causes.

Paul Adams is a local orthopaedic surgeon with a fellowship in orthopaedic sports medicine.
Email at optimumortho@hotmail.com.