second opinion
Q:
I injured my shoulder months ago ulder several sev and it is still painful. nful. What Wh could be wrong?
Loel Payne, M.D., is an orthopaedic surgeon with Tidewater Orthopaedic Associates Shoulder Specialists. He completed a fellowship in shoulder surgery and sports medicine at the Hospital for Special Surgery in New York. He has written multiple articles and book chapters and lectured nationally on shoulder conditions.
38 THE HEALTH JOURNAL
A: Each year an estimated four million people seek medical attention for shoulder injuries. As a shoulder surgeon, I frequently see patients with one of three main shoulder complaints: their shoulder is unstable after an injury or dislocation, their shoulder is stiff and they have limited movement, or they feel pain and weakness when trying to reach overhead—pain that often gets worse at night. Here’s a look at the three most common sources of shoulder pain: Shoulder instability is more prevalent in younger patients and often occurs after a fall when the ball (humeral head) of the shoulder joint is knocked out of the socket (glenoid). The cartilage (labrum) that supports the glenoid may tear, or the ligaments that connect the humeral head to the glenoid may stretch. This injury can lead to a continuing sensation that the shoulder is slipping out of its socket.
Shoulder stiffness, or “frozen shoulder,” is a condition where the shoulder spontaneously stiffens and becomes painful even though the patient has not experienced an injury. For reasons not well understood, the lining of the shoulder joint thickens and contracts, thus limiting movement. The condition is more common in middle-aged women and is particularly worse in diabetics. People often tolerate a stiff, painful shoulder for months until they can’t reach behind their back or out to the side. Arthritis of the shoulder causes similar symptoms but can be ruled out with X-ray imaging.
Rotator cuff pain is the most common cause of shoulder pain. The rotator cuff is comprised of four muscles and their tendons that attach to the humeral head. Rotator cuff pain is usually caused by inflammation of the tendons, a condition called tendonitis or bursitis. The bursa is a small, fluid-filled sac that rests on top of the rotator cuff tendons and helps lubricate the tendons as they glide under the acromion, a bony ledge found on top of the shoulder. If a bone spur develops here, it pinches or rubs (impinges) on the tendons and bursa, causing bursitis. Repetitive overhead motion produces a similar type of pain. The outer portion of the upper arm hurts each time the arm is raised overhead (some people feel pain when lying on their side, which makes sleeping uncomfortable). The rotator cuff tendons can also tear as a result of repetitive rubbing, similar to how rubbing an old rope between your hands will cause it to tear, as a result of a traumatic injury such as a fall. The pain of a rotator cuff tear is similar to that caused by bursitis, but the night pain is worse and weakness in the shoulder and arm may develop.
Q: What are my treatment options for chronic shoulder pain? A: Exercises designed to strengthen the rotator cuff are often the best means of treating shoulder instability caused by stretched ligaments. A torn labrum, however—especially in younger patients—often requires a surgical repair to prevent further dislocation. If detected early, a frozen shoulder can be managed with non-surgical interventions such as anti-inflammatory medications (e.g., ibuprofen), physical therapy to stretch the shoulder and cortisone injections into the joint. Sometimes a patient will benefit from physical manipulation—stretching the shoulder while a patient is under anesthesia—to help regain mobility in the shoulder. If other measures fail, a surgeon can cut through the tight areas of the joint’s lining to improve movement. Bursitis pain usually resolves with rest, ice and occasional medication. Physical therapy or a cortisone injection may be needed if the pain persists. Arthroscopic surgery to remove the bone spur and inflamed bursa is recommended as a last resort treatment. Complete rotator cuff tears do not heal without surgery, though some patients choose to live with the condition. Q: Is shoulder surgery painful? How long is the recovery time?
A: Advancements in the understanding of shoulder injuries as well as newer treatment options are dramatically improving surgical outcomes with better results and reduced pain. For most patients, today’s surgeons can restore shoulder function to near normal. In the past, shoulder repairs were done through large, open incisions and required an overnight hospital stay. Modern arthroscopic techniques now allow surgeons to repair tears directly, without compromising other structures in the shoulder. Arthroscopic surgery works like this: A small camera is inserted into the shoulder joint to inspect the problem, and the tear is repaired through two or three additional quarterinch incisions. Anchors that are eventually absorbed by the body are inserted into the bone where the rotator cuff tendon or cartilage has torn, and sutures are passed through the torn tissue and tied to secure the repair. The surgery is performed in an outpatient setting and can be done without general anesthesia. There is still a lengthy three-to four-month recovery process involved, but sparing healthy tissues starts the patient on the right path toward full rehabilitation.