The Shoulder Pain Clinic

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Bicipital tendinitis, or biceps tendinitis, is long head of the biceps tendon inflammation and is a common cause of shoulder pain due to its position and function. Inserts the origin on the supraglenoid tubercle to the insertion on the medial radial tuberosity

The damage can be a partial or complete tear.  A complete tendon tear results in a deformity of the arm Popeye bulge in arm.

Symptoms: Pain in front or anterior aspect of the shoulder, which worsens with overhead lifting or activity

Imaging Tests:

  1. X-rays. 
  2. Magnetic resonance imaging (MRI) and ultrasound. 

Treatment:

A. Nonsurgical Treatment:

  1. Biceps tendinitis is mostly treated conservatively.
  2. Rest. 
  3. Ice application
  4. Nonsteroidal anti-inflammatory drugs (NSAIDs). 
  5. Physiotherapy.

B. Surgical Treatment:

  1. If nonsurgical treatment fails surgery is an option.
  2. Arthroscopic Biceps tenodesis.

Frozen shoulder or adhesive capsulitis is a “chronic inflammatory process involving the capsule of the shoulder causing a thickening and contracture of capsule which secondarily becomes adherent to the humeral head.”

This causes restriction of both active and passive shoulder motion that occurs in the absence of a known inherent shoulder disorder.”

Signs and symptoms gradual in onset and slowly progress. Symptoms get better, usually within 1 to 3 years. The three phases of Adhesive capsulitis are

The Three Stages of Frozon Shoulder:

  1. Freezing Phase: Gradual onset of shoulder pain at rest with sharp pain extremes of motion, and pain at night with sleep interruption (Can last from 2-9 months)
  2. Frozen Phase: Pain starts to subside and progressive loss of shoulder range of movement. Pain only with extremes of movement (Can last for about 12 months)
  3. Thawing Phase: Spontaneous, progressive improvement in range of movement (May last upto 3 years).

Treatment for frozen shoulder involves range-of-motion exercises. Sometimes treatment involves corticosteroids and numbing medications injected into the joint. Arthroscopic surgery is needed to loosen the joint capsule so that it can move more freely.

What is the rotator cuff?

The rotator cuff are muscles and tendons in your shoulder. They help elevation arms away from your body. The rotator cuff keeps the head of the humerus in centre of shoulder joint. They constitute 4 muscle tendons which are Supraspinatus, Infraspinatus, Teres minors, Subscapularis.

What are the types of rotator cuff tears?

Types of torn rotator cuffs include:

  • Partial: With an incomplete or partial tear, the tendon still somewhat attaches to the arm bone.
  • Complete: full thickness tear the tendon separates completely from the bone.

SYMPTOMS AND CAUSES

What causes a rotator cuff tear?

Fall on an outstretched hand can cause a broken collarbone or dislocated shoulder that tears the rotator cuff.

More commonly, rotator cuff tears occur over time with ageing due to daily wear and tear (degenerative tear). People over 40 are most at risk.

Causes of degenerative tears include:

  • Overuse: Repetitive shoulder movements during sports or on the job can stress muscles and tendons, causing a tear.
  • Degenerative tears due to reduced blood flow in ageing process.

What are risk factors for rotator cuff tears?

  1. Smoking.
  2. Being age 40 or older.

Degenerative tears are more common among people who do the same repetitive overhead shoulder movements, such as:

  1. Carpenters.
  2. Mechanics.
  3. Painters.
  4. Recreational and professional athletes who play baseball, wrestlers and tennis

What are the symptoms of a rotator cuff tear?

Post traumatic  rotator cuff tear there is Shoulder pain and arm weakness. With degenerative tears, you may have mild pain that improves with over-the-counter pain relievers. Over time, the pain gets worse, and pain relievers don’t help. Not everyone has pain, but most people have some degree of arm and shoulder weakness.

Signs of a rotator cuff tear include:

  1. Significant pain
  2. Pain in overhead and trouble reaching behind the back
  3. Progressive weakness of the shoulder
  4. Pain in the shoulder, especially at night
  5. Difficulty sleeping on the affected shoulder

DIAGNOSIS AND TESTS

How is a rotator cuff tear diagnosed?

A physical examination for basic evaluation to differentiate from cervical spine problems.

To confirm a diagnosis, you may get:

  1. An X-ray to check for arthritis or bone spurs.
  2. An MRI or ultrasound to look for tendon tears.

MANAGEMENT AND TREATMENT

What are the complications of a rotator cuff tear?

A complete tear can lead to shoulder weakness and inability to perform activities of daily living. The injured arm and gradually leads to Shoulder Arthritis which requires Shoulder Arthroplasty.

What are nonsurgical options for rotator cuff tears?

Rotator cuff tears seldom heal without surgery, with shoulder strengthening function might improve with reduced pain.

Nonsurgical treatments include:

  1. An arm sling and rest to give your shoulder time to heal. You may need to modify activities and stop certain work or sports for a period of time.
  2. Nonsteroidal anti-inflammatory drugs (NSAIDs) to minimize pain and swelling.
  3. Physical therapy to learn strengthening and stretching exercises.

What are the surgical management of rotator cuff tears?

  1. Arthroscopic rotator cuff repair.
  2. Arm sling pouch after surgery to immobilize your arm for six weeks followed by physiotherapy to regain the strength and function.

What is a dislocated shoulder?

A shoulder dislocation means the ball and socket bones of the shoulder are displaced, with ball of the proximal humerus out of its normal position.

CAUSES & SYMPTOMS:

What can cause a shoulder dislocation?

A shoulder dislocation is usually caused by a fall on outstretched hand or direct blow to the shoulder. This can happen during sports activities. Dislocated shoulders are more common in younger age group.

What are the symptoms of a dislocated shoulder?

Symptoms of a dislocated shoulder include:

  1. Extreme pain and/or weakness
  2. Swelling
  3. Bruising or redness
  4. Muscle spasms
  5. Shoulder visibly out of place

DIAGNOSIS AND TESTS:

How is a dislocated shoulder diagnosed?

This require X-rays, a magnetic-resonance-imaging (MRI) scan to spot tissue damage or a computerized-tomography (CT) scan.

MRI Shows : Labrum & cartilage Injuries – Bankart lesion, Humeral avulsion of the glenohumeral ligament (HAGL), glenoid labral articular defect (GLAD), anterior labral periosteal sleeve avulsion (ALPSA)

CT SCAN Shows: Bony Bankart lesion, Hill-Sachs defect, greater tuberosity fracture, lesser tuberosity fracture

MANAGEMENT AND TREATMENT:

How is a dislocated shoulder treated?

With simple maneuvers the shoulder joint is replaced back in its original position process called “closed reduction.” It’s closed because it doesn’t require surgery.

  1. If spasms haven’t started, the patient may not need pain medication, using mild sedation or analgesic the shoulder is relocated.
  2. Wear an shoulder immobilizer for 6 weeks and check X-ray is done to confirm the position.
  3. Ice application to be continued for 3- 4 days.

Is surgery ever necessary for a dislocated shoulder?

For the 1st time dislocations, no surgery is required. MRI is advised to check associated pathology and treated accordingly.

Prevention

  1. Is there a way to prevent shoulder dislocation?
  2. Athletes can wear protective gear during sports activities.

What is shoulder impingement syndrome?

Shoulder impingement occurs when the outer aspect of your shoulder blade called the acromion rubs against rotator cuff which is beneath acromion causing pain and irritation while overhead elevation of shoulder.

How does shoulder impingement syndrome develop?

When your rotator cuff is injured it is inflammed. Swelling causes inflammation leading to reduced subacromial space. Like a vicious cycle, the rubbing of the rotator cuff tendons results in swelling, which further narrows the space below the acromion.

Who gets shoulder impingement?

  1. Shoulder impingement syndrome seen in people who have overhead sports like volleyball, baseball, tennis & swimming, baseball, volleyball and tennis.
  2. Shoulder impingement might also happen due to fall onto an outstretched arm or directly onto the shoulder.

How common is shoulder impingement?

Shoulder impingement syndrome is thought to be the cause of 40% to 60% of all shoulder pain complaints.

What causes shoulder impingement?

The acromion is the bony tip of the outer edge of your shoulder blade that comes off the top of the back side of this bone. Shoulder impingement occurs when the tendon develops friction against the acromion.

The causes of this impingement include:

  1. When tendon is torn or swollen. This can be due to overuse, degenerative wear and tear, injury.
  2. Irritated & inflamed which is called as Bursitis. Bursa is the fluid-filled sac between tendon and the acromion which helps muscles and tendons glide over bones. Inflamed bursa is due to overuse of the shoulder.
  3. When acromion is hooked or bone spurs due to ageing over acromion.

What are the symptoms of shoulder impingement syndrome?

Symptoms of shoulder impingement syndrome include:

  1. Overhead elevation of arm pain.
  2. Affected side pain on lying.
  3. Pain or achiness at night, which affects your ability to sleep.
  4. Pain reaching into a back pocket.

DIAGNOSIS AND TESTS:

  1. X-rays  – Rule out arthritis and may be bone spurs.
  2. Magnetic resonance imaging (MRI ) and Ultrasound can show tears in the rotator cuffand bursitis.
  3. Neer test – A diagnosis of impingement syndrome may be made if a small amount of an anesthetic (painkiller), injected into the space under the acromion, relieves your pain.

TREATMENT:

How is shoulder impingement syndrome treated?

Treatments for impingement syndrome include

  1. Ice should be applied to the shoulder for 20 minutes thrice a day
  2. NSAIDS – Can be tried to reduce the inflammation and pain.
  3. Platelet Rich Plasma injections
  4. Corticosteroid injection
  5. The activities in which you need to frequently reach overhead or behind your back. These motions usually make shoulders with impingement syndrome worse.
  6. Physical Therapy

SURGERY:

  • Surgery is considered if nonsurgical treatments don’t relieve your pain. One surgery called a Subacromial decompression (SAD) or arthroscopic shoulder decompression where acromion tip is shaved  for the rotator cuff.

What is a SLAP tear?

Superior Labrum, Anterior to Posterior tears (SLAP tears), also known as labrum tears which causes shoulder pain due to injury or overuse. 

The L in SLAP refers to glenoid labrum. Labrum plays two important roles in keeping your shoulder functioning and pain free. Labrum is a cushion for the top part of your upper arm bone. This cushion helps your upper arm bone stay in position and in shoulder socket.

There are several ways to tear labrum. SLAP tears are common injuries for people who play sports. Your labrum can be torn by an injury or simply over time as you age.

Some SLAP tears can be treated with rest and physical therapy, but some may require surgery.

What happens if a SLAP tear goes untreated?

  • If not treated properly SLAP tear symptoms worsen leading to chronic shoulder pain and reducing the ability to use your arm and shoulder.

Recovery period from a SLAP tear?

  • It can take up to 6 months to 1 year to recover from a SLAP tear.

CAUSES AND SYMPTOMS:

What causes SLAP tears?

SLAP tears have three causes:

  • Chronic injury – Seen in overhead athletes  like volley ball or softball, swimming or lifting weights.
  • Acute injury – Fall on outstretched hand.
  • Aging – Degenerative tear is usually seen in people age 40 and older.

What are SLAP tear symptoms?

Common SLAP tear symptoms include:

  1. Persistent dull ache or deep sharp pain.
  2. Reaching overhead or stretching of arm behind head.
  3. Popping sound or a grinding sensation when you move your shoulder.
  4. A feeling of shoulder dislocation

DIAGNOSIS AND TESTS:

How to diagnose SLAP tears?

  1. Physical examination.
  2. Magnetic resonance imaging (MRI) or MRI arthrogram.

Indications for SLAP Tear surgery ?

  1. The tear’s location and profession of the patient.
  2. Patient typical activities.
  3. Previous non-surgical treatment.

Are there different types of SLAP tears?

There are several different SLAP types and sub-types. The most common SLAP tear is the type 2 tear. Type 2 tears have several sub-types, each describing different ways a type 2 tear might appear:

  • Type 1: Signs of fraying or shredding but still functions. Type 1 tears are often seen in elderly.
  • Type 2: Most common SLAP tear type. In Type 2 tears, the biceps tendon & labrum are torn from the shoulder socket.
  • Type 3: Torn labrum tissue is caught in the shoulder joint.
  • Type 4: The tear that started in labrum tears your bicep tendon.

TREATMENT:

How are SLAP tears treated?

We generally recommend non-surgical therapies first before concluding surgery is the best option. SLAP tears can take months to fully heal.

Here are common SLAP tear treatments:

  1. Rest.
  2. Anti-inflammatory drugs.
  3. Platelet Rich Plasma (PRP)
  4. Physical therapy.
  5. Debridement.
  6. Arthroscopic labral surgery to repair your labrum.
  7. Bicep tenodesis.

What happens after SLAP tear surgery?

  1. Arm sling to injured shoulder isn’t bearing weight. Need to wear the sling for several weeks to several months.
  2. Shoulder might feel stiff.
  3. Shoulder might feel weak.
  4. Shoulder might have limited range of motion.
  5. Physiotherapy to help you regain strength and function.

Preventions:

  • Warm up your shoulder muscles with stretches before playing sports.