The Shoulder Pain Clinic

Spectrum of Shoulder problems

Shoulder pain

  • AC Joint
  • Adhesive capsulitis
  • Biceps Tendinopathy
  • Coracoid Impingement
  • Sub acromial
  • impingement
  • SLAP Tear
  • Shoulder arthritis
  • Cervical spine disorders

Shoulder weakness

  • Supraspinatus tear
  • Infraspinatus tear
  • Teres minor tear
  • Subscapularis tear
  • Pathology of Trapezius, Pectoralis major, Lattismus dorsi, Serratus anterior.
    Scapular dyskinesis
  • Nerve palsies – Axillary nerve, Suprascapular nerve, Brachial plexus injury

Shoulder instability

  • Atraumatic shoulder instability
  • Anterior Instability
  • Posterior Instability
  • Multi Directional Instability
  • Sternoclavicular Joint Instability
  • Acromioclavicular Joint Instability

Orthopedic Shoulder Surgery and Replacement

The Dr. Srivanth’s Orthopaedic Clinic offers patients superior care and rehabilitation specializing in shoulder injuries. The shoulder is a complex joint with a large range of motion, which makes it more susceptible to injuries. Made up of three bones, the shoulder is a ball and socket joint, connecting the humerus, shoulder blade and clavicle. The humerus connects loosely into the joint which allows for the wide range of motion but also makes the joint more susceptible to injury.

Bones and Joints

The bones of the shoulder:

  • The humerus is the upper arm bone. This is the “ball” of the shoulder’s “ball and socket” joint.
  • The scapula is the flat, triangular bone commonly called the shoulder blade. Prominent areas of the scapula serve as attachment points for many muscles and ligaments.
  • The glenoid is the shallow “socket” on the side of the scapula that receives the ‘ball’ of the humerus. Together they form the “ball and socket” arrangement of the shoulder.
  • The scapular spine is a horizontal ridge along the back of the scapula that divides the scapula into upper and lower regions.
  • The acromion is the end of the scapular spine. It projects up to form the top of the shoulder.
  • The coracoid process is a projection towards the front of the scapula and is an attachment site for several muscles and ligaments.
  • The clavicle is the collarbone. Although it appears to be straight, it actually forms an S-shape when seen from above.
  • The thorax or rib cage, is an anchor for several muscles and ligaments. Although the ribs do not physically attach to the scapula, the thorax stabilizes and maintains proper positioning of the scapula so that the arm can function to its fullest capacity.

Additionally, there are four bone junctions, or joints:

  • The glenohumeral joint is the main joint of the shoulder. Here, the glenoid on the scapula and the head of the humerus come together. The fairly flat socket of the glenoid surrounds only 20% – 30% of the humeral head. Because of its poor fit, this joint relies heavily on the surrounding soft tissue for support. The labrum, a ring of fibrocartilage tissue, attaches to the glenoid and deepens the socket to encircle more of the humerus.
  • The acromioclavicular joint, or AC joint, is the bony point on the top of the shoulder. It stabilizes the scapula to the chest, by connecting the acromion on the scapula to the clavicle, or “collarbone”. A thick disk of fibrocartilage acts as a shock absorber between the two bones. The surrounding capsule and ligaments give this joint great stability.
  • The sternoclavicular joint, or SC joint, connects the other end of the clavicle to the sternum, or “breastbone”. Like the AC joint, this joint contains a fibrocartilage disk that helps the bones achieve a better fit. It also gets excellent support from its joint capsule and surrounding ligaments.
    The scapulothoracic articulation is the area where the scapula, embedded in muscle, glides over the thoracic rib cage. The surrounding muscles and ligaments keep the scapula properly positioned so that the arm can move correctly.
    Cartilage

There are two types of cartilage in the shoulder:

  • Articular cartilage is the shiny white coating that covers the end of the humeral head and lines the inside surface of the glenoid. It has two purposes:
  • To provide a smooth, slick surface for easy movement
  • To be a shock absorber and protect the underlying bone
  • Fibrocartilage is the thick tissue that forms the disks of the AC and SC joints and the labrum, the ring that deepens the glenoid. Fibrocartilage has three roles:
  • To act as a cushion in shock absorption
  • To help stabilize the joint by improving the fit of the bones
  • To act as a spacer and improve contact between the articular cartilage surfaces

Ligaments
The shoulder relies heavily on ligaments for support. Ligaments attach bone to bone and provide the “static” stability in a joint. Ligaments will alternately become tight and loose with normal motion. They keep the joint within the normal limits of movement.

  • The glenohumeral ligaments attach in layers from the glenoid labrum to form the joint capsule around the head of the humerus.
  • The coracoacromial arch is the group of ligaments that spans the bony projections of the coracoid process and the acromion.
  • The coracoclavicular ligaments and the acromioclavicular ligament provide most of the support for the AC joint.

Muscles and Tendons
Muscles and tendons work together in the shoulder to provide the “dynamic” stability of the shoulder.

There are four muscle groups in the shoulder:

  • The rotator cuff muscles are the subscapularis, the supraspinatus, the infraspinatus, and the teres minor. They are the primary stabilizers that hold the “ball” of the humerus to the glenoid “socket”. The socket is too shallow to offer much security for the humerus. These four muscles form a “cuff” around the humeral head, securing it firmly in the socket. As its name implies, this group of muscles also rotates the arm. The rotator cuff protects the glenohumeral joint from dislocation, allowing the large muscles that control the shoulder to power the arm with great mobility.
  • The biceps tendon complex also helps keep the humeral head in the glenoid and helps raise the arm.
  • The scapulothoracic muscles attach the scapula to the thorax. Their main function is to stabilize the scapula to allow for proper shoulder motion.
  • The superficial muscles of the shoulder are the large, powerful outer layer of muscles that are important to the overall function of the shoulder. This group includes the deltoid muscle, which covers the rotator cuff muscles.

Bursae
A bursa is a pillow-like sac filled with a small amount of fluid. Bursae (plural) reduce friction and allow smooth gliding between two firm structures, like bone and tendon or bone and muscle. There are over 50 bursae in the human body; the largest is the subacromial bursa (under the acromion) in the shoulder. The subacromial bursa and the subdeltoid bursa (under the deltoid muscle) are often considered as one structure. This bursa separates the rotator cuff and the deltoid muscle, from the acromion.

What are the signs and symptoms of frozen shoulder?
The major symptoms of frozen shoulder are pain and loss of motion

  • The onset of symptoms may be gradual or sudden, depending on the cause of the condition. With primary adhesive capsulitis, the onset of symptoms is usually gradual. A sudden onset of symptoms may follow an injury to the shoulder.
  • The pain and loss of function associated with this condition can become so severe that it can significantly affect the quality of life, and prevent some patients from sleeping well or working.

How is frozen shoulder diagnosed?

The diagnosis of frozen shoulder is made only after a careful history and physical examination is performed. Pain and loss of motion can be symptoms of many shoulder conditions, so a detailed assessment of the shoulder’s full range of motion is important. A history of surgery or injury, or the presence of illnesses such as diabetes, is information the physician needs in order to make the correct diagnosis.

It is important to recognize the different patterns of motion loss. Primary adhesive capsulitis is usually associated with loss of motion in all directions. Secondary adhesive capsulitis more often has more defined loss of motion; affecting some movements, but not others.

In most cases, the history and examination are sufficient to determine the presence or absence of frozen shoulder. Imaging may occasionally be necessary to confirm the diagnosis and to identify other underlying problems.

  • X-rays cannot reveal the cause of shoulder stiffness in most cases of primary adhesive capsulitis. However, in secondary adhesive capsulitis, X-rays can show signs of arthritis, fractures, or metallic plates that may be contributing to motion loss.
  • An MRI (Magnetic Resonance Image) shows soft tissue and may be used in cases in which another disorder is suspected, such as a rotator cuff tear.
  • An arthrogram may be used with an MRI to provide further information about structures in the shoulder. A dye is injected into the shoulder and images are obtained. The dye creates a contrast on the image, making the specific location of adhesions and the reduced space typical of frozen shoulder more visible.

How is frozen shoulder treated?

Non-Operative Treatment

For most patients with primary adhesive capsulitis, a supervised physical therapy program can help restore lost motion, although it can take six to eighteen months to accomplish this. It is often necessary to combine a home program with supervised physical therapy for maximum gains.

Shoulder stiffness that results from secondary adhesive capsulitis is generally more resistant to non-operative treatment. A supervised physical therapy program is always tried first. However, even an aggressive stretching program with an experienced therapist is often ineffective when frozen shoulder follows an injury or previous surgery.

In some cases, non-steroidal anti-inflammatory medications can be helpful with this condition. Other treatments such as ice, heat, and ultrasound may help alleviate some of the pain. These treatments are recommended as long as they are effective.

Supervised tor home herapy programs continues as long as the patient is making improvement. If the patient is not improving operative treatment may be considered. The expected time for resolution of frozen shoulder varies depending on the underlying causes and from patient to patient. The decision to undergo surgical treatment is made on a case by case basis depending on many factors. These include the cause of the frozen shoulder, the duration of treatment and underlying medical conditions.

Operative Treatment

Operative procedures to treat frozen shoulder include closed manipulation, as well as arthroscopic and open surgical techniques. Operative treatment of primary adhesive capsulitis should only be considered once severe pain has subsided, and discomfort is present only at the extremes of motion. Severe pain represents the inflammatory stage of the disease. Surgery during this inflammatory phase may actually increase injury to the joint capsule, adding to the patient’s loss of motion. Arthroscopic release of the contracted shoulder tissue is preferred by Dr. Srivanth as opposed to closed manipulation of the shoulder. This is because arthroscopic release is more precise and typically restores better motion than simply tearing the contracted tissues with a closed manipulation.

Most patients who have not done well with a non-operative therapy program will do well with a closed manipulation or an arthroscopic capsular release procedure that is followed by aggressive motion therapy.

Arthroscopic Capsular Release

Arthroscopic capsular release has proven to be a safe, effective way to release the scar tissue from the capsule. During an arthroscopy, a small fiberoptic instrument is inserted into the joint. The scar tissue surrounding the joint is removed and a gentle manipulation follows. This will significantly reduce the risk of fracture or injury if the frozen shoulder has been present for some time. If necessary, other disorders within the shoulder can be addressed at the same time.

Open Release

On rare occasions, an open procedure to release the adhesions may be required. This may be the case if tightening is present between tissues outside the joint capsule that are not accessible with arthroscopy. Patients who have had previous surgery or a severe joint injury are often candidates for an open release.

What types of complications may occur?

Complications after frozen shoulder surgery are generally infrequent. The most common problems associated with any of these procedures result from too little release, which fails to adequately reduce stiffness, or (very rarely) from too much release, which may cause shoulder instability. Fractures of the humerus have been reported with closed manipulation. Older patients with fragile bones (osteoporosis) are more at risk for this type of complication. In rare cases, previous surgical repairs have been damaged. Although arthroscopic releases are relatively safe, releases in certain areas inside the joint have led to nerve injury.

Non-Operative

The recovery from non-operative treatment of frozen shoulder can take one to three years. It is important for patients with frozen shoulder to understand the natural course of the disease and how long it can persist. A home stretching program, combined with a supervised program with a skilled therapist, can speed the recovery process in many cases.

Operative

Following surgery:

  • Patients usually remain in the hospital for one to two days. During this time, pain medication is delivered directly to the joint through a catheter.
  • While in the hospital, patients begin an aggressive shoulder motion program supervised by a physical therapist.
    Patients are encouraged to use the treated arm for daily activities. A sling is not worn.
  • Patients are put on a home stretching program that is to be done between structured therapy appointments.
  • Surgical incisions are to be kept clean, dry, and covered until the doctor sees the patient at the follow-up visit, normally about ten days after surgery. Stitches are usually removed at this time.
  • Progress is closely monitored with regular office visits. Specific weaknesses or motion limitations are addressed during these visits.
    The strengthening phase of a rehabilitation program begins after the patient has achieved a full, pain-free arc of motion. This generally takes at least three months.

Why did I develop a frozen shoulder?

We do not have a good explanation for the development of frozen shoulder in most patients. The majority of cases seem to be more prevalent in women, diabetics, and those with hypothyroidism. Others who develop frozen shoulder are those who have sustained an injury and developed stiffness as a result. The trauma can be quite mild or severe, and the body’s response to the event is probably more important than the event itself.

How can frozen shoulder be treated?

The resolution of a frozen shoulder can be very slow, but physical therapy can speed up the healing process. Frozen shoulder begins with pain followed by the rapid development of stiffness. Usually when the pain starts to subside physical therapy can be effective in stretching the capsule back out. Occasionally in unmanageable cases surgery is indicated. This is true only in cases in which the pain has subsided and the residual capsular contracture has not responded to six months or more of physical therapy. Early surgery in the face of frozen shoulder will lead to more problems with stiffness after surgery.

I have been diagnosed with a rotator cuff tear in addition to frozen shoulder; why won’t the surgeon repair the rotator cuff now?

Surgery in the face of a frozen shoulder is not recommended because of the immobilization required after a rotator cuff repair. The shoulder becomes more inflamed after the surgery and the immobilization required to heal the cuff repair leads to increased stiffness. The only way to deal with this combination of problems is to allow physical therapy to stretch out the frozen shoulder. Once that has been accomplished, the rotator cuff repair can be performed. The shoulder will probably be stiffer than the average cuff repair after the immobilization period ends, but research has shown that physical therapy can help regain lost motion.

Subacromial Impingement Syndrome

The symptomatic irritation of the rotator cuff and subacromial bursa within the subacromial space. Subacromial impingement comprises a spectrum of conditions, ranging from subacromial bursitis to rotator cuff tendinopathy and full-thickness rotator cuff tears. Rotator cuff provide dynamic stability to maintain the humeral head within the glenoid fossa and form a force couple with the deltoid. Any dysfunction of the rotator cuff can lead to pathologic contact and compression of the supraspinatus
tendon near its insertion on the greater tuberosity with the under-surface of the
anterior edge of the acromion and coracoacromial (CA) ligament—this is termed
Impingement. Acromial morphology was analyzed, and certain acromial types have been correlated with the incidence of subacromial impingementa curved (type II) and a hooked (type III) acromion predisposes to impingement.

Patients presenting with subacromial impingement are almost always over the age
of 40 and commonly complain of night pain, which is increased when lying on
the affected shoulder. There is usually an insidious onset of shoulder pain over a
period of weeks to months. Lateral and/or superolateral pain radiates down towards the elbow is common. The range of motion is generally well preserved. Pain is often aggravated with an abduction of the arm and when reaching behind the back.

AC Joint Separation

An acromioclavicular joint separation, or AC separation, is a common injury among athletes that have contact, such as football, or cyclists that fall over the handlebars. The shoulder separation happens when the tip of the shoulder endures a direct and forceful blow. The result of a shoulder separation is the clavicle separating from the scapula, which can include injury to the muscles, tendons and ligaments. Typically, an AC separation does not require surgery. Although there is great discomfort with an AC joint separation, including instability and pain with pressure, it will usually heal on its own within 12 weeks. There are six categories of shoulder separation:

  • Grade I – slight displacement of the joint. The acromioclavicular ligament may be stretched or partially torn. This is the most common type of injury to the AC joint.
  • Grade II – partial dislocation of the joint in which there may be some displacement that may not be obvious during a physical examination. The acromioclavicular ligament is completely torn, while the coracoclavicular ligaments remain intact. 
  • Grade III – complete separation of the joint. The acromioclavicular ligament, the coracoclavicular ligaments, and the capsule surrounding the joint are torn. Usually, the displacement is obvious on clinical exam. Without any ligament support, the shoulder falls under the weight of the arm and the clavicle is pushed up, causing a bump on the shoulder.
  • Grades IV through VI are rare, typically an injury from a car accident, and surgery is required for these. 

Frozen Shoulder

Frozen shoulder is a term for stiffness and pain in the shoulder joint that gradually develops and worsens over time. The exact cause of a frozen shoulder has not yet been determined although it is more prevalent in patients that have had some form of arm injury in which the shoulder was immobile for a long period of time or a pre-existing disease, such as diabetes. A frozen shoulder has three stages:

  • Freezing stage – pain is experienced when the shoulder has any sort of movement and your range of motion begins to decrease
  • Frozen stage – the pain begins to decrease although the shoulder becomes more stiff, resulting in difficulty of performing daily activities
  • Thawing stage – the pain continues to decrease and your range of motion begins to slowly increase until you have close to the normal range of motion

The process of a frozen shoulder can be a long one, up to three years for the three stages, although there are some non-surgical treatments available. A few of the non-surgical treatments include physical therapy, cortisone injections or anti-inflammatory medications. If the non-surgical treatments are not reducing the pain, your doctor may recommend surgical treatments in which manually stretch the scar tissue in the shoulder or cut through the portions of the joint that are causing the pain. One of the best prevention methods is to regularly perform exercises that maintain the shoulder range of motion. 

Rotator Cuff Tear

Shoulder pain is common among all ages, with a large number of injuries classified as impingement syndrome or rotator cuff tears. Shoulder impingement syndrome occurs when the tendons of the rotator cuff are compressed as the shoulder is moving. This results in damage to the tendons and the bursa, a sac on top of your shoulder that allows the tendons to move freely, and pain is experience when the arm is raised away from the body. Impingement can develop over time with repetitive motions or as a result of an injury. There are three categories of impingement:

  • Grade I – marked by inflammation of the bursa and tendons
  • Grade II  – progressive thickening and scarring of the bursa
  • Grade III – rotator cuff degeneration and tears are evident

A rotator cuff tear causes weakness in your shoulder and pain that can hinder daily activities such as brushing your hair or reaching above your head. If the tendons in the shoulder are injured, this will cause the bursa to also become inflamed. If there is a tear in a rotator cuff tendon, the tendon will break away from the head of the humerus. A tear is typically a result of a certain movement, such as lifting a heavy object, or it can be caused by degeneration. The two types of tears are partial and full, partial means that the tendon is damaged but full is when the tendon is completely separated from the bone. If a tear occurs from an incident, you will typically feel sudden and intense pain, and possibly hear a popping of the tendon. If the tear develops over time, you will notice weakness in your shoulder and an increase of pain. Depending on the severity of the tear, it may be recommended that you rest your shoulder, use anti-inflammatory medications, have a cortisone shot or begin physical therapy. Surgical procedures may be recommended if you have experienced the symptoms for longer than six months or if the tear is too large to heal on its own. 

Shoulder Dislocation

Shoulder instability, or dislocation is a term used when the joint is loose and can potentially slip out of the socket. There are two types of instability, traumatic onset which is related to a sudden injury and atraumatic onset which is not related to a sudden injury. Knowing the difference between the two is very beneficial when determining the correct treatment. A patient that has experienced an injury to the shoulder that then causes repeated dislocations is and example of traumatic onset, while atraumatic onset is described as a shoulder with general looseness that leads to the shoulder being unstable. 

Once the joint slips out of the socket it is considered dislocated. Typically an injury to the shoulder resulting in it becoming dislocated is the reason the shoulder becomes unstable. Although the shoulder is put back into place after being dislocated, the cartilage surrounding the socket has been stretched out or torn resulting in the joint becoming less secure. Shoulder instability can lead to the shoulder repeatedly becoming dislocated when performing daily activities. This injury is very common in pitchers, swimmers and volleyball players. 

Shoulder Labral Tears

The labrum is a piece of cartilage is located on the socket side of the shoulder that stabilizes the joint while acting as a bumper to restrain the humerus from excessive movement. The labrum also holds the humerus securely to the glenoid. 

Injuries of the labrum are typically caused by falling with an outstretched arm, a direct hit to the shoulder, extreme overhead reach as if trying to catch a ball while sliding on the ground. It is very common for athletes that throw a ball or weight lifters to experience a tear of the labrum due to the repetitive motion of the shoulder. 

The symptoms of a labrum tear include instability, shoulder dislocation, pain throughout the day or night, catching or popping when moving the shoulder, decrease of range of motion or loss of strength. To rule out other injuries as the cause to your pain, your doctor will oftentimes order an X-ray of the shoulder. 

Glenohumeral (Shoulder) Arthritis

Wear and tear of the shoulder leads to damage to the cartilage and over time becomes arthritis of the shoulder, or glenohumeral arthritis. As the cartilage layer is destroyed over the years of continuous use, there becomes a bone-on-bone environment in which bone spurs are created from the friction. This causes pain and decreases the range of motion. In addition to the normal wear and tear, other factors can increase the chances of developing shoulder arthritis including, trauma, infection, chronic inflammation, osteonecrosis, chronic rotator cuff tears or post-surgical changes within the shoulder. Your doctor will most likely order X-rays to determine the exact injury and the type of arthritis. Treatment for shoulder arthritis can be non-surgical or surgical depending on the severity. 

Total Shoulder Replacement

Shoulder replacements on the shoulder are not as common as knee and hip replacements, but they are equally successful in alleviating the patient’s pain. If non-surgical treatments, such as physical therapy or medications, are not efficient in reducing the pain in the shoulder, shoulder replacement surgery is a great alternative. As with other replacement surgeries, the damaged parts of the shoulder are removed and replaced with prosthetic components. Individuals that best benefit from shoulder replacement surgery suffer from severe shoulder pain that interferes with their daily activities, pain while the shoulder is resting, weakness of shoulder and lack of range of motion.