The shoulder is composed of three bones: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). The top of the upper arm bone fits into a rounded socket in the shoulder blade. The socket is known as the glenoid. The muscles and tendons keep the arm bone centered in the shoulder socket. These tissues are known as the rotator cuff and cover the top of the upper arm bone and attach it to the shoulder blade. The primary function of the rotator cuff is to raise and lower the arm.
Shoulder problems typically involve the soft tissues such as muscle, tendon or ligament. Most issues can be placed into two major categories, instability or rotator cuff (i.e. impingement).
Rather than bones, many shoulder problems involve the soft tissues, muscles, ligaments, and tendons. A majority of these problems fall into three major categories: Tendonitis/bursitis, Injury/instability and Arthritis.
A tendon is a cord which connects muscle to bone or other tissue. Similar to the wearing process on the sole of a shoe which eventually splits from overuse, most tendinitis is a result of the wearing process that takes place over a period of years. Typically, tendinitis is one of several types:
Acute tendinitis following some overuse problem such as excessive ball throwing and other sports – or work-related activities.
Chronic tendinitis which can be attributed to degenerative disease or repetitive wear and tear due to age.
The splitting and tearing of tendons which may result from acute injury or degenerative changes in the tendons due to advancing age. Rotator cuff injuries are among the most common of these disorders. The rotator cuff is composed of muscles and their tendons which provides shoulder motion and stability.
If you have a dislocated shoulder, it can either be partially dislocated or fully dislocated. This can happen from falling or from contact sports like rugby or football. A hard hit pulls the arm out of the shoulder socket. It will swell up, become numb and weak, and bruise.
As the most flexible joint in the body, the shoulder is capable of performing a wide range of activities. However, with this incredible range of motion, it is at high risk for instability. The instability can lead to pain. Overuse can lead to rotator cuff tears. Causes of a rotator cuff tear can be improper lifting, falling down, or repetitive strain on the shoulder. Treating a rotator cuff non surgically may be appropriate depending on the severity of the injury. In many cases, the best thing to do is administer RICE (rest from the activity causing the pain, apply ice to the injured area, compress the injured area, and elevate the injured area above the heart to reduce swelling by forcing the fluid to go downhill away from the injured joint).
When it hurts to sleep on the affected shoulder, lifting the arms is uncomfortable, the pain resides in the dominant arm or the affected shoulder continues to make noises, it is a good idea have a doctor give you an examination.
In some cases, excessive use of the shoulder leads to inflammation and swelling of a bursa, a condition called bursitis. Bursas are fluid-filled sacs located around the joints which lessen the friction caused by movement of the joint, like the shoulder. Bursitis usually occurs in association with rotator cuff tendinitis. Sometimes the many tissues in the shoulder become inflamed and painful, which in turn may limit the use of the shoulder. The joint may stiffen as a result, a condition known as a “frozen shoulder.” The good news is that with appropriate care, this condition will usually resolve itself.
Injury or Instability
Sometimes the bones of the shoulder joints move (or, in an injury, are forced) out of their normal position. This condition, instability, can result in a dislocation of the shoulder joint. Recurring dislocations, which may be partial or complete, cause pain and unsteadiness when you raise your arm or move it away from your body. When you lift your arm over your head, the shoulder may feel as if it is slipping out of place or an uncomfortable, unusual feeling that some people refer to as having a “dead” arm.
Shoulder pain may also result from arthritis. There are many types of arthritis, but generally it involves wear and tear changes with inflammation of the joint, causing swelling, pain and stiffness. Arthritis may be attributed to sports, work or normal aging. People will often avoid shoulder movements in an attempt to lessen the pain arising from these conditions. Unfortunately, this can lead to a tightening or stiffening of the soft tissue parts of the joint, resulting in a painful restriction of motion.
A specialist may recommend a series of exercises to strengthen the muscles around the shoulder. A skilled physical therapist can help educate you in this program and make sure the exercises are done properly. This can restore stability and balance to the shoulder and provide relief from pain and instability. Non-steroidal anti-inflammatory medicines (i.e. ibuprofen) can help with the pain and inflammation. Steroid injections can be very effective at rapidly reducing inflammation and pain, making the rehab process easier.
Most common shoulder problems can be managed successfully without surgery. Unfortunately, for those problems that can not be treated non-surgically, the patient may have to undergo one of the following surgeries to completely fix the issue.
Total Shoulder Replacement Surgery
Arthritis or injury can also damage the shoulder joint preventing a person from lifting their arm. In severe cases, the only treatment available is shoulder joint replacement surgery. Shoulder replacement surgery has been around since the 1950s and was originally used for severe fractures, but because of its success, it has since been broadened to address arthritis. Today, about 23,000 people in the U.S. have shoulder replacement surgery. Patients with bone-on-bone contact are typically good candidates for shoulder replacement surgery, where an artificial ball and socket joint is installed into the shoulder.
Reverse Shoulder Replacement
Reverse shoulder replacement is another variation that was developed in the 1980s. This is used for those with completely torn rotator cuffs or have had a shoulder replacement surgery that did not relieve symptoms or restore motion significantly. In reverse shoulder replacement surgery, the position of the ball and socket are “reversed” where the ball is applied to the shoulder and the plastic socket is attached to the upper arm. This enables the person to lift the arm using a different muscle than the rotator cuff.
Minimally invasive techniques (also known as arthroscopy) and improved tools allow orthopedic surgeons to fix rotator cuff tears usually through 3-4 small incisions, less than ½ inch.
The rotator cuff tear is repaired by suturing the torn tendon back to the humerus. Recovery is less painful and scars are less noticeable. During surgery for a rotator cuff tear, the surgeon removes debris from the damaged shoulder cuff tendon. This is called a debridement and is typically completed arthroscopically.
Next, if bone spurs are present, the surgeon will next smooth the acromion area to prevent the acromion from pinching the tendon.
Shoulder Impingement Surgery
This minimally invasive procedure is often performed on an outpatient basis. Shoulder impingement helps relieve pain by decompressing the small enclosed area around the rotator tendon of the shoulder joint. During the procedure, the bursa is removed and the orthopaedic surgeon trims back the acromion bone to allow for normal pain-free motion. In most cases, this procedure is performed arthroscopically.
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