Dr. Richard Bachrach - Center for Sports & Osteopathic Medicine Shoulder Pain

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"I can’t close my bra in the back." "The pain in my shoulder is terrible when I turn on it in bed at night. "It hurts like hell when I try to put on my T-shirt, fuhgget about taking it off." "The pain starts in my shoulder and goes down my arm to the elbow." "Sorry, you’ll have to pick up the tab, I can’t get to my wallet."

These are typical of the things we hear from patients consulting us about shoulder pain. Most ailments afflicting the shoulder have a gradual, often imperceptible onset. We keep thinking it’s going to get better, but our range of motion decreases progressively because of our natural avoidance of moving into pain. Muscles and tendons shorten, joints tighten and movements are more limited, until daily activities become so difficult we finally have to scream for help.

ANATOMY
The shoulder is not a biomechanically efficient joint, nor is it one single joint. The head of the upper arm bone (humerus) sits rather insecurely in an extremely shallow cup at the outer upper angle of the shoulder blade (scapula) called the glenoid fossa. Essentially, it is held in place by the muscles and ligaments attached to it. Extreme movements in any direction, but particularly overhead and/or to the back, subject those tethers to stretching which eventually results in slight tearing of ligaments and tendons. The body attempts to protect these structures and sets up a reaction called inflammation. The inflammatory response is associated with swelling due to increased blood flow, paradoxically further restricting motion and increasing pain.

CAUSES OF SHOULDER PAIN
The primary sources of injury are muscle weakness, imposing too great a stress on the less elastic tendons, and technique faults resulting in inappropriate muscle use in throwing or swimming, weight lifting or other such activities. A lax shoulder joint capsule also overstresses the muscles. Prior shoulder injury predisposes to tendinitis. A mighty football heave on a Sunday morning without warming up can take the place of a whole slew of repetitive injuries and cause significant shoulder damage.

A classic example is rotator cuff impingement tendinitis. This most common condition involves the supraspinatus muscle and tendon, which passes from the upper part of the back of the scapula, and passes laterally, underneath the acromioclavicular joint (another one of those shoulder joints) which connects the scapula to the collar bone (clavicle). The tendon is inserted into a prominence on the lateral aspect of the humerus, the greater tuberosity. This muscle (along with the infraspinatus) rotates the arm outwards and brings it away from the midline (abducts). When the arm is raised repetitively to the side and then above the head, the supraspinatus tendon may be compressed in a "tunnel" between the acromioclavicular joint, the ligaments forming an arch over the shoulder, and the humerus. This movement is obviously essential in swimming and tennis, and these two sports, along with football (quarterbacks), weight training and baseball are associated with a great frequency of incidence of rotator cuff injury. With increased repetitions, the tendon begins to fray just like a rope. Fluid and inflammatory tissue accumulates, further compressing it. Pain increases in intensity and movement range decreases. The muscle weakens. Finally, we realize, hopefully before endstage complete tear, that it won’t get better by itself.

MANAGEMENT
What to do? First stop doing the things that make it hurt. Certainly, if you know what did it, stop that particular activity! At least for a while… until you can do it right. Ice, applied locally for 20 minutes every two to three hours, will be helpful. Aspirin, in the absence of sensitivity, two tablets every four hours, may do some good. Certainly don’t take aspirin or any of the so-called non-steroid anti-inflammatory medications if you have an ulcer or gastritis history or if you have been allergic to aspirin. Acetaminophen (Tylenol) is an excellent pain reliever but has no anti-inflammatory effect.

Inability to return to full active range of motion without significant discomfort, through your own efforts, will necessitate consultation with a physician. Persistent pain and restricted motion will result in shortening of muscles, tendons and ligaments leading to chronic shoulder pain and, frequently’ to what is known as "frozen shoulder". This, in turn, may require intensive, expensive and painful physical therapy. Physical therapy will include manual mobilization of the shoulder joint, passive and active exercises, ultra-sound and electrical stimulation. Corticosteroid injection with a local anaesthetic into the shoulder may be necessary to supplement more conservative therapy, but this is reserved for cases unresponsive to physical therapy and is not to be used with any frequency.

Another frequent cause of shoulder pain lies in the "joint" between the scapula and the rib cage. This is commonly due to muscular imbalances between the muscles that connect the scapula to the chest. These, in turn derive from aberrant movement patterns creating myofascial pain syndromes and their associated trigger points.

TREATMENT depends on the appropriate stretching and strengthening exercises, normalizing movement patterns and correcting other perpetuating factors such as poor posture. This is supplemented by OMT, physical therapy modalities, trigger point injection with local anaesthetic and, often, acupuncture.

Shoulder pain may be referred from the neck (cervical spine). This is frequently related to intervertebral disc arthritis, degeneration or herniation with consequent impingement on the nerve root or roots exiting the cervical spine between the vertebrae and innervating the skin and muscles of the shoulder. A further discussion of this topic will appear shortly

What can I do?

Learn the correct way to do what you do.

Keep in good aerobic and musculoskeletal condition.

Warm-up, stretch.

Play, then stretch again.

Listen to your body!

Have fun!

And if none of the above works, see us at the Center for Sports & Osteopathic Medicine. Sooner rather than later!