Shoulder pain is one of the most common symptoms with which patients present to orthopaedic surgeons in Hong Kong.
There are many causes including inflammation, injury and fracture, instability and arthritis/ degeneration. Tumour and infection are rare causes of shoulder pain, but secondary stiffness is not uncommon.
By far the most common cause of shoulder pain is inflammation – specifically tendinitis and bursitis.
The shoulder has a greater chance of causing problems as, unlike for example the hip joint, which has a deep bony cup enclosing the round femoral head, with excellent bony stability, the shoulder has a vertical flat cup with no containment of the round head and therefore no bony stability. Stability comes from the soft tissues that surround the shoulder joint. This allows for the wide range of motion and mobility in the shoulder.
The muscles and tendons around the shoulder, most importantly the rotator cuff, keep the arm bone centered in the shoulder socket and stabilised. This covers the upper arm bone and helps to attach it to the shoulder blade.
A large bursa lies over the rotator cuff tendon which helps to reduce friction between the gliding muscles and the bony acromion. Excessive use of the shoulder can lead to inflammation and swelling of the bursa or bursitis.
CAUSES OF THE SHOULDER PAIN
Shoulder pain becomes more common with increasing age, it can occur in the young adult, but becomes increasingly common with age – because of increasing use, often repeated stress or injury in sport or general use and also with increasing degeneration of the tissues. It can occur following an injury, which may be quite trivial, following overuse, or increasingly with age - these cases often arising spontaneously.
SYMPTOMS OF THE SHOULDER PAIN
Initially there tends to be little pain with movement at desk top height, but pain develops with elevation of the arm from use of the rotator cuff and rubbing or impingement of the cuff under the acromion so that pain occurs with activities such as putting on a jacket or T shirt, tucking a shirt in, doing up a bra and reaching out.
As there is no bony stability in the shoulder, when movement is restricted because of pain, stiffness “frozen shoulder” develops. Once this occurs, there is more pain, more difficulty exercising and mobilizing, thus prolonging and complicating the recovery process.
A less common presentation is acute calcific tendinitis, which classically presents with rapid onset of severe shoulder pain and global decreased range of motion approaching 100%. Fortunately, these cases often respond very well to high dose anti-inflammatory treatment.
AC JOINT ARTHRITIS
This is a very common problem found increasingly with age and can cause pain in its own right, or increase impingement and friction of the rotator cuff with elevation of the arm. This occurs more so with increasing age, particularly in patients who have played contact sport such as rugby and racquet sports with overhead activity.
AC joint arthritis tends to cause localised pain at the top of the shoulder on the AC joint, and often in the last 30-40 degrees of elevation of the arm.
HOME TREATMENT OF THE SHOULDER PAIN
Simple analgesics such as panadol and Ibuprofen may be used, with a gentle "range of motion" exercise program and cold packs.
If the pain increases or persists longer that a few days to a week it is better to seek advice from a doctor as delaying treatment may increase the chance of developing stiffness.
INVESTIGATION IN HONG KONG
An Xray can be done but more often than not will be “normal”. Usually the diagnosis is obvious and treatment can be started.
There is NO rush to MRI scan as this will not really change the treatment options. MRI can be done if progress is slow, or if other pathology is suspected.
Other tests such as ultra sound, electrical studies, arthrogram (injecting dye into the joint), CT scan and arthroscopy may be considered.
TREATMENT IN HONG KONG
The mainstay treatment is Physical therapy, rest, gentle stretching of the stiffness through the pain barrier, exercise and anti-inflammatory medication. Other medications such as analgesics and muscle relaxants can be used to help control pain so that you are able to exercise more. Thera bands (large rubber bands) are often used.
Other modalities can be use such as acupuncture, shockwave therapy and cortisone injection.
Surgery is available but is the last option, and most people do not require this.
Partial thickness and small full thickness tears in the rotator cuff are not uncommon and most do not require surgery.