Shoulder

When do people hurt their shoulder?  They either fall on it, hurt it in a car accident or overwork it.   It can either start hurting right away, have a delayed onset or start mild and increase over time.   It may also start after performing a lot of overhead activity.  The onset initially can be sudden or gradual after a precipitating event, slowly building over hours or days.

The pain can vary between being mild and intermittent to excruciating and continuous.   The pain can start initially over the shoulder and then progress down the arm, up to the neck or around to the back.  It can even radiate down to the fingers.  This is a sign that the shoulder injury is overloading surrounding muscles and nerves like the brachial plexus, a group of nerves going from the spinal column into the arm.

So what do you do about it? Well if you fell on it or otherwise injured it in a high energy manner and perhaps heard a crack, then you need to call your doctor.  You may have broken a bone and should have it attended to.  If you are not sure call the doctor.

If the pain is not severe, the first thing you do is to rest it. Keep your elbow by your side.  Don’t use it.  Sleep propped up.  Don’t roll on it. Don’t splint it or hitch it up.  Let your shoulder relax and fall back squeezing your shoulder blade next to your spine. You can ice it.  You can take anti inflammatory agents.  Most shoulder problems will get better day to day. If it doesn’t you need to see your doctor.

What is the doctor going to do?  He or she is going to try to find out why you are not getting better.  Your doctor is going to ask you questions, examine you, perhaps get an xray.  Depending  on how you hurt yourself and what your doctor finds you’ll be directed to do any one of a number of things.  You may be directed to continue resting while starting physical therapy.  You may be given medication.  You may be directed to have another study such as an MRI or CAT scan.  You may be advised to have surgery.

What kind of problem occurs in your shoulder to cause you all this aggravation? . When you have shoulder pain, depending on the energy of the injury it comes mostly from either the bones, muscles and /or ligaments and capsule.  Breaking a bone takes more energy and frequently is associated with a lot of pain and is usually of sudden onset.  In situation where the onset is gradual, the structures most commonly involved include the muscles and the capsuloligamentous structures associated with the joints of the shoulder.

To understand the why and the wherefore of what’s injured in your shoulder,  you need to understand the structure of the shoulder.  The shoulder is made up of three bones: the shoulder blade, the humerus and the clavicle. These three bones are connected through two joints: the glenohumeral joint and the acromialclavicular joint.  They in turn are attached to the rib cage through two joints: the scapulothoracic and the sternoclavicular joints .

Lets talk about the problems associated with glenohumeral joint.  The most common structure associated with this joint that is injured is the rotator cuff.  The glenohumeral joint consists of a ball which forms the upper end of the arm bone.  This ball sits in a shallow socket which is at upper outer corner of the shoulder blade.

One of the structures that holds the ball in the socket is a group of muscles that are attached to the front, top and back of the shoulder blade,  extend past  the socket over the ball of the upper arm bone, attaching to the outer aspect of the ball. These muscles together are called the rotator cuff. These scapular muscles pull the ball into the socket and keep it in joint.

There is another bone that comes off the scapula behind the socket that comes up over the joint forming a roof. There is a muscle attached to this roof that extends over the upper arm bone attaching between a quarter to a third of the way down.  This muscle moves the arm bone and is called the deltoid.

The rotator cuff can get irritated as it passes between the ball of the upper arm bone and the roof, called the acromion.  This is because this space can narrow down and cause the acromion to rub on the rotator cuff. Now if the arm bone is raised up without the shoulder blade moving,  just short of 90 degrees to the floor, the ball hits the acromion near where the rotator cuff attaches.  In real life we can place our arm straight above our head without the ball hitting the acromion.

Our body does this by rotating the shoulder blade and acromion ahead of the ball of the arm bone, so that the space between the acromion and ball doesn’t narrow and the rotator cuff is not injured.  In people with weakness and tightness of the muscles and ligaments about the shoulder blade, the shoulder blade and acromion is not able to rotate ahead of the ball.

The space between the two closes down and the rotator cuff gets injured.  Over time this causes injury with associated pain and eventual deterioration and tearing of the cuff.  If you identify the problem early physical therapy may be enough to take care of the problem.   If you wait until the rotator cuff tears and bone spurs develop surgery is needed.

Physical  therapy works  by loosening and toning the muscles about the shoulder blade and shoulder.  This allows the motion between the shoulder blade and chest wall and between the ball and socket of the shoulder to be better coordinated. As a result the space between the ball and the roof doesn’t narrow down and the rotator cuff moves more freely.  The damage to the rotator cuff is able to heal and the pain goes away.

In the situation where the pain doesn’t go away with therapy or if there is a rotator cuff tear, surgery is needed.  The surgery does many things.  It fixes the tear.  It removes bone spurs.  It removes inflammatory tissue.   Frequently it can be done through small incisions with an arthroscope.  The surgery can be done as an outpatient.  Recovery takes a few months with strengthening continuing after that.  The less injury, the less surgery,  the quicker the recovery.

Normal Anatomy of the Shoulder Joint

The shoulder is the most flexible joint in the body making it the most susceptible to instability and injury. It is a ‘ball-and-socket’ joint. A ‘ball’ at the top of the upper arm bone, humerus, fits neatly into a ‘socket’, called the glenoid, which is part of the shoulder blade, scapula.

The shoulder joint is made up several bones and soft tissues. It has three bones, the collarbone (clavicle), scapula, and humerus.

Humerus provides attachment to muscles of the upper arm. Scapula is the bone that connects the upper arm bone with the collarbone. It is a flat bone and roughly triangular in shape and provides attachment to the muscles of back and neck.

The clavicle is an S-shaped short bone that connects the shoulder girdle to the body (trunk). It supports the shoulder in a functional position with the axial skeleton so that the arm has maximum range of movement. It also protects major underlying nerves and blood vessels as they pass from the neck to the axilla.

The coracoid process is the extension of the scapula around the shoulder joint at the front portion of the scapula. The acromial process is the extension of scapula around the shoulder joint at the back that forms a roof, acromion.
Glenoid is the smooth shallow depression at the end of scapula that forms the socket of shoulder joint.

The soft tissues of shoulder joint include:

Rotator cuff – A group of 4 tendons make rotator cuff and it holds the head of the humerus in the socket.
Biceps tendon – The biceps tendon is a long cord-like structure which attaches the biceps muscle to the shoulder and helps to stabilize the joint.

Caraco Clavicular Ligament – This ligament connects the clavicle with the corocoid process of the scapula.
Acromio Clavicular Ligament – It connects the clavicle with the acromion process.

Glenoid labrum – The Glenoid labrum is a ring of fibro cartilage surrounding the cavity of the scapula for stabilization of the shoulder joint.

Articular cartilage or the capsule – It is a capsule that surrounds the shoulder joint and helps to keep the ball and socket normally aligned.

Shoulder Instability

Shoulder instability is a chronic condition that causes frequent dislocations of the shoulder joint. A dislocation occurs when the end of the humerus (the ball portion) partially or completely dislocates from the glenoid (the socket portion) of the shoulder. A partial dislocation is referred as subluxation, whereas the complete separation is referred as dislocation.

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Rotator Cuff Tear

The rotator cuff is a group of tendons in the shoulder joint that cover and provide support to the shoulder joint, enabling wider range of motion. A tear in the rotator cuff is one of the most common causes of shoulder pain in middle aged adults and older individuals.

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Frozen Shoulder

Frozen shoulder is a painful shoulder condition that limits movement and causes stiffness in the joint. It is also called adhesive capsulitis and may progress to the state where you may find it very hard to move your arm.

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Shoulder Impingement

Various supporting structures aid in the smooth movement of the shoulder joint. The joint is held together and stabilized by a group of tendons called the rotator cuff. A fluid-filled sac called a bursa, located above the rotator cuff, helps in the frictionless movement of the shoulder.

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Clavicle Fracture

Clavicle fracture or broken collarbone is a very common injury associated with contact sports such as football and martial arts, as well as impact sports such as motor racing. A direct blow over the shoulder, fall on an outstretched arm or motor vehicle accident may also cause the clavicle bone to break.

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Shoulder Arthroscopy

Arthroscopy is a minimally invasive diagnostic and surgical procedure performed for joint problems. Shoulder arthroscopy is performed using a pencil-sized instrument called an Arthroscope.

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Shoulder Joint Replacement

Shoulder joint replacement is a surgical procedure performed to replace a damaged shoulder joint with artificial implants. It is usually performed to relieve shoulder pain when the joint is severely damaged by osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, rotator cuff tear arthropathy, avascular necrosis (tissue death), fracture and failed former shoulder replacement surgery.

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Shoulder Disorders and Replacement

Shoulder Joint Arthritis

The term arthritis means inflammation of a joint, and is associated with cartilage damage. Cartilage is a cushioned padding lining the bones that make up a joint in order to absorb stress during movement.

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Shoulder Dislocation

The shoulder is made up of a ball and socket joint – the ball-shaped head of the upper arm bone (humerus) articulates in the socket of the glenoid cavity of the shoulder blade (scapula).

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Glenoid Labrum Tear

The glenoid is a shallow cavity of the shoulder blade (scapula). The ball-shaped head of the upper arm bone (humerus), articulates with the glenoid to form the ball-and-socket joint of the shoulder joint. A soft tissue called the labrum surrounding the socket further stabilizes this joint so that the humerus head fits snugly in the cavity.

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Click on the topics below to find out more from the Orthopedic connection website of American Academy of Orthopaedic Surgeons.

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