Why Does My Shoulder Still Hurt?
Working on personal injury cases for so long, it is common to discuss with my clients why their shoulder injuries still hurt so long after a traumatic injury, like a car wreck or slip and fall. Early in their treatment, clients have more hope they will get better and get back to normal. But that is not always the case, even with intensive physical therapy and other interventions. The shoulder is a complex ball and socket joint made up of five articulations and three bones. The arm moves fluidly through a synchronous and coordinated movement of all these joints and bones. Injuries to the shoulder are usually from falls, accidents or sports trauma. The structures of the shoulder which are injured are usually the rotator cuff, the shoulder labrum, the AC joint, and fractures or dislocations of the clavicle (collarbone). Although many shoulder injuries are repairable through careful rehabilitation, it all starts with a proper assessment from a physician and usually x-ray and MRI imaging.
What Causes Shoulder Pain?
Simply put, the shoulder is really several joints that combine with muscles and tendons to allow a wide range of motion in the arm — from scratching your back to throwing a football. But that mobility comes with a price: difficulties with the shoulder may lead to problems with instability or impingement of the bony structures or soft tissue in your shoulder, resulting in the sensation we all know and love as pain. The most common causes of shoulder pain include:
1. Avascular Necrosis (death of bone tissue due to limited blood flow)
2. Brachial Plexus Injury
3. Broken Arm
4. Broken Collarbone
5. Bursitis (Joint Inflammation)
6. Cervical Radiculopathy
7. Dislocated Shoulder
8. Frozen Shoulder
9. Heart Attack
11. Osteoarthritis (disease causing the breakdown of joints)
12. Rheumatoid Arthritis (Inflammatory Joint Disease)
13. Rotator Cuff Injury
14. Separated Shoulder
15. Sprains And Strains
16. Tendinitis (inflammation of the tendon from overuse, but also from infection and rheumatic disease)
17. Tendon Rupture
18. Torn Cartilage
When Is Shoulder Pain an Emergency Situation?
Shoulder pain accompanied by difficulty breathing or a sense of tightness in the chest may be a symptom of a heart attack and requires immediate medical attention! Ask someone to drive you to urgent care or the emergency room if the shoulder pain is caused by an injury and is accompanied by any of the following: (1) a joint that appears deformed; (2) inability to use the joint or move your arm away from your body; (3) intense pain; or, (4) sudden swelling. Likely less serious would be shoulder pain accompanied by mere swelling, redness, or tenderness and warmth around the joint.
Minor shoulder pain can possibly be relieved by over-the-counter pain medications such as acetaminophen (Tylenol), ibuprofen (Advil), or Aleve. Of course, rest and icing (15–20 minutes a few times daily) also help for minor shoulder pain.
Major Types of Shoulder Pain?
Most shoulder problems fall into four major categories: tendon inflammation (bursitis or tendinitis) or tendon tear; instability; arthritis; fracture or dislocations. Let’s look at each of those a little more closely —
Bursitis: Bursae are small fluid-filled sacs that are located in joints throughout the body including the shoulder. They act as cushions between bones in the overlying soft-tissues and help reduce friction between the gliding muscles and the bone. Sometimes excessive use of the shoulder leads to inflammation and swelling of the bursa between the rotator cuff and the part of the shoulder blade known as the “acromion.” The result is a condition known as subacromial bursitis. Bursitis often occurs in association with rotator cuff tendinitis. The many tissues in the shoulder can become inflamed and painful.
Tendinitis: A tendon is a cord that connects muscle to bone. Most tendinitis is a result of inflammation in the tendon.
Tendon tears: Splitting and tearing of tendons may result from acute injury or degenerative changes in the tendons due to advancing age, long-term overuse and wear and tear, or a sudden injury such as a car wreck. These tears may be partial or may completely separate the tendon from its attachment to bone. Usually with a complete tear, the tendon is pulled away from its attachment to the bone. Rotator cuff and biceps tendon injuries are among the most common of these types of injuries.
Impingement: Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the underlying soft tissues when the arm is lifted away from the body. As the arm is lifted the top of the shoulder blade rubs or impinges on the rotator cuff tendons and bursae. This can lead to bursitis and tendinitis causing pain and limiting range of motion and ease of movement.
Instability: Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse. Shoulder dislocations can be partial when the ball of the upper arm comes partially out of the socket. This is called a “subluxation.” A complete dislocation is when the ball comes all the way out of the socket. Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Recurring dislocations caused pain and unsteadiness when you raise your arms or move away from your body. Repeated partial or total dislocations lead to an increased risk of developing arthritis in the joint.
Arthritis: Shoulder pain can also result from arthritis. There are many types of arthritis. The most common type of arthritis in the shoulder is osteoarthritis, also known as “wear and tear” arthritis. Symptoms such as swelling, pain, and stiffness typically begin during middle age. Osteoarthritis develops slowly and the pain it causes worsens over time. Osteoarthritis may be related to sports or work injuries or chronic wear and tear, or other traumatic injuries like car wrecks or slip and falls. Other types of arthritis can be related to rotator cuff tears, infection, or an inflammation of the joint lining.
Fracture: Shoulder fractures commonly involve the clavicle (collarbone), humerus (upper arm bone), and/or scapula (shoulder blade). Shoulder fractures in older patients are often the result of a fall from standing height. In younger patients, shoulder fractures are often caused by a high-energy injury, such as a motor vehicle crash or contact-sports injury. Fractures cause severe pain, swelling, and bruising about the shoulder area.
What Do I Need to Know About a Rotator Cuff Injury?
Rotator cuff disease is the most common cause of shoulder pain, particularly in people over age 30. Treatment usually focuses on resting the injured tendon to allow healing, decrease inflammation, and correcting imbalances that caused stress on the injured area. For most people, tendinitis resolves with treatment and occasionally goes away on its own. Tendons are tough bands of tissue that connect muscles to bones. Repetitive activities and overuse can injure tendons and lead to pain and impaired functioning called tendinitis (a.k.a. tendinopathy). Although usually caused by overuse, tendinitis can also be caused by other conditions. Tendinitis is common and occurs more often as people age. Tendinitis is more prevalent in people who routinely perform activities that require repetitive movement that increased stress on susceptible tendons.
The rotator cuff is composed of four muscles, each of which has a tendon that attaches to the upper arm bone. Rotator cuff tendinitis occurs when the tendons are injured often as a result of repetitive overhead reaching, pushing, or lifting with outstretched arms. Athletes who perform overhead activities such as swimming, tennis, throwing, golf, weightlifting, volleyball, and gymnastics are also at higher risk of rotator cuff injuries. Tendinitis is usually treated with rest to avoid aggravating activities, ice, anti-inflammatory drugs, and physical therapy if necessary.
The rotator cuff tendon(s) may be torn due to injury, chronic tendinopathy, or a combination of both. Typically the injury is caused by a fall, direct blow, or a rapid use of force (pulling on a lawnmower starter cable, for instance). To treat a rotator cuff injury, a physician will first try to identify the major factors that contributed to the injury by taking a careful history and performing a biomechanical assessment and physical exam. Interventions may include: ergonomic adjustments; postural retraining; mobility/flexibility interventions; strengthening and stability exercises to restore balance and coordination to the shoulder complex; treatment of any underlying pathological tissue with manual therapy or other modalities, taping, ice/heat, NSAIDs, injections, or dry needling. Such conservative treatments are adequate in the large majority of people although younger people with a medium- to large-sized tear — especially one affecting the dominant arm — may be candidates for surgical repair.
Rotator cuff injury symptoms can be grouped into two categories: (1) Tendinitis: People with rotator cuff tendinitis typically complain of shoulder pain at the tip of the shoulder and the upper, outer arm. The pain is often aggravated by reaching, pushing, pulling, lifting, positioning the arm above the shoulder level, or lying on the side. The pain may prevent comfortable sleep or awaken a person from sleep, particularly if one sleeps or rolls onto the shoulder. (2) Tear: People with rotator cuff tears nearly always complain of weakness in the specific muscle-tendon unit and may have exquisite pain in the shoulder. The severity of the tear does not necessarily correlate with the severity of a person’s pain — a partial tear may be severely painful, while a complete tear may have little to no pain.
Treatment for rotator cuff injuries typically focus on decreasing pain and swelling of the tendon, preserving or restoring normal range of motion, strengthening muscles important to shoulder function, and restoring normal shoulder mechanics. The main goal of treatment should be to preserve the ability to move the shoulder. In many people, a decreased ability to move the shoulder means they use the joint less frequently which can further reduce range of motion and possibly lead to a frozen shoulder. The two basic modalities for treatment are conservative (non-surgical) and surgery. Conservative treatments usually include icing, resting, reducing inflammation with NSAIDs, heating and massage, and stretching and range of motion exercises. If pain persists after several weeks of physical therapy exercises, your clinician may recommend further evaluation and treatment such as injection of a steroid/local anesthetic mixture into the joint.
What Do I Need to Know about a Frozen Shoulder?
Frozen shoulder is a condition that causes shoulder pain and limits a shoulder’s range of motion. The limitation in movement affects both active and passive range of motion. That means that movement is restricted at the shoulder joint both when someone tries to move her own arm and when someone else tries to move it for her (such as a doctor). Frozen shoulder is sometimes called “painful stiff shoulder,” as well as a couple of complex-sounding medicolegal terms called “adhesive capsulitis,” and “periarthritis.” Frozen shoulder often happens due to a shoulder injury, such as a rotator cuff tear, a bone fracture affecting the shoulder, or shoulder surgery. It can also happen, but less frequently, after people have other types of surgery such as heart or brain surgery. Frozen shoulder can happen without a preceding injury and affects people with certain diseases and conditions like diabetes. Frozen shoulder seems to be more common among people in the following groups: those immobilized for prolonged periods; those who have had a stroke; those who have Parkinson’s disease; and those who have diseases affecting the thyroid gland.
In most cases, frozen shoulder gets better on its own even without treatment. Some people never regain the full range of motion they had before. There is no obvious course of action that is right for everyone but there are a few treatment options for frozen shoulder. These include physical therapy, medications to manage pain and inflammation, and surgery in the most extreme cases. Recovery can be a slow process and one needs to give treatment time to work. Depending on your situation, your clinician may recommend you see a physical therapist or that you do certain exercises on your own. Start out slow and do not push yourself too much at first; let pain be your guide. If an exercise hurts too much, modify it or stop it.
What Do I Need to Know about Shoulder Impingement Syndrome?
Shoulder impingement syndrome (SIS) is another condition that causes shoulder pain. To diagnose SIS, clinicians look for a specific set of shoulder symptoms along with certain clinical findings, which together suggest the patient has the condition. Simply put, one part of the person’s shoulder is compressed against another part and this causes pain with some shoulder movements. It is not an injury to a specific structure in the shoulder. The main symptom is shoulder or arm pain occurring when a person lifts her arms overhead. Typically a clinician will not recommend x-rays or MRIs to diagnose. Most people get better with rest and rehabilitation. SIS is more common among those who regularly do any of the following activities: swimming, throwing, playing tennis, lifting weights, playing golf, playing volleyball, painting, and stocking shelves.
There are typically three stages of SIS: Stage 1 — people younger than 25, consisting of swelling and inflammation; Stage 2 — people age 25 to 40, consisting of weakening of the tendons in the shoulder (tendinopathy); Stage 3 – people older than 40, consisting of a rotator cuff tear, biceps tendon rupture, or changes to the bones in the shoulder. The changes associated with each of the stages happened when the muscles, tendons, and other soft tissues in the shoulder get compressed in the upper arm bone and the other bony parts of the shoulder. Soft tissues become compressed for a number of reasons, including when the joint loosens making it possible for the upper arm bone to move more than it should, or the bones can develop spurs that jut out into the joint. People who spend a lot of time at a desk or computer with their head forward and shoulders hunched are predisposed to shoulder impingement.
The treatment for shoulder impingement syndrome depends on your individual situation. If you possibly have a rotator cuff tear or other types of tears, your clinician may recommend you see an orthopedic surgeon to consider surgical repair. Conservative treatment, on the other hand, likely consists of a course or combination of medications, exercises, stretches, and avoiding painful activities. The focus should be on restoring mobility, then on strengthening the muscles to stabilize the shoulder blade, and finally regaining overall strength and function. Some clinicians suggest injections of medications called glucocorticoids (commonly called steroids). There are other treatments for SIS that remain unproven and should be avoided such as electrical stimulation, therapeutic ultrasound, laser, and acupuncture.
How Can My Lawyer Help Me with My Shoulder Injury?
Your job during a personal injury lawsuit is to focus on your health and rehabilitation of functioning. You want to get back to maximum medical improvement. Let the lawyer worry about the implications of your injury on your lawsuit because if you focus on that aspect of your problems it can be harder to get better. Your focus should be on your recovery and following the recommendations of your therapists and physicians to do so. Remember that in Alaska you only have two years to sue for a personal injury, so you should consult with an attorney skilled in personal injury litigation as soon as possible. (Please see my other blog on the statute of limitations.) Keep in mind that a lawyer is your legal advocate and must give you sound advice rather than telling you whatever they think you want to hear to get you to hire them. If you have any further questions about this topic, feel free to call my office in at 907.262.9164 or send me an email personally at Eric@TrialGuy.com.