Shoulder Pain and its Causes
Are you suffering from aches and pain in your shoulder? Shoulder discomfort may impact up to 67% of Americans during some point during their lifetime. (https://www.health.com/pain/shoulder-pain-causes#01-shoulder-pain-feature-gallery). Although this statistic is surprising, examining the design and purpose of the shoulder can provide some enlightenment as to why this particular joint is prone to injury.
The shoulder joint is a very complex joint—and it is one of the largest joints in the body as well. Designed to be extremely mobile, the shoulder joint moves in such a way as to allow us to raise an arm overhead, toss a set of keys on a desk, and lift a heavy object. This joint can move freely in a variety of positions. But this extreme flexibility comes at a cost: the shoulder joint is not as stable as some other major joints in the body. This causes the shoulder joint to be prone to pain from overuse, wear-and-tear, or even damage to one of the muscles, ligaments or tendons.
Shoulder pain can drastically impact the performance of normal daily tasks. Damage to the structure of the shoulder can prevent a person from doing things such as lifting a gallon of milk out of a refrigerator. It can cause intense pain when that same person tries to go to sleep at night. It can even cause such sensitivity to touch that minor pressure on a particular portion of the shoulder can cause great discomfort. When shoulder pain and discomfort is impacting someone’s daily routine, it is time to seek out medical attention in order to determine the correct course of action that will provide relief of pain and correct the underlying issue.
Taking a look at the structure of the shoulder can provide some enlightenment as to where injury commonly appears and why this leads to pain.
The upper arm bone, called the humerus, fits inside the shoulder blade, called the scapula. The glenohumeral joint serves to attach the arm to the body. This is sometimes referred to as a ball-and-socket type of construction.
The collarbone is connected to the acromion (a bony structure that projects from the scapula, found at the highest portion of the shoulder) by the acromioclavicular joint (also called the AC joint). (https://www.webmd.com/pain-management/picture-of-the-shoulder#1
Another joint found in the shoulder is the sternoclavicular (SC) joint. The SC joint is found where the collarbone meets the breastbone. (https://orthoinfo.aaos.org/en/diseases–conditions/sternoclavicular-sc-joint-disorders/)
In addition to several joint structures, there is a major group of muscles that directly impacts the shoulder’s ability to move in a wide range of direction while maintaining some stability. This collection of muscles and tendons is referred to as the rotator cuff. (https://www.webmd.com/pain-management/picture-of-the-shoulder#1)
How the Shoulder Should Move
The shoulder should allow the arm to move in a variety of positions. The shoulder typically is able to achieve forward flexion, which is movement where a straight arm is raised in front of the body, palm down. It should be able to perform abduction, which consists of movement where a straight arm is raised to the side of the body, palm down. The shoulder should be able to move in an external rotation, where the elbows are at the person’s side, palms facing each other. The shoulder is then able to rotate the hands outwards while the elbows remain against the side of the body. Finally, the shoulder should allow for some internal rotation, which occurs when the arm is placed behind the back, with the elbow in a bent position. (http://www.ori.org.au/shoulder/movement.html)
In determining how well, or how poorly, a shoulder joint is functioning, a medical professional may measure the above positions to see if the range of motion is within normal limits or not. After seeing the range of motion, the medical professional will often conduct additional strength testing.
Conditions Related to Poor Shoulder Mechanics or Injury
Rotator Cuff Problems
The rotator cuff, consisting of several muscles and tendons whose purpose is to stabilize the shoulder, is used much of the time that you use your shoulder. There are several conditions that can result from mechanical problems in the rotator cuff. Overusing the rotator cuff can lead to a condition called tendinitis. This injury causes the rotator cuff area to become inflamed. Bursitis is another inflammatory type of injury that results when the fluid-filled sacs located between tendons and bones in the rotator cuff become inflamed.
Rotator cuff tears (tears in the rotator cuff muscles) often will result when the shoulder is overused or when there is an acute injury. The rotator cuff also can be torn following an accident or a bad fall. It can also tear as a result of daily wear-and-tear on someone who is very active or aging. Usually a rotator cuff tear results in more significant pain.
Some of the more common symptoms of a rotator cuff injury include:
- Patient is avoiding particular activity that causes pain
- Patient does not retain full range of motion
- Patient experiences pain when sleeping on the shoulder suspected of injury
- Patient experiences pain upon light touch or manipulation of the shoulder
- Patient experiences pain when stretching to reach something overhead or to move something heavy with that arm
- Patient is experiencing weakness in the arm (especially when trying to raise the arm above shoulder height)
Anyone experiencing any of these possible symptoms for more than a week should arrange to see a medical professional.
Another shoulder problem that may require medical intervention is pain in the scapular region (pain located between the shoulder blades). Someone experiencing scapular pain may have a dull aching pain located in the upper back. Occasionally there may be mild shooting pains associated with this as well.
This type of pain is usually caused by a mild strain to a tendon or a muscle, often caused by lifting something heavy without assistance. It can also be caused by poor posture, especially in an office worker who must sit at a desk or work on a computer for hours at a time.
In most instances, this type of pain resolves on its own and does not require any medical intervention. Some things that a person suffering from mild scapular pain can do to alleviate pain is to apply warm compresses to the area to relax muscle tissue, do some gentle stretching or even consider massage therapy.
There are, however, some instances when scapular pain is indicative of a more serious underlying medical condition. Some examples of this include:
- Rotator cuff tear
- Fracture of the spine
- Spinal disc injury (bulging or herniated disc)
- Narrowing of spinal cord, called spinal stenosis
- Arthritis of the spine or neck joints
- Compression of nerves (impingement)
- Various cancers, and even
- Heart attack (especially among women)
Looking at the serious nature of many of the possible underlying causes of scapular pain, it is advisable to seek the advice of a medical professional if you are experiencing pain between the shoulder blades that persists or is in conjunction with other symptoms. If the pain is sharp or extreme, and involves pain in the chest and/or breathing difficulties, emergency medical treatment should be pursued immediately.
Thoracic Spine Pain
The thoracic spine region ranges from the bottom of the neck to the top of the lower back. This region is often referred to as the mid/upper back. There are instances where pain in the thoracic area may cause pain and discomfort that is felt throughout the body. Sometimes there is referred pain that is felt in the shoulder region. In this case, the shoulder pain is a sign of an underlying condition, but the underlying condition is not caused by a mechanical defect or injury to the shoulder itself.
Another common cause of shoulder pain is called impingement. Impingement refers to a pinched nerve. If there is a pinched nerve in the spine, that condition is called radiculopathy. This can occur when there are changes, usually over time, in the bones and cartilage near a nerve bundle or nerve roots. When the changes lead to inflammation, it can result in pressure being exerted on the nerves. When this occurs, it can result in weakness, burning or even the loss of feeling in the shoulder itself, the arm, or hand. These symptoms can even be felt all the way to the fingertips.
One way to determine if the symptoms you are experiencing may be caused by a pinched nerve as opposed to another shoulder injury is that the pain is experienced in only one shoulder. You may feel sharp pain at the site that is the probable location where the actual impingement is taking place. You may feel pins and needles feelings all the way down the arm. The symptoms may grow worse as you turn your head to one side or the other.
Another shoulder injury or condition that may be the cause of pain and weakness is one of several different types of degenerative condition. Shoulder joints are subject to a great deal of wear and tear. Arthritis can develop as the joint becomes unstable. It can cause pain in the joint, inflammation, and limit the range of motion.
The two main kinds of degenerative arthritis that can occur in the shoulder are osteoarthritis (abbreviated OA) and rheumatoid arthritis (abbreviated RA).
Osteoarthritis is more common than any other type of arthritis in the shoulder. Osteoarthritis develops as a result of wear and tear in a joint. The resulting symptoms of this type of arthritis include tenderness, stiffness and pain.
Another common type of arthritis that can develop in the shoulder joint is rheumatoid arthritis. Since rheumatoid arthritis is an autoimmune condition, it can result in the development of pain in both shoulders at the same time, as compared to one shoulder.
Some symptoms of rheumatoid arthritis include:
- Warmth and tenderness in the shoulder joints
- Swelling of the joints
- Stiffness in the shoulders, often in the morning
- Loss of weight with no apparent reason
- Tired, fatigued feeling
- The appearance of bumps underneath the skin in the arms or the shoulders (these are called rheumatoid nodules)
Evaluating Your Shoulder
If your shoulder pain is severe enough or is beginning to impact your daily activities, it is time to consult a medical professional. At this point, you will have several expectations. First, you want your healthcare provider to determine the underlying medical condition causing your pain and discomfort. After your provider makes that determination, he or she can develop an intervention plan to alleviate pain and resolve the problem. The ultimate goal is to enable you to return to an active lifestyle.
You can expect several things as you meet with your healthcare professional. You will be given an extensive questionnaire regarding your symptoms: what symptoms are you experiencing, when did they begin, how do they impact your life, and more. Your provider will meet with you and probably do a range-of-motion evaluation. This is where they’ll will check weakness in your shoulder during certain types of arm positions.
At this point, your healthcare provider may send you for x-rays as a first step. There are some changes in the bony structure of the shoulder that are possible to see by way of a non-invasive x-ray. Your provider can even see some degenerative changes in an x-ray.
Your healthcare provider may decide to do an ultrasound of your shoulder. This method of testing is especially helpful in examining the rotator cuff. An ultrasound is very helpful in discovering if shoulder impingement is involved in the shoulder condition. It is also useful in determining if there is shoulder instability involved.
If your provider suspects that there is underlying damage that is not evident by the x-rays, your next step will probably be an MRI. An MRI is a magnetic resonance imaging scan. The MRI utilizes a magnetic field combined with radio waves to produce images of the shoulder joint.
The MRI can reveal detailed images of the bones, muscles, tissues and tendons in the shoulder joint. Your doctor can use this information to diagnose the cause of pain in your shoulder and to obtain a better understanding of the underlying condition that is causing the shoulder problems.
Some of the advantages of an MRI are that it is non-invasive, it is not painful, and it reveals a wealth of information about the area that is the subject of the scan.
Your doctor may decide to do an arthography in conjunction with your MRI. This involves injecting contrast into the shoulder joint prior to the MRI. This enables the MRI to reveal even more details. It is especially helpful in revealing information about the lining of the joint itself and the supporting structures.
The Difference Between Joint Pain and Muscular Pain
When someone is in pain from an as-yet undiagnosed ailment, it is sometimes difficult to determine exactly where the pain is originating from. Pain can be referred pain (originates in one place but is perceived to be felt somewhere else). If the pain is muscle pain, muscles spasms are often also indicated. Exercising the area may alleviate the muscle spasms because lactic acid is released during mild exercise or massage.
Compare this to joint pain. With joint pain, there are no accompanying muscle spasms. Joint pain often includes inflammation of the area, which means stiffness may accompany joint pain.
It is important to spend time concentrating on the exact symptoms you are experiencing prior to the first visit with the medical professional who will be determining the cause of your pain. This will help your doctor determine the best treatment plan for your particular condition.
Returning to an Active Lifestyle
With many individuals, the shoulder pain they have been dealing with has reduced their normal activity levels. Some people who are dealing with rotator cuff tear may have given up some recreational activities they used to enjoy; they may have faced work restrictions. For such a patient, having a successful surgical intervention means a return to active lifestyle after having appropriate physical therapy following surgery.
Consulting a medical professional who is well-experienced in dealing with the various causes of shoulder pain is your first stop if your shoulder pain is interfering with your lifestyle. Once an appropriate course of treatment has been determined, if that treatment involves surgery, it is imperative that you follow all recommendations from the physician post-treatment. This means keeping the shoulder in the sling for the recommended period of time, attending all physical therapy appointments and doing everything that is asked of you. Taking the allotted time to recover from the surgery will allow your body to heal. Getting plenty of rest and staying hydrated are important. Your provider will have information advising you how best to prepare for your surgery and what to expect afterwards.
Ultimately, if you are experiencing shoulder pain that is impacting your normal daily activities, it is something that is damaging to your quality of life. Making the decision to pursue treatment is one of the best decisions you can make. Since there are so many possible underlying conditions that can be diagnosed by medical examination and testing, it is likely that there are medical interventions available that will improve your quality of life.
A return to an active lifestyle is within reach.
You just have to take the first step.