Common causes for shoulder pain in adults

“Shoulder pain can be very uncomfortable and can affect even the smallest aspects of your daily routine, like picking up your grandchild or even your handbag,” says Dr Heckroodt Laubscher, a shoulder surgeon at the Centre for Sports Medicine and Orthopaedics at Netcare Rosebank Hospital. “Diagnosing what causes the pain can be very difficult. Not only does pain often occur in different parts of the shoulder, neck and upper arm, but the anatomy of the shoulder is highly complex”.

Shoulder pain is more common than you may think, adds Dr Laubscher. “The shoulder is an important joint in your body due to its range of movement. It enables you to move your arm up and down and side to side, and because it can rotate it allows you to reach out in all directions. The shoulder's great mobility causes it to be inherently unstable. The development of a weakness or defect in some of its stabilisers, such as the muscles or bone, is fairly common and can lead to poor function and persistent pain.”

Dr. Laubscher sheds some light on the many possible causes of shoulder pain:

1. Impingement Syndrome (subacromial bursitis)

“This is the most common cause of shoulder pain,” explains Dr Laubscher. “Usually the pain is associated with ‘overhead activities' such as washing hair or placing objects on high shelves. The pain is usually dull and aching in nature.

“Although this problem often occurs in middle-aged patients, the symptoms are not necessarily associated with any muscle weakness. The symptoms can be treated without surgery and conservative treatment is successful in up to 80% of patients.

The other 20% may however need to undergo surgery.”

Non-surgical treatment includes the use of oral anti-inflammatory, cortisone shoulder infiltrations and home exercises.

2. Rotator Cuff Syndrome or Tear

This condition specifically relates to the rotator cuff muscles of the shoulder. “These muscles play an integral role in using your arm above shoulder height and behind your back. They attach to the upper arm by means of a tendon,” explains Dr Laubscher.

These tendons can detach from the bone, leading to pain and weakness of the arm. “This means overhead functions are often difficult due to the inability to lift the arm above chest height,” he adds.

The cause for these tears can vary from traumatic to degenerative (“wear and tear”). Surgery is often needed to regain full use of the arm and the full function of the arm is usually only regained three to six months after surgery.

3. Cervical spine pathology

“Pathology (the conditions and processes of a disease) in the neck can often result in complex symptoms in the shoulder. These symptoms are frequently misdiagnosed,” cautions Dr Laubscher.

A typical sign of cervical spine pathology is “pins and needles” (parastesia) sensations that spread into the hand and fingers. “This pain can be excruciating, even when you are not using your shoulder. The pain in the shoulder is a constant pain, felt day and night.”

Physiotherapy may be indicated, but this usually only offers the patient moderate relief.”

4. Frozen Shoulder (Adhesive Capsulitis)

This is a common condition which affects mostly female patients in their 40' or 50's. “Patients typically suffer with severe pain, especially at night, and progressive shoulder stiffness,” explains Dr Laubscher.

Patients with Type One or Type Two diabetes (diabetes mellitus) have a higher chance of developing this condition. “Other associated risk factors include trauma to the shoulder, recent shoulder surgery, or even conditions such as hypo- or hyperthyroidism and Parkinson's disease.” Non surgical treatment measures are in most cases sufficient, but patients with severe and persistent complaints will most likely need surgery.

5. Calcifying Tendonitis

“Calcium crystals are deposited in the tendon of the rotator cuff muscles. These can increase in size and eventually rupture causing extreme pain. Various non-surgical treatment options may provide relief,” says Dr Laubscher.

Surgical removal with the help of arthroscopy is also an option and can give complete relief. Recurrence after treatment does, however, occur in 10% of patients.

6. Shoulder instability or dislocation

This type of pain is usually associated with an acute dislocation of the joint. “Once the joint is reduced, which means the ball is back in the socket, the pain and discomfort improves considerably.”

Pain may flare up again with episodes of dislocation or even partial dislocation, referred to as subluxation. “This happens especially if a soft tissue or bony lesion is still present in the shoulder. The pain is therefore mostly episodic in nature and associated with certain activities.”

In cases where a lesion predisposes the patient to repeat dislocation or in highly active sportsmen, surgery is recommended to prevent recurring episodes of dislocation. Multiple episodes of shoulder dislocation or subluxation may lead to osteoarthritis of the shoulder in the long term.

7. AC joint Arthritis

The AC joint is located at the top of the shoulder and connects the clavicle (collar bone) with the scapula (shoulder blade). “Degeneration of the joint can lead to chronic pain especially when bringing the arm in front of the chest. The pain usually localises to an area at the back of the shoulder and arthroscopic excision of the tip of the clavicle often relieves the pain,” explains Laubscher.

8. Biceps related pathology (tendonitis or SLAP)

Tendonitis occurs with overuse or impingement of the tendon compressed inside the shoulder joint. The biceps tendon travels through the shoulder joint and attaches to a part of the shoulder blade inside the joint. “This attachment can get damaged or loosen, which we refer to as SLAP. This especially occurs in athletes who perform repetitive throwing actions like cricket and baseball players.”

A fall on an outstretched arm can also lead to detachment of the tendon. “Symptoms often occur only during a throwing action. Repairing this loose attachment with key-hole surgery (arthroscopy) may give relief of the symptoms.”

9. Brachial plexus neuritis

Neuritis (nerve inflammation) can cause complex shoulder and upper limb symptoms. “In these cases, inflammation is present in a big bundle of nerves on the way to the upper arm. Symptoms are similar to that of cervical spine radiculopathy where a nerve is pinched in the neck.”

Often in this condition the pain commences in the neck and shoulder, but it is accompanied by weakness in the arm, wrist and hand. Specialised tests are necessary to confirm the diagnosis and treatment usually entails large doses of steroids. Recovery can take up to six months.

10. Shoulder joint arthritis

This type of arthritis is not as common as hip and knee arthritis and mostly affects older patients. Various factors can contribute to its development such as previous trauma or fracture in the upper end of the humerus (the long upper arm bone).

“Neglected chronic rotator cuff tears may also lead to arthritis. Replacement with a metal joint gives relief and improvement of function,” says Dr Laubscher

Warning signals

When should you really start worrying if you experience shoulder pain?

According to Dr. Laubscher, signs to look out for and which should prompt you to see your doctor are:

• History of trauma with weakness that lasts more than a few days
  
• Inability to lift arm above shoulder height (using your other arm to help)
  
• Consistent shoulder pain at night and at rest
  
• Deformity in your shoulder
  
• Neck and shoulder pain accompanied with “pins-and-needles” down the arm
  
• Limited movement, e.g.: inability to tuck your shirt in at the back
  
• Repetitive/recurrent shoulder dislocations

Diagnosis

There are many diagnostic tools available to the doctor. A proper physical examination can provide answers but the diagnosis should be confirmed before treatment commences. Dr Laubscher explains, “Shoulder and possibly neck X-rays should be a baseline examination for any shoulder problem. These can often reveal bony pathology and calcifications. However, if an X-ray does not provide all the answers an ultrasound (sonar) can help.”

Sonar can usually reveal the answer in 80% of cases. “The accuracy of this tool depends solely on the operator, therefore experienced sonographers play a big role in confirming the correct diagnosis. If a diagnosis still eludes the attending doctor then an MRI or CT scan may be necessary.”

Dr Laubscher highlights the following treatment options:

Home exercises or home treatment

Exercises performed at home can often help in giving relief from pain and discomfort. Impingement syndrome can be treated successfully in 80% of cases by doing strengthening exercises of the rotator cuff muscles at home.

“These exercises are very specific and should be performed on a daily basis. Stretching exercises will also give relief of symptoms. Always make sure that you perform these exercises correctly and diligently. Heat and ice treatments to the shoulder can also offer relief from pain. Ice packs are ideal in acute shoulder injuries such as a fall or intense sporting activities. Heat pads help in cases of overuse injury and arthritic conditions of the shoulder.”

Anti-inflammatories or pain medication

This is a common aid for various shoulder conditions. Anti-inflammatories help to treat inflammation and swelling that causes pain. Always check with your doctor whether it is safe for you to take such medication, as it can be detrimental to your health. Need for prolonged use (more than 4 weeks) should be seen as a sign of bigger problems in which case consulting a specialist is recommended.

Cortisone infiltration

“Many patients have an aversion to injections or needles but remember that correctly executed infiltration can give immediate and adequate pain relief in certain shoulder conditions.”

Pain in calcific tendonitis and impingement syndrome responds well to these infiltrations. “The positive effect is only acquired if the drugs are injected into the right place.”

Physiotherapy

Physiotherapy has an important role to play in the management of various painful shoulder conditions including neck related shoulder pain. “Treatment modalities usually concentrate on pain relief and obtaining range of motion. Patients should remember that if their symptoms continue despite intensive physiotherapy they should seek medical advice from a doctor.”

Surgery

Surgery is indicated in cases where conservative treatment such as cortisone infiltrations and physiotherapy has not been successful. “Depending on the diagnosis, various surgical procedures are available. Most shoulder procedures today can be performed by means of key-hole (arthroscopic) surgery. This means that patients do not have to recover from large surgical wounds but only retain small scars (1cm) where the camera and instruments have been inserted. Ask your surgeon if he/she has the required skills to perform arthroscopic surgery and whether the hospital has the necessary instruments and equipment.”

“Shoulder conditions can be very debilitating and painful,” concludes Dr Laubscher. “Do not neglect your symptoms and seek advice sooner rather than later so that appropriate treatment can commence.”