Painful Shoulder by MikeJenny


									Painful Shoulder
Normal Anatomy
       Shoulder pain involves any pain in or around
the shoulder joint.

   The shoulder is the most mobile joint in the
human body. The joint includes four tendons.
   The purpose of a tendon is
to hold muscle to bone. Together,
these four "rotator cuff" tendons
stabilize the upper arm bone to the
shoulder socket and allow a wide
range of motion in the shoulder.
 Mechanism of the pain

      Any swelling, inflammation, tearing, or bony
changes around these tendons causes pain when a
person tries to move the arm above the head,
behind the back, or straight out in front.
Reasons beyond that pain
    Because of its high level of mobility, the shoulder
has heavy reliance on the muscles around the
shoulder to act as dynamic stabilisers during
movement of the arm. Dysfunction of the stabilising
mechanics, either at the shoulder joint itself or around
the shoulder blade, combined with or without
abnormalities in the anatomical arrangement of the
structures around the joint, or biomechanical faults
make the shoulder particularly prone to pain and
        How common are these

Around 11 patients out every 1000 visit their GPs
with shoulder complaints each year.
Most Common Causes:

Frozen Shoulder. (Idiopathic Adhesive Capsulitis).

Painful Arc Syndrome.
             Frozen shoulder
• Frozen shoulder is clinical syndrome charachterized by gross
  restriction of shoulder movement associated with contraction
  and thickening of the joint capsule.affect middle age.

• Also associated with severe pain disturb sleeping,

• There is frequently history of a minor trauma lead to shoulder
  cuff tearing, initiating prolonged inflammatory changes and
  contraction of shoulder cuff responsible of symptoms.

• If there is no improvement with appropriate treatment for 4
  monthes , manipulation of the shoulder under general
                         Other Causes

Bursitis / Rotator Cuff Tendonitis
  The most common diagnosis in patients with shoulder pain is
  bursitis or tendonitis of the rotator cuff.

Rotator Cuff Tear
  Rotator cuff tears occur when the tendons of the rotator cuff
  separate from the bone. Surgery is sometimes necessary for
  this condition.

Calcific Tendonitis
  Calcific tendonitis is a condition of calcium deposits within a
  tendon -- most commonly within the rotator cuff tendons.
  Treatment of calcific tendonitis depends on the extent of
Shoulder Instability
  Instability is a problem that causes a loose joint. Instability can
  be caused by a traumatic injury (dislocation), or may be a
  developed condition.

Shoulder Dislocation
  A dislocation is an injury that occurs when the top of the arm
  bone becomes disconnected from the scapula.

Shoulder Separation
  Also called an AC separation, these injuries are the result of a
  disruption of the acromioclavicular joint. This is a very
  different injury from a dislocation!

Labral Tear
  A Bankart lesion is a type of labral tear most commonly due to
  dislocation of the joint. Bankart lesions cause problems of
  persistent instability.
SLAP Lesion
  The SLAP lesion is also a type of labral tear. The most
  common cause is a fall onto an outstretched hand.

  Shoulder arthritis is less common than knee and hip arthritis,
  but when severe may require a joint replacement surgery.

Biceps Tendon Rupture
  A proximal biceps tendon rupture occurs when the tendon of
  the biceps muscle ruptures near the joint.
          Referred shoulder pain
•   Whiplash
•   Fractured humerus
•   Ruptured bicep tendon
•   Disc conditions
•   Thoracic outlet syndrome
•   Ectopic pregnancy
•   Diaphragm irritation
•   Diaphragm conditions
•   Liver abscess
•   Referred gallbladder pain
         Referred shoulder pain
• Gallbladder conditions - usually right shoulder
• Gallstones
• Cholangitis
• Cholecystitis
• Internal bleeding (see Bleeding symptoms) -
  often causing shoulder-tip pain
• Referred heart pain
• Angina
• Heart attack
• Polymyalgia rheumatica

Determining the source of the problem in the shoulder is
  essential to recommending the right method of

The first step is a thorough medical history.

Next, perform a physical examination including the
Shoulder movements
Plain X-ray of the shoulder:
             - Antro-posterior.
             - Lateral.
CT.Scan; provides a more detailed view of the shoulder area

MRI and ultrasound are other valuable diagnostic tools because
 they provide images of the soft tissues without using
 radiation .

Special investigations.
If you suspect infections :
    WBC                     Blood culture
    Chest x-ray             Aspiration of joint

EMG (electromyogram), which can indicate nerve damage

an arthrogram, an X-ray study in which dye is injected into
  the shoulder to allow the orthopaedist to better see the joint
  and its surrounding muscles and tendons

Arthroscopy : is a surgical procedure in which the
  orthopaedist looks inside the joint with a lighted telescope.
  It is sometimes used to diagnose causes of shoulder pain
  and indicate soft tissue injuries that are not apparent in the
  physical examination, X-rays and other tests.
Normal Antro-posterior view
Normal Lateral View
• It depends entirely on the cause of the problem.

• Shoulder Pain Treatment Basics :
   – The first treatment for many common conditions is to rest
     the joint, and allow the acute inflammation to subside.
   – Acute rotator cuff tears require immobilization in a sling.
     But It is important to use caution when resting the joint,
     because prolonged immobilization can cause a frozen

   Ice and Heat Application:
     Ice packs and heat pads are among the most commonly
     used treatments for shoulder pain.
Stretching: Stretching the muscles and
  tendons that surround the joint can help with
  some causes of shoulder pain.

Physical Therapy: Physical therapy is an
 important aspect of treatment of almost all
 orthopedic conditions. Physical therapists
 use different modalities to increase strength,
 regain mobility, and help return patients to
 their pre-injury level of activity. Some
 specific exercises may help you stregthen
 the muscles around the joint and relieve
 some of the pain associated with many
Treatment Medications :

Anti-Inflammatory Medication

Cortisone injections
      Common Causes of Pain and
       Dysfunction of the Shoulder
•   rotator cuff strains/tears
•   rotator cuff tendinitis
•   glenohumeral (shoulder joint) instability
•   glenohumeral dislocation/subluxation
•   acromioclavicular joint injury
•   fractures of the clavicle (collar bone), or scapula
    (shoulder blade)
•   adhesive capsulitis (frozen shoulder)
•   biceps tendinitis
•   referred pain from the cervical or thoracic spine
•   referred pain from soft tissues
•   nerve entrapments (eg suprascapular, long thoracic) or
    brachial plexus injury
•   levator scapula syndrome
• If you have had shoulder pain in the past,
  use ice and ibuprofen after exercising.

• Learn proper exercises to stretch and
  strengthen your rotator cuff tendons and
  shoulder muscles. A doctor or physical
  therapist can help.
• If you are recovering from tendinitis,
  continue to perform range-of-motion
  exercises to avoid "frozen shoulder."

• In sports-related activities, learn proper
  technique to prevent painful and
  expensive shoulder problems.
• Clinical Orthopaedic Examination McRae
• AAOS: American Academy of Orthopaedic
• Essential orthopedics and trauma

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