Shoulder Problems: The Causes And The Solutions

Our arms are a very important extension of our body, due to the instrumental role they play in helping us carry out a wide range of daily tasks. This also makes them very privy to injury, especially at the shoulder joint, which is the most movable joint of the body.

What Makes Up The Shoulder?

It is made up of three bones; the clavicle, scapula and humerus, which link up with each other as joints. It consists of two joints:

  • Acromioclavicular Joint: A gliding synovial joint formed between the lateral part of the clavicle and acromion, the frontal extension of the scapula. It acts as a pivot point, allowing a greater degree of rotation of the shoulder
  • Glenohumeral Joint: A ball and socket joint between the upper part of the humerus and the glenoid cavity of the scapula. It allows a wide range of movement: circumduction, flexion/extension, lateral/medial rotation and abduction/adduction. This joint is further reinforced by muscles known as the rotator cuff that add stability to the joint.

The bones are held in place by ligaments, tendons and muscles. Bursa are present to facilitate easy movement of the joints.

Causes of Shoulder Problems:

  1. Dislocation: Also known medically as luxation, is when the ball of the humerus loses contact with the glenoid cavity and ‘pops out’. This is often causes by over abduction or extreme rotation of the arm. Most dislocations are antero-inferior
  • Signs and Symptoms:
        • Pain, increases with muscle spasms
        • Visible dislocation
        • Bruising and swelling around the shoulder
        • Numbness and muscle weakness
  • Diagnosis: A physical examination can usually be enough to diagnose a dislocation. X rays are used to confirm and also detect any fractures. MRIs may also be used to assess soft tissue damage.
  • Treatment: Shoulder reduction techniques i.e. traction and Stimson technique are used to set it back in its place. This is followed by a period of immobilization to promote healing, and then a course of physical therapy to strengthen the muscles. Surgical intervention is needed for fractures, rotator cuff tears or labral tears.
  1. Separation: This occurs when there is loss of contact between the clavicle and acromion because ligaments holding the joint in place are damaged as a result of a blow to the shoulder or fall on an outstretched arm.
    • Signs and Symptoms:
          • Inability to rotate the arm 180 degrees
          • Shoulder pain and tenderness
          • Bump over area of AC joint
    • Diagnosis: X rays are used to visualize the separation.
    • Treatment: There is a period of immobilization where ice and pain medicines can be prescribed to help manage pain. Afterwards, physical therapy is recommended to regain movement. This conservative treatment may take up to 3 months. Surgery is needed is this method does not work or there are ligament tears that need to be repaired.
  2. Sterno-Clavicular Separation: While this joint does not make up the shoulder joint, injury here can destabilize the shoulder due to the clavicle being out of place. This is rare and often occurs on accident, where the clavicle separates from the clavicle.
    • Signs and Symptoms:
          • Pain and discomfort
          • Palpable bump (anterior dislocation)
          • Dysphagia or Dyspnea (posterior dislocation)
    • Diagnosis: X rays are ordered to assess the separation, though standard view may not provide definitive diagnosis. A CT scan is also important in case of a posterior separation, as the posterior dislocation of the clavicle can cause damage to the surrounding structures; arteries, veins and organs. They can also be visualized by a contrast study.
    • Treatment: Conservative treatment of ice, analgesia and shoulder sling for immobility. The joint will need to be reduced. Surgery is needed to reduce posterior dislocations to avoid harm surrounding.
  3. Inflammation and Impingement Syndrome: Inflammation in the tendons of the rotator cuff muscles, it is called tendonitis. This can cause the inflamed and thickened rotator cuff tendon to get trapped under the acromion causing impingement syndrome. This is often accompanied by inflammation of the bursa causing bursitis. The inflammation can be caused by over use of the shoulder joint as in sports; it can also be a consequence of the aging process involving shoulder motion. Rheumatoid arthritis can also contribute to inflammation
    • Signs and Symptoms:
          • Slow onset pain in the upper 1/3 of arm and upper shoulder
          • Sharp pain when shoulder is at certain angles such as arm abduction or overhead
          • Difficult sleeping on shoulder
    • Diagnosis: ultrasound scans are used to diagnose the inflammation causing tendinitis and bursitis. Injected lidocaine into the space under acromion causing relief from pain is a way to establish impingement syndrome.
    • Treatment: Anti-inflammatory medicines, ultrasound and electrical manipulation is used to help manage the pain. Gentle stretching exercises are a lot part of the treatment regime. If this does not help, steroid injections are added to the treatment plan. Surgery to repair damage is often the last resort.
  4. Rotator Cuff Tears: Rotator cuff are a group of 4 muscles; supraspinatus, infraspinatus, teres minor, and subscapularis, that stabilize the shoulder joint. They may be injured due to trauma or degenerate because of aging and overuse. Supraspinatus is the muscle most commonly affected.
    • Signs and Symptoms:
          • Shoulder pain, worsening with movement
          • Clicking sound with movement
          • Gradual loss of motion and weakness
    • Diagnosis: An instrumental part of diagnosis is the patient’s history and a physical examination. This includes information about the patient’s activities. MRIs are the most common tools used to visualize tears, their positions and extent.
    • Treatment: Pain management requires anti-inflammatory agents, ice packs and corticosteroid injections. A conservative approach is followed, where after a period of rest, the patient has physical therapy where exercises are done to combat stiffness and bring back range of motion. Surgery is needed for more severe cases.
  5. SLAP tear: It is an injury to the glenoid labrum which causes inability to properly carry out overhead motions. It is often as a result of
    • Signs and Symptoms:
          • Dull, deep ache in shoulder region
          • Weakness in overhead movement
    • Diagnosis: A MRI is needed to look at soft tissue damage
    • Treatment: Surgical intervention is necessary to repair the damage where the labrum is reattached to the glenoid.
  6. Frozen Shoulder: it is when the joint capsule surrounding the bones and tendons becomes irritated. The inflammation then proceeds until the capsule scars or ‘freezes’. This severely limits movement. Rheumatoid disease and shoulder surgery can attribute to frozen shoulder.
    • Signs and Symptoms:
          • Pain with movement
          • As disease progresses, loss of movement especially external rotation of the shoulder
          • Stiff shoulder
    • Diagnosis: Diagnosis is made by history and physical examination, after all other causes for shoulder stiffness and loss of motion are ruled out
    • Treatment: It is a self-resolving condition. Physical therapy is of limited help.
  7. Fractures: They occur when there is a partial or complete break through the clavicle, scapula or humerus bones. It is caused by impact injury where there is a blow to the shoulder or fall on outstretched arm.
    • Signs and Symptoms:
          • Severe pain, with redness and bruising
          • Visible displacement of bone
    • Diagnosis: X rays are used to visualize the bones. They also reveal the severity, type and position of fracture.
    • Treatment: The bones are first set back in place, this may require surgery. Then the bones are immobilized such as with an arm sling or clavicle splint. Lastly strengthening exercises are done after the bone has healed to build up muscle loss and fortify the bone.
  8. Arthritis: Arthritis is the loss of cartilage of the joint. I can occur in both the AC joint and the glenohumeral joint. It can be a result of injury, excessive use of joint, normal wear, infection and inflammation.
    • Signs and Symptoms:
          • Pain
          • Loss of motion
    • Diagnosis: X rays can show loss of normal space between the bones. It can also show other arthritic changes and its stages.
    • Treatment: Conservation therapy consisting of pain management, physical therapy and exercises is a very important in dealing with early arthritis. In later, more severe stages, surgery may be needed. For glenohumeral joint arthritis, this means shoulder replacement surgery, where the ball of the humerus is replaced with an artificial one. The glenoid cavity is also capped. For AC joint arthritis, resection arthroplasty is used where a portion of the clavicle is cut off and scar tissue is allowed re fill up its place.

Factors such as smoking, obesity, bad posture and sedentary lifestyle have led to a rise in shoulder problems. Shoulder injuries are also a result of the other end of spectrum, where joint stress as a result of competitive sports and body building lead to wear and tear of structures. It is important to find a balance where we allow our shoulders and body required periods of rest and exercise so they can continue to function optimally for a long time.