Shoulder pain

Shoulder problems are extremely common and can be both extremely painful and disabling. They can interfere with your work, prevent you from taking part in your leisure activities and keep you awake at night. The shoulder is a complex joint and there are many different conditions that can affect it. These conditions may occur individually or in combinations, which can make them difficult to diagnose and treat, so you need a skilled and experienced clinician to examine and treat you. We will describe the most common conditions below:

Sub-acromial impingement syndrome is the most common condition to affect the shoulder. It is a condition that occurs when the bursa or tendons in your shoulder get damaged and trapped as you lift your arm up. It can encompass a range of different tissues that may cause problems either singly or together. There are a range of different names or terms that are given to these conditions, this can be confusing when different professionals use different terms to describe your shoulder condition. 

It can be referred to as sub-acromial bursitis, supraspinatus tendinopathy or tendinitis, painful arc syndrome, sub-acromial impingement syndrome or just impingement syndrome.

What are the causes of impingement syndrome?

Impingement can occur following a fall or other trauma such as a sports injury, when the bursa or tendons in the shoulder get injured and then swell and get inflamed and thickened. It can also occur through over use of the shoulder particularly with your arm up at or above head height. This may be a one off bout of works such as DIY, or the result of many years of work. The result is a swelling and inflammation of the tendons and/or bursa in the shoulder.

When the tendons/bursa are swollen there is less room for them beneath the bone at the top of the shoulder joint (the acromion). When you try to lift your arm or put your hand behind your back the swollen tissues get pinched causing pain. Because they are inflamed this pinching can be extremely painful and can continue after you have stopped the activity and at night. 

This can become an ongoing condition where the tissues get repeatedly trapped, get more swollen and inflamed and then are more vulnerable to further damage. 

How is impingement syndrome diagnosed?

To diagnose impingement syndrome your clinician should ask you about when and where your shoulder hurts and examine how it moves. 

Ultrasound scans are the most commonly used investigation as they are relatively cheap and show the relevant tissues well. 

How is impingement syndrome treated?

Initially it is often treated with simple exercises and avoiding the provocative movements. 

If your shoulder does not settle down with exercises you may try physiotherapy. The physiotherapist will assess your shoulder and work out the best way of treating it. 

If physiotherapy does not work a steroid injection is usually the next step. The steroid is an extremely strong anti-inflammatory drug which will will settle the inflamed tissues, make them less sensitive and reduce the swelling. When the swelling settles there is more room for the tissues and they don't get pinched as badly. The steroid works best if it is put into the bursa using ultrasound guidance. If it is put into the tendons if can weaken them and they may tear. 

If you shoulder does not respond to steroid injections or keeps coming back, you may need to try surgery. This is obviously a more serious option. The surgeon will probably use key hole surgery to remove some bone from your shoulder and make more room for the tissues. 

It is best to do a course of physiotherapy exercises after either a steroid injection or surgery to get your shoulder moving again and strengthen the muscles. 

Tendinopathy is a chronic or long term tendon condition. More content coming soon...

Tendon tears in the shoulder usually occur because the tendon has deteriorated in quality to such a degree that it tears under relatively low forces. This occurs with advanced or severe tendinopathy. The tears may be small and have a relatively small effect on shoulder function or they can involve a complete tear across multiple tendons. More content coming soon...

What is Frozen Shoulder?

Frozen Shoulder, also known as Adhesive Capsulitis or Peri-arthritis is a condition that causes pain and stiffness in the shoulder or upper arm. 

It is usually described as occuring in 3 stages: Freezing, Frozen and Thawing.

In the initial stage Freezing stage the shoulder becomes very painful and the pain increases with any movement. It is often too painful to sleep and you may not be able to wash your hair of put your hand behind your back. 

In the Frozen stage the pain gradually settles but the shoulder remains stiff and movement is limited. It will be painful to try to stretch the shoulder, but you can usually find comfortable positions for it. 

In the Thawing stage the movement gradually returns and hopefully in time your shoulder returns to normal. 

The classic description describes each stage as last 4-8 months, but in some cases they can last longer than 8 months and the stiffness may never go on its own.

What causes Frozen Shoulder?

Frozen shoulder can start spontaneously for no clear reason or it can occur after a minor injury or a more serious injury or surgery. If is not clear why it happens, but for some reason the capsule that surrounds the shoulder joint gets inflamed and swollen and becomes painful to move. 

Adhesions can form across folds in the capsule which prevent movement. It is these adhesions that can prevent the shoulder from moving properly even when the severe pain has settled. 

How is frozen shoulder treated?

Frozen shoulder are commonly treated  with exercise or physical therapy, pain killers, steroid injections or other injection therapy or in the worst cases with surgery

Exercise or physical therapy In the Freezing stage of frozen shoulder it can be really difficult to exercise because the pain can be intense on movement. If you can move your shoulder a little this will help it. You can try the normal pain killers that you would take or discuss getting stronger ones from your doctor’s surgery. You can try heat or ice packs but you should be careful not to burn yourself. 

The sort of exercise you can try in the first stage is just gentle swinging your arm backward and forwards or side to side while bending forward and leaning on a chair.

As the pain settles you can try exercises that work into the stiffness. Such as using a pulley to pull the stiff arm up with the good arm or lying on your back and using one arm to take the other arm up either with a stick or just locking your hands together. If you can get to 90o gravity will help to take your arm up further.

How hard should I push the exercises?

It's not easy for people to know how hard to push exercises. If you push too hard then you can make your shoulder worse and more painful, if you don't push hard enough you don't achieve anything. 

Our advice is to start gently and slowly, then if you are not making your shoulder too sore you can push a little harder. If you gradually build up the stretch and do it in a slow and controlled way you are unlikely to do yourself harm. When you are exercising you may get some discomfort as your shoulder starts to stretch, and your shoulder may be uncomfortable afterwards for a while, but if it is still hurting more after 30 -40 minutes you are probably pushing a bit too hard so just ease back a little.

Pain killers

Steroid injections or other injection therapy 

Surgery. More content coming soon...

The acromio-clavicular joint or ACJ is a small joint between the clavicle (collar bone) and the scapula (shopulder blade). It is not a particular common cause of shoulder pain, but oftend shows quite marked signs of osteo-arthritis or degenerative change on XR or ultrasound and therefore can be in-correctly diagnosed as the source of shoulder pain. It is most commonly injured in sports such as rugby or falling from a horse. 

There are no muscles that directly cross the joint and so it can be difficult to omprove the stability of the joint with strengthening exercises. Steroid injections are an extremely effective way of treating the ACJ when it is causing shoulder pain. It is a small, superficial joint that can be injected with a small amount of steroid and tends to respond very well. It is very easy to inject with ultrasound guidance, but can be very difficult to inject without utrasound. For theis reason we would strongly recommend the uuse of Ultrasound for this injection.