Health Topics
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Publication Date May 2001
Questions and Answers about Shoulder Problems
This booklet first answers general questions about the
shoulder and shoulder problems. It then answers questions about specific
shoulder problems (dislocation, separation, tendinitis, bursitis, impingement
syndrome, torn rotator cuff, frozen shoulder, and fracture) as well
as shoulder pain caused by arthritis of the shoulder.
How Common Are Shoulder Problems?
According to the American Academy of Orthopaedic Surgeons,
about 4 million people in the United States seek medical care each year
for shoulder sprain, strain, dislocation, or other problems. Each year,
shoulder problems account for about 1.5 million visits to orthopaedic
surgeons--doctors who treat disorders of the bones, muscles, and related
structures.
What Are the Structures of the Shoulder and How Does the
Shoulder Function?
The shoulder joint is composed of three bones: the clavicle
(collarbone), the scapula (shoulder blade), and the humerus (upper arm
bone) (see diagram). Two joints facilitate shoulder movement. The acromioclavicular
(AC) joint is located between the acromion (part of the scapula that
forms the highest point of the shoulder) and the clavicle. The glenohumeral
joint, commonly called the shoulder joint, is a ball-and-socket type
joint that helps move the shoulder forward and backward and allows the
arm to rotate in a circular fashion or hinge out and up away from the
body. (The "ball" is the top, rounded portion of the upper arm bone
or humerus; the "socket," or glenoid, is a dish-shaped part of the outer
edge of the scapula into which the ball fits.) The capsule is a soft
tissue envelope that encircles the glenohumeral joint. It is lined by
a thin, smooth synovial membrane.
The bones of the shoulder are held in place
by muscles, tendons, and ligaments. Tendons are tough cords of tissue
that attach the shoulder muscles to bone and assist the muscles in moving
the shoulder. Ligaments attach shoulder bones to each other, providing
stability. For example, the front of the joint capsule is anchored by
three glenohumeral ligaments.
The rotator cuff is a structure composed of tendons that,
with associated muscles, holds the ball at the top of the humerus in
the glenoid socket and provides mobility and strength to the shoulder
joint.
Two filmy sac-like structures called bursae permit smooth
gliding between bone, muscle, and tendon. They cushion and protect the
rotator cuff from the bony arch of the acromion.
What Are the Origin and Causes of Shoulder
Problems?
The shoulder is the most movable joint in the body. However,
it is an unstable joint because of the range of motion allowed. It is
easily subject to injury because the ball of the upper arm is larger
than the shoulder socket that holds it. To remain stable, the shoulder
must be anchored by its muscles, tendons, and ligaments. Some shoulder
problems arise from the disruption of these soft tissues as a result
of injury or from overuse or underuse of the shoulder. Other problems
arise from a degenerative process in which tissues break down and no
longer function well.
Shoulder pain may be localized or may be referred to areas
around the shoulder or down the arm. Disease within the body (such as
gallbladder, liver, or heart disease, or disease of the cervical spine
of the neck) also may generate pain that travels along nerves to the
shoulder.
How Are Shoulder Problems Diagnosed?
Following are some of the ways doctors diagnose shoulder
problems:
- Medical history (the patient tells the doctor about an injury or
other condition that might be causing the pain).
- Physical examination to feel for injury and discover the limits
of movement, location of pain, and extent of joint instability.
- Tests to confirm the diagnosis of certain conditions. Some of these
tests include:
- x ray
- arthrogram--Diagnostic record that can be seen on an x ray after
injection of a contrast fluid into the shoulder joint to outline
structures such as the rotator cuff. In disease or injury, this
contrast fluid may either leak into an area where it does not
belong, indicating a tear or opening, or be blocked from entering
an area where there normally is an opening.
- MRI (magnetic resonance imaging)--A non-invasive procedure in
which a machine produces a series of cross-sectional images of
the shoulder.
- Other diagnostic tests, such as injection of an anesthetic into
and around the shoulder joint, are discussed in specific sections
of this booklet.
Dislocation
What Is a Shoulder Dislocation?
The shoulder joint is the most frequently dislocated major
joint of the body. In a typical case of a dislocated shoulder, a strong
force that pulls the shoulder outward (abduction) or extreme rotation
of the joint pops the ball of the humerus out of the shoulder socket.
Dislocation commonly occurs when there is a backward pull on the arm
that either catches the muscles unprepared to resist or overwhelms the
muscles. When a shoulder dislocates frequently, the condition is referred
to as shoulder instability. A partial dislocation where the upper arm
bone is partially in and partially out of the socket is called a subluxation.
What Are the Signs of a Dislocation and How Is It Diagnosed?
The shoulder can dislocate either forward, backward, or
downward. Not only does the arm appear out of position when the shoulder
dislocates, but the dislocation also produces pain. Muscle spasms may
increase the intensity of pain. Swelling, numbness, weakness, and bruising
are likely to develop. Problems seen with a dislocated shoulder are
tearing of the ligaments or tendons reinforcing the joint capsule and,
less commonly, nerve damage. Doctors usually diagnose a dislocation
by a physical examination, and x rays may be taken to confirm the diagnosis
and to rule out a related fracture.
How Is a Dislocated Shoulder Treated?
Doctors treat a dislocation by putting the ball of the
humerus back into the joint socket--a procedure called a reduction.
The arm is then immobilized in a sling or a device called a shoulder
immobilizer for several weeks. Usually the doctor recommends resting
the shoulder and applying ice three or four times a day. After pain
and swelling have been controlled, the patient enters a rehabilitation
program that includes exercises to restore the range of motion of the
shoulder and strengthen the muscles to prevent future dislocations.
These exercises may progress from simple motion to the use of weights.
After treatment and recovery, a previously dislocated
shoulder may remain more susceptible to reinjury, especially in young,
active individuals. Ligaments may have been stretched or torn, and the
shoulder may tend to dislocate again. A shoulder that dislocates severely
or often, injuring surrounding tissues or nerves, usually requires surgical
repair to tighten stretched ligaments or reattach torn ones.
Sometimes the doctor performs surgery through a tiny incision
into which a small scope (arthroscope) is inserted to observe the inside
of the joint. After this procedure, called arthroscopic surgery, the
shoulder is generally immobilized for about 6 weeks and full recovery
takes several months. Arthroscopic techniques involving the shoulder
are relatively new and many surgeons prefer to repair a recurrent dislocating
shoulder by the time-tested open surgery under direct vision. There
are usually fewer repeat dislocations and improved movement following
open surgery, but it may take a little longer to regain motion.
Separation
What Is a Shoulder Separation?
A shoulder separation occurs where the collarbone (clavicle)
meets the shoulder blade (scapula). When ligaments that hold the joint
together are partially or completely torn, the outer end of the clavicle
may slip out of place, preventing it from properly meeting the scapula.
Most often the injury is caused by a blow to the shoulder or by falling
on an outstretched hand.
What Are the Signs of a Shoulder Separation and How Is
It Diagnosed?
Shoulder pain or tenderness and, occasionally, a bump
in the middle of the top of the shoulder (over the AC joint) are signs
that a separation may have occurred. Sometimes the severity of a separation
can be detected by taking x rays while the patient holds a light weight
that pulls on the muscles, making a separation more pronounced.
How Is a Shoulder Separation Treated?
A shoulder separation is usually treated conservatively
by rest and wearing a sling. Soon after injury, an ice bag may be applied
to relieve pain and swelling. After a period of rest, a therapist helps
the patient perform exercises that put the shoulder through its range
of motion. Most shoulder separations heal within 2 or 3 months without
further intervention. However, if ligaments are severely torn, surgical
repair may be required to hold the clavicle in place. A doctor may wait
to see if conservative treatment works before deciding whether surgery
is required.
Tendinitis, Bursitis, and Impingement Syndrome
What Are Tendinitis, Bursitis, and Impingement Syndrome
of the Shoulder?
These conditions are closely related and may occur alone
or in combination. If the rotator cuff and bursa are irritated, inflamed,
and swollen, they may become squeezed between the head of the humerus
and the acromion. Repeated motion involving the arms, or the aging process
involving shoulder motion over many years, may also irritate and wear
down the tendons, muscles, and surrounding structures.
Tendinitis is inflammation (redness, soreness, and swelling)
of a tendon. In tendinitis of the shoulder, the rotator cuff and/or
biceps tendon become inflamed, usually as a result of being pinched
by surrounding structures. The injury may vary from mild inflammation
to involvement of most of the rotator cuff. When the rotator cuff tendon
becomes inflamed and thickened, it may get trapped under the acromion.
Squeezing of the rotator cuff is called impingement syndrome.
Tendinitis and impingement syndrome are often accompanied
by inflammation of the bursa sacs that protect the shoulder. An inflamed
bursa is called bursitis. Inflammation caused by a disease such as rheumatoid
arthritis may cause rotator cuff tendinitis and bursitis. Sports involving
overuse of the shoulder and occupations requiring frequent overhead
reaching are other potential causes of irritation to the rotator cuff
or bursa and may lead to inflammation and impingement.
What Are the Signs of Tendinitis and Bursitis?
Signs of these conditions include the slow onset of discomfort
and pain in the upper shoulder or upper third of the arm and/or difficulty
sleeping on the shoulder. Tendinitis and bursitis also cause pain when
the arm is lifted away from the body or overhead. If tendinitis involves
the biceps tendon (the tendon located in front of the shoulder that
helps bend the elbow and turn the forearm), pain will occur in the front
or side of the shoulder and may travel down to the elbow and forearm.
Pain may also occur when the arm is forcefully pushed upward overhead.
How Are These Conditions Diagnosed?
Diagnosis of tendinitis and bursitis begins with a medical
history and physical examination. X rays do not show tendons or the
bursae but may be helpful in ruling out bony abnormalities or arthritis.
The doctor may remove and test fluid from the inflamed area to rule
out infection. Impingement syndrome may be confirmed when injection
of a small amount of anesthetic (lidocaine hydrochloride) into the space
under the acromion relieves pain.
How Are Tendinitis, Bursitis, and Impingement Syndrome
Treated?
The first step in treating these conditions is to reduce
pain and inflammation with rest, ice, and anti-inflammatory medicines
such as aspirin, naproxen (Naprosyn*), ibuprofen (Advil, Motrin, or
Nuprin), or cox-2 inhibitors (Celebrex or Nobic). In some cases
the doctor or therapist will use ultrasound (gentle sound-wave vibrations)
to warm deep tissues and improve blood flow. Gentle stretching and strengthening
exercises are added gradually. These may be preceded or followed by
use of an ice pack. If there is no improvement, the doctor may inject
a corticosteroid medicine into the space under the acromion. While steroid
injections are a common treatment, they must be used with caution because
they may lead to tendon rupture. If there is still no improvement after
6 to 12 months, the doctor may perform either arthroscopic or open surgery
to repair damage and relieve pressure on the tendons and bursae.
* Brand names included in this booklet are provided as
examples only, and their inclusion does not mean that these products
are endorsed by the National Institutes of Health or any other Government
agency. Also, if a particular brand name is not mentioned, this does
not mean or imply that the product is unsatisfactory.
Torn Rotator Cuff
What Is a Torn Rotator Cuff?
One or more rotator cuff tendons may become inflamed from
overuse, aging, a fall on an outstretched hand, or a collision. Sports
requiring repeated overhead arm motion or occupations requiring heavy
lifting also place a strain on rotator cuff tendons and muscles. Normally,
tendons are strong, but a longstanding wearing down process may lead
to a tear.
What Are the Signs of a Torn Rotator Cuff?
Typically, a person with a rotator cuff injury feels pain
over the deltoid muscle at the top and outer side of the shoulder, especially
when the arm is raised or extended out from the side of the body. Motions
like those involved in getting dressed can be painful. The shoulder
may feel weak, especially when trying to lift the arm into a horizontal
position. A person may also feel or hear a click or pop when the shoulder
is moved.
How Is a Torn Rotator Cuff Diagnosed?
Pain or weakness on outward or inward rotation of the
arm may indicate a tear in a rotator cuff tendon. The patient also feels
pain when lowering the arm to the side after the shoulder is moved backward
and the arm is raised. A doctor may detect weakness but may not be able
to determine from a physical examination where the tear is located.
X rays, if taken, may appear normal. An MRI can help detect a full tendon
tear, but does not detect partial tears. If the pain disappears after
the doctor injects a small amount of anesthetic into the area, impingement
is likely to be present. If there is no response to treatment, the doctor
may use an arthrogram, rather than an MRI, to inspect the injured area
and confirm the diagnosis.
How Is a Torn Rotator Cuff Treated?
Doctors usually recommend that patients with a rotator
cuff injury rest the shoulder, apply heat or cold to the sore area,
and take medicine to relieve pain and inflammation. Other treatments
might be added, such as electrical stimulation of muscles and nerves,
ultrasound, or a cortisone injection near the inflamed area of the rotator
cuff. The patient may need to wear a sling for a few days. If surgery
is not an immediate consideration, exercises are added to the treatment
program to build flexibility and strength and restore the shoulder's
function. If there is no improvement with these conservative treatments
and functional impairment persists, the doctor may perform arthroscopic
or open surgical repair of the torn rotator cuff.
Frozen Shoulder (Adhesive Capsulitis)
What Is a Frozen Shoulder?
As the name implies, movement of the shoulder is severely
restricted in people with a "frozen shoulder." This condition, which
doctors call adhesive capsulitis, is frequently caused by injury that
leads to lack of use due to pain. Rheumatic disease progression and
recent shoulder surgery can also cause frozen shoulder. Intermittent
periods of use may cause inflammation. Adhesions (abnormal bands of
tissue) grow between the joint surfaces, restricting motion. There is
also a lack of synovial fluid, which normally lubricates the gap between
the arm bone and socket to help the shoulder joint move. It is this
restricted space between the capsule and ball of the humerus that distinguishes
adhesive capsulitis from a less complicated painful, stiff shoulder.
People with diabetes, stroke, lung disease, rheumatoid arthritis, and
heart disease, or who have been in an accident, are at a higher risk
for frozen shoulder. The condition rarely appears in people under 40
years old.
What Are the Signs of a Frozen Shoulder and How Is It
Diagnosed?
With a frozen shoulder, the joint becomes so tight and
stiff that it is nearly impossible to carry out simple movements, such
as raising the arm. People complain that the stiffness and discomfort
worsen at night. A doctor may suspect the patient has a frozen shoulder
if a physical examination reveals limited shoulder movement. An arthrogram
may confirm the diagnosis.
How Is a Frozen Shoulder Treated?
Treatment of this disorder focuses on restoring joint
movement and reducing shoulder pain. Usually, treatment begins with
nonsteroidal anti-inflammatory drugs and the application of heat, followed
by gentle stretching exercises. These stretching exercises, which may
be performed in the home with the help of a therapist, are the treatment
of choice. In some cases, transcutaneous electrical nerve stimulation
(TENS) with a small battery-operated unit may be used to reduce pain
by blocking nerve impulses. If these measures are unsuccessful, the
doctor may recommend manipulation of the shoulder under general anesthesia.
Surgery to cut the adhesions is only necessary in some cases.
Fracture
What Happens When the Shoulder Is Fractured?
A fracture involves a partial or total crack through a
bone. The break in a bone usually occurs as a result of an impact injury,
such as a fall or blow to the shoulder. A fracture usually involves
the clavicle or the neck (area below the ball) of the humerus.
What Are the Signs of a Shoulder Fracture and How Is
It Diagnosed?
A shoulder fracture that occurs after a major injury is
usually accompanied by severe pain. Within a short time, there may be
redness and bruising around the area. Sometimes a fracture is obvious
because the bones appear out of position. Both diagnosis and severity
can be confirmed by x rays.
How Is a Shoulder Fracture Treated?
When a fracture occurs, the doctor tries to bring the
bones into a position that will promote healing and restore arm movement.
If the clavicle is fractured, the patient must at first wear a strap
and sling around the chest to keep the clavicle in place. After removing
the strap and sling, the doctor will prescribe exercises to strengthen
the shoulder and restore movement. Surgery is occasionally needed for
certain clavicle fractures.
Fracture of the neck of the humerus is usually treated
with a sling or shoulder immobilizer. If the bones are out of position,
surgery may be necessary to reset them. Exercises are also part of restoring
shoulder strength and motion.
Arthritis of the Shoulder
What Is Arthritis of the Shoulder?
Arthritis is a degenerative disease caused by either wear
and tear of the cartilage (osteoarthritis) or an inflammation (rheumatoid
arthritis) of one or more joints. Arthritis not only affects joints;
it may also affect supporting structures such as muscles, tendons, and
ligaments.
What Are the Signs of Shoulder Arthritis and How Is It
Diagnosed?
The usual signs of arthritis of the shoulder are pain,
particularly over the AC joint, and a decrease in shoulder motion. A
doctor may suspect the patient has arthritis when there is both pain
and swelling in the joint. The diagnosis may be confirmed by a physical
examination and x rays. Blood tests may be helpful for diagnosing rheumatoid
arthritis, but other tests may be needed as well. Analysis of synovial
fluid from the shoulder joint may be helpful in diagnosing some kinds
of arthritis. Although arthroscopy permits direct visualization of damage
to cartilage, tendons, and ligaments, and may confirm a diagnosis, it
is usually done only if a repair procedure is to be performed.
How Is Arthritis of the Shoulder Treated?
Most often osteoarthritis of the shoulder is treated with
nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, or
cox-2 inhibitors. (Rheumatoid arthritis of the shoulder may require
physical therapy and additional medicine, such as corticosteroids.)
When non-operative treatment of arthritis of the shoulder fails to relieve
pain or improve function, or when there is severe wear and tear of the
joint causing parts to loosen and move out of place, shoulder joint
replacement (arthroplasty) may provide better results. In this operation,
a surgeon replaces the shoulder joint with an artificial ball for the
top of the humerus and a cap (glenoid) for the scapula. Passive shoulder
exercises (where someone else moves the arm to rotate the shoulder joint)
are started soon after surgery. Patients begin exercising on their own
about 3 to 6 weeks after surgery. Eventually, stretching and strengthening
exercises become a major part of the rehabilitation program. The success
of the operation often depends on the condition of rotator cuff muscles
prior to surgery and the degree to which the patient follows the exercise
program.
If you receive a shoulder injury, here's what you can do:
RICE = Rest, Ice, Compression, and Elevation
Rest--Reduce or stop using the injured area for 48 hours.
Ice--Put an ice pack on the injured area for 20 minutes
at a time, 4 to 8 times per day. Use a cold pack, ice bag, or
a plastic bag filled with crushed ice that has been wrapped in
a towel.
Compression--Compression may help reduce the swelling.
Compress the area with bandages, such as an elastic wrap, to help
stabilize the shoulder.
Elevation--Keep the injured area elevated above the level
of the heart. Use a pillow to help elevate the injury.
If pain and stiffness persist, see a doctor.
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Where Can People Get Additional Information
About Shoulder Problems?
National Institute of Arthritis and Musculoskeletal
and
Skin Diseases Information Clearinghouse
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484 or
877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366
http://www.niams.nih.gov/
The clearinghouse provides information about various forms
of arthritis and rheumatic disease and bone, muscle, and skin diseases.
It distributes patient and professional education materials and refers
people to other sources of information. Additional information and updates
can also be found on the NIAMS Web site.
American Academy of Orthopaedic Surgeons
P.O. Box 2058
Des Plaines, IL 60017
Phone: 800-824-BONE (2663) (free of charge)
www.aaos.org
The academy provides education and practice management services for orthopaedic surgeons and allied health professionals. It also serves as an advocate for improved patient care and informs the public about the science of orthopaedics. The orthopaedist's scope of practice includes disorders of the body's bones, joints, ligaments, muscles, and tendons. For a single copy of an AAOS brochure, send a self-addressed stamped envelope to the address above or visit the AAOS Web site.
American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345
Phone: 404-633-3777
Fax: 404-633-1870
www.rheumatology.org
This national professional organization can provide referrals
to rheumatologists and allied health specialists, such as physical therapists.
One-page fact sheets are also available on various forms of arthritis.
Lists of specialists by geographic area and fact sheets are also available
on their Web site.
American Physical Therapy Association
1111 North Fairfax Street
Alexandria, VA 22314-1488
Phone: 703-684-2782 or
800-999-2782, ext. 3395 (free of charge)
www.apta.org
This national professional organization represents physical
therapists, allied personnel, and students. Its objectives are to improve
research, public understanding, and education in the physical therapies.
A free brochure titled "Taking Care of Your Shoulder: A Physical Therapist's
Perspective" is available on the association's Web site or by sending
a business-size, stamped, self-addressed envelope to the address above.
Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
Phone: 404-872-7100 or 800-283-7800 (free of charge)
or call your local chapter (listed in the telephone directory)
www.arthritis.org
This is the major voluntary organization devoted to arthritis.
The foundation publishes pamphlets on arthritis, such as "Arthritis
Answers," that may be obtained by calling the toll-free telephone number.
The foundation also can provide physician and clinic referrals. Local
chapters also provide information and organize exercise programs for
people who have arthritis.
Acknowledgments
The NIAMS gratefully acknowledges the assistance of James
Panagis, M.D., M.P.H., of the NIAMS; Frank A. Pettrone, M.D., of Arlington,
Virginia; and Thomas J. Neviaser, M.D., of Fairfax, Virginia, in the
preparation and review of this booklet.
The mission of the National Institute of Arthritis
and Musculoskeletal and Skin Diseases (NIAMS), a part of the National
Institutes of Health (NIH), is to support research into the causes,
treatment, and prevention of arthritis and musculoskeletal and
skin diseases, the training of basic and clinical scientists to
carry out this research, and the dissemination of information
on research progress in these diseases. The National Institute
of Arthritis and Musculoskeletal and Skin Diseases Information
Clearinghouse is a public service sponsored by the NIAMS that
provides health information and information sources. Additional
information can be found on the NIAMS Web site at http://www.niams.nih.gov/.
NIH Publication No. 01-4865