Common Causes of Shoulder Pain Explained by Dr. Mandeep S. Dhillon

Introduction

In the last 20 years of my Outpatient experience, the maximum number of cases I have seen have been related to shoulder pain. No age is immune from this problem, and the patient profile that visits me has ranged from young athletes who have a shoulder instability with or without a frank dislocation, to mid-forties high achievers who either lifted some luggage during traveling, or were over enthusiastic with activities on the weekend, to the elderly population who have presented with different stages of frozen shoulder or impingement symptoms. 

What is Shoulder Impingement?

It is surprising to know that most people including paramedics and technicians who take x-rays, are unaware of what shoulder impingement really is ! It simply means something gets “pinched”, or the 2 bones abut against one another in certain positions of the shoulder, leading to pain. This can happen to anyone and the causes are diverse. If we look at the shoulder, it is basically a joint between the arm bone (Humerus), whose upper end is not fully round, and the shoulder blade (Scapula), which makes a hollow partial cup, with a hood on top (Acromion) from where the arm is partially suspended. Complex muscles and ligaments suspend the arm and provide the motor strength for function to this joint. Normally there is enough compensatory mechanism to prevent these fine structures from being pinched between the 2 main bones.  The problem starts when this fine tuning of muscles is lost, and impingement starts, which initially maybe painless, progresses to episodic pain with certain activities, and may even lead to “tearing” of the tissues; this sets up a vicious cycle aggravating the problem.

Causes of Shoulder Impingement

In young adults this maybe because of minor abnormalities of shape of the hooked part of the bone (Acromion), which often has a sharp pointy end that pinches the muscles (Rotator cuff) in between, when one lifts the arm. This maybe compounded in people who are throwers, or play sports needing overhead activity (Badminton, Tennis). Over a period of time the impingement causes wear and tear and leads to actual muscle tears. This may start in the reverse manner too; we often see patients with a rotator cuff tendon tear, who ultimately develop impingement syndromes. In this scenario the muscle function is lost, and when an attempt is made to lift the arm up, instead of a smooth rotation movement, the bone is actually pulled vertically up, causing impingement. This is more frequent in the older patients, in whom the rotator cuff gradually becomes weak either due to repeated minor injuries, or excessive sport/work involving overhead activities. It may also develop due to aging related arthritis in the neighboring bones that cause bone spikes to develop, further pinching the rotator cuff and damaging it. In this age group, because of overall activity restriction and poor muscle tone, the tendency to reduce pain by restricting movements may often lead to the stage when tissues around the shoulder contract, and the patient ends up with a frozen shoulder!  Pain becomes worse at night, and activity is further restricted, and the cycle continues.

Prevention and Treatment of Shoulder Impingement

So, how can it be prevented? Prevention, early diagnosis, and good non-operative measures that focus on strengthening and stretching exercises will help a vast majority of the cases when treatment is initiated early, and the patient is diligent. A small percentage will need some operative intervention. If bony spikes pressing tendons are visualized on specialized x-rays and MRIs, minor operations can be done to remove them (using arthroscopy), thus freeing up the space, allowing unhindered motion. If the tendon tissue is frayed, it can be smoothened out and in cases where there are actual tears, repair is often possible. It is important to note that not all age-related tears are repairable; however even unrepairable cuff tears can be helped by operation, since the extra sensitive tissue that is being pinched can be removed, and pain maybe relieved. Even with an un-repaired rotator cuff, the body compensates to a great level to regain good shoulder function once pain is relieved.

Dr. Mandeep S. Dhillon | Fortis Mohali

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