Pain in the Arm
“You know that feeling in your shoulder. It is a nagging ache and it goes down your deltoid. You cannot lie on your favorite side when you sleep and now you cannot rest well. You are starting to have problems with washing your hair and don’t even get started with putting on T-shirts and hanging up your clothes. This pain is affecting your swing/ stroke/bat. Come to think of it, it is getting to your other shoulder too.”
These are the common problems my patients with shoulder pain have to deal with on a daily basis. Three main issues bother such patients. Pain, Movement, Function which is a symptom translated from the pain and lack on motion.
The pain often radiates down the arm but stops short at the deltoid because the inflammation of the bursae (fluid filled sac) extends there. There is usually no numbness of the arm unlike a pinged neck nerve (cervical spine radiculopathy)
Functionally, the patient cannot raise the arm and thus is unable to wash his/her hair or face. The pain affect his/her sports performance. Often, the patient finds that he/she cannot follow through during the golf swing, have weaker strokes at the baseline or is having a weaker pitch.
Not everyone with Shoulder Pain is Frozen
The shoulder joint is a ball and socket joint. It is akin to golf ball on a golf tee (with the ball 3 times the size of tee) within a House.
Looking at the diagram, there is a Roof (Supraspinatus tendon), a Front door (Subscapularis tendon) and a Back door (Infraspinatus and Teres Minor). Above the Roof, there is a Tree Branch (Acromion Spur). One of the reasons why there is a tear is because the Tree Branch keeps hitting the Roof and makes a Hole in the Roof (Cuff Tear). With a Hole, it leaks when it Rains and that can be quite a Pain!!
The Golf Tee (glenoid) is pretty flat and there is a CUP made of material that looks like Young Coconut Flesh (Labrum). This deepens the golf tee and makes the shoulder joint a more congruent one.
There are three main common causes I see. These are:
- Rotator cuff problems
- Instability (labral problems)
- Frozen shoulder
In my practice, Rotator Cuff problems outnumber instability 3:1 and Rotator Cuff problems outnumber frozen shoulder 4:1. Therein lies the necessity for a proper diagnosis. This is where a “completely new and innovative INVESTIGATION” technique becomes extremely important.
Let me introduce: a Proper History and Physical Examination
Even before we look into doing any scans, I believe that through a proper understanding of the patient’s problems and symptoms, finding out what exactly is affecting the patient, followed by a targeted physical examination looking for specific signs; a proper provisional diagnosis can be made. Using this knowledge, the Xrays and scans can then guide us like a satellite navigation map to decide what needs to be done for the patient. I believe that patients are the ones to be treated and not the scans.
This is commonly also known as五十肩 (50 year old Shoulder), Urat bahu bengkak and commonly includes:
- Cuff Tendinosis
- Cuff Tears which can be incomplete, complete or
- Massive tear which can be Irreparable
- Cuff tear Arthropathy (CTA)
This is also known as Adhesive Capsulitis. As its name suggest, the shoulder is FROZEN. This means that the shoulder is stuck both actively (moves by its own power) and passively (moved by the other arm or someone else). It can be Primary (no one really knows why type) vs Secondary (caused by something else). Risk factors for Primary Frozen shoulder commonly include:
- Endocrine causes (Diabetes Mellitus, Thyroid problems),
- Neurological causes (Stroke)
- Heart (Heart attack)
- Secondary frozen shoulder can be due to shoulder fractures, Cuff issues or Labral issues too.
- Labral Injuries
These often occur after an injury. Patients may have had a dislocation or a subluxation (partial dislocation) previously and the symptom of the shoulder being unstable is recurrent now. The labrum may tear at different areas and in additional to instability; patients may often complain of pain and may have painful clicks in the shoulder during certain movement. A proper examination will include looking for signs of instability, other types of labral tears and signs of generalized hyperlaxity (Loose jointed).
Don’t live with it!
“See your doctor cos something can be done”
I cannot emphasize enough that a Proper History and Physical Examination leading to targeted Investigations will then bring about a Proper Diagnosis. This will include locating the source of pain, Range of Motion tests and Special tests. For labral injuries, we look out for Hyperlaxity Signs too. Thereafter, Xrays, Ultrasound and/or MRI/ CT scans are done and interpreted together with looking at the patient’s problems.
Get back your Swing
This will be based on the diagnosis and looking at what exactly is bothering the patient. (At Roland Shoulder & Orthopaedic Clinic, We Help Patients not Treat Scans)
This depends on whether there is a hole in the roof or not and how big the hole is and if it is a complete hole.
If there is no hole, an incomplete hole or small hole, NON OPERATIVE management lasting for 3-6 months is often started. (There is nothing CONSERVATIVE about not operating)
- Controlling Inflammation and pain – Analgesia (pain killers) and/or NSAIDs (Non Steroidal Anti Inflammatory Drugs)
- Subacromial (below the tree branch) Hydrocortisone & Lignocaine injections (I usually use 1% lignocaine with Triamcinolone)
- Mobility Exercises
- Strengthening of the
- External and Internal Rotators
For patients with Acute tears (occurring after an injury), Large Complete tears or patients that have failed non operative management, Surgery is offered. In my practice, a large majority of cuff problems which require surgery is done through Key Hole techniques now. This includes
- Arthroscopic Subacromial Decompression and rotator cuff repair which is shaving down the offending tree branch above the roof and repairing the roof and/or repairing the front door too if that is torn.
- Arthroscopic Mumford procedure (distal clavicle resection) if that is giving the patient problems .
- Addressing the Biceps tendon (Tenotomy/Tenodesis) if that is giving patients problems .
A large majority of shoulder problems are treated using key hole (Arthroscopic) techniques as they are can usually produce equal results to open surgery. Patients often have less pain, a shorter hospital stay and the scars are cosmetically more pleasing.
However, this is not suitable for all cases and this depends of the condition and severity of the problem.
Primary Frozen shoulders follow a process of Freezing, Frozen and then Thawing. The thawing process can occasionally, unfortunately, last for a very long time of up to a year or 2. Seeing a doctor early will allow us to:
- Ensure that the it is truly a Frozen shoulder. (again through a proper history/ physical examination/ appropriate scan/s)
- Find out if it is cause by another shoulder problem (Secondary Frozen Shoulder)
- Speed up the thawing process or if necessary, BREAK the ICE!
Speeding up the thawing process includes:
Non operative management of Glenohumeral H&L (injecting into the house itself), Physiotherapy, Medication like pain killers and anti-inflammatory medications. It is important to treat underlying issues if it is a secondary cause.
In my practice, if all else fails, I offer to break the ice but under direct vision. I kinda like to see what I intend to break. As such, I offer an Arthroscopic Capsular Release
For patients with labral injuries, if recurrent instability is the main problem, surgery should be considered early. This is because in younger patients, the risk of persistent instability is very high. With each dislocation, the risk of getting a large piece of the golf tee being broken off (Bony Bankart) or the golf ball being cored in (Hil sachs Lesion) becomes higher. As such, I offer Arthroscopic Shoulder Stabilization (Keyhole stabilization surgery) where the torn labrum can be repaired. This is for patients without a large piece of the golf tee that is broken off or a large part of the golf ball being cored. Unfortunately, if that happens, open procedures to restore the bone loss usually at the side of the golf tee may then be suitable.
For some patients with a SLAP (Superior Labrum Anterior Posterior) tears (top part of the cup) or a posterior labral tear (back part of the cup), pain and clicking is the main problem. For patients with SLAP tear, I believe that a trial of non operative Management should first commence. This must include Scapular Stabilization exercises so as to provide a stable platform for the shoulder joint to mobilize. Only if that fails, I will then offer surgery to address the SLAP tear. In patients with posterior labral injuries complaining of pain and clicks, ASS can be offered to repair the cup.
What if the Whole House is Damaged?
For patients with Cuff Tear Arthropathy (damage to the shoulder cartilage due to prolonged roof tendon tear) and usually for patients > 65years, the option of a joint replacement is offered. This is because with the cartilage being worn out, a repair or replacement of the roof tendons will not resolve the arthritis causing the pain. In patients with CTA, a Reverse Shoulder Arthroplasty (RSA) is usually offered.
This is a replacement surgery and it offers excellent pain relieve, a good functional Range of Motion of 140-150 degrees of forwards flexion. Patients can return to daily upper limb activities like comb/ wash hair, wash face, brush teeth after surgery.
In conclusion, you don’t have to live with your shoulder pain. Seek help early if the shoulder strain simply doesn’t go away after 2-3 weeks. A proper History and Physical Examination and Appropriate Investigations will usually lead to a Diagnosis and proper Treatment.