Shoulder ailments come in all shapes and sizes. From the teenage gymnast to the elderly gardener, limitations from shoulder pain are quite disabling. Confirming the correct diagnosis and integrating proper treatment pathways will again allow the patient to position their arm in space and return to the activities they love. Common shoulder problems can be identified by taking a comprehensive history, performing a detailed shoulder exam, and complimenting these with diagnostic tests as necessary.
Subacromial impingement syndrome occurs in the middle aged population. Structurally, this occurs when the rotator cuff and humerus impinge on anterior acromial osteophytes and the coracoacromial ligament. This causes anterolateral shoulder pain mainly with overhead activities. On exam, a patient will have pain with forward flexion of the shoulder, and this will worsen with internal rotation. Also present will be weakness of the rotator cuff. Radiographs will show narrowing of the supraspinatus outlet with acromial curvature or osteophytes. Often times conservative care of impingement syndrome such as NSAID's, rest, physical therapy, and injections are quite successful. Failing this, however, arthroscopic decompression of the subacromial space has excellent results.
Rotator cuff disease can worsen from tendinopathy associated with impingement to partial or complete tears of the rotator cuff. Full thickness rotator cuff tears can be attritional secondary to long term impingement in the elderly, or from severe trauma in the younger population. Night pain is a common complaint. Weakness of the rotator cuff is generally quite profound with limited active motion, but relatively good passive range of motion. Acromial osteophytes can be seen on radiographs, but the imaging study of choice is theMRI as this shows the rotator cuff directly. Partial thickness of the rotator cuff may respond to NSAID's, physical therapy or injections. If refractory to this conservative care, then arthroscopic repair is indicated. Surgical intervention is the only way to repair a full thickness rotator cuff tear, as conservative treatment will not produce healing.
Acromioclavicular (AC) joint arthritis also presents with anterior shoulder pain, but this is located directly over the joint. This is often seen in middle aged and elderly patients. Swelling of the AC joint is present, and hypertrophy and degenerative changes are seen radiographically. Pain typically worsens with reaching across the front of the body. This can be treated with NSAID's, injections, or arthroscopic resection of the distal clavicle.
Glenohumeral arthritis presents insidiously in the sixth and seventh decades, post-traumatically at a younger age, or with conditions like rheumatoid arthritis or avascular necrosis. Patients are limited in their active and passive ranges of motion. Crepitation is present throughout all planes of motion. Pain is present with activities of daily living and also significant at night. X-rays will show a loss of joint space, marginal osteophytes, and subchondral cysts. Treatments include NSAID's, injections, or varying degrees of joint replacement surgeries.
Adhesive capsulitis occurs in the 50 to 60 year old age group. The initial phase presents with pain and inflammation. This progresses to marked restrictions of both active and passive range of motion. It is often associated with diabetes, hypothyroidism, or trauma. It may take a year or longer to resolve with conservative care. Imaging studies are often normal. Treatment with heat and aggressive range of motion exercises in physical therapy are helpful. If continued restrictions persist and the patient if functionally limited, then arthroscopic lysis of adhesions with manipulation under anesthesia is beneficial.
Glenohumeral instability is often seen in the younger more physically demanding patients. This can be post-traumatic unidirectional which is often unilateral, recurrent and associated with a labral or rotator cuff tear. Idiopathic multidirectional instability is bilateral and is most often seen in young females in their teens or twenties. Symptoms include a "dead arm" sensation, crepitation, subluxations, or impingement syndrome. They will exhibit a positive apprehension and relocation sign. A physical therapy program for stabilization exercises can be helpful. Arthroscopic stabilization can be performed if conservative means fail.
If conservative care of shoulder problems fail to eliminate pain and return the patient to full activities, then Dr. Angelo Cammarata is available for consultation and expert care. He is board certified in orthopaedics and has done a fellowship in upper extremity care. He is a regional expert and referral source for shoulder ailments, and has, for four consecutive years, been selected as one of America's Top Doctors by the Consumer Research Council of America.