Dr Toshimenla Pongener
MBBS, MD (PMR) Jr Consultant, Dept of PMR, CIHSR, Dimapur
Introduction: The shoulder is structurally and functionally complex as it is one of the most freely mobile joints of the human body. It is formed by the glenoid cavity of scapula and humeral head forming the glenohumeral joint. The glenohumeral joint is ball and socket synovial joint and is highly moveable. This shoulder range of motion being freely moveable is prone to dislocation and injury.
It is stabilized by two components: static and dynamic stabilizer. Static includes glenoid labrum, joint capsule and ligaments around it. Dynamic stabilizers includes the contractile tissue of shoulder complex i.e. tendon, muscles and myotendinous junction of the rotatory cuff (Supraspinatus, infraspinatus, subscapularis and teres minor) and periscapular muscles. It controls the fine tuning of the humeral head within the glenoid fossa.
Major movements of the shoulder joint: Flexion, extension, abduction, adduction, horizontal abduction and adduction, internal and external rotation.
Common causes of shoulder pain: Adhesive capsulitis/frozen shoulder, rotatory cuff instability or tear, AC joint pain, rotatory cuff tendinopathy, shoulder subluxation or dislocation, glenohumeral instability, shoulder osteoarthritis, myofascial pain syndrome, painful arc syndrome, traumatic injury, repetitive strain injury etc.
Risk factors/conditions associated with shoulder pain:
1. People who frequently work by lifting heavy objects or household related activity using shoulder for overhead activity with poor ergonomics e.g.: painters, electrician, shelf stockers.
2. Sports involving moving your arms overhead with force (repetitive strain injury): tennis players, basketball players, badminton players, swimmers.
3. People who frequently work out at gym (shoulder dumbbell or bench press, weightlifting) without supervision can lead to shoulder injury by adopting improper lifting techniques.
4. Medical conditions: diabetes, thyroid disorder, stroke-CRPS.
5 Age: <40 yrs (instability, rotatory cuff tendinopathy or tear)
40 yrs (rotatory cuff tear, adhesive capsulitis, osteoarthritis)
Diagnosing cause of shoulder pain:
Taking proper history and clinical examination is a must to find out the cause of shoulder pain. Evaluating the etiology causing the pain at the shoulder by asking the symptoms, clinical signs, performing tests like (drop arm test, speed test, Hawkins-Kennedy impingement, empty can, lift off test etc.) along with range of motion of the joint by your physician plays an important factor in finding out the cause.
What should I do if I have shoulder pain?
Orthopaedician or PMR (Physical Medicine and Rehabilitation) specialist can be your first responder. After assessing the patient, medication and exercise will be prescribed and according to the need of the patient, they will be sent to subunit (under PMR department) like Physiotherapy, Occupational therapy, Prosthetic and Orthotic who will aid in therapy for shoulder exercise, therapeutic modalities, ergonomics and bracing.
Treatment:
It will depend upon the cause of shoulder pain which has to be clinically examined by a physician. After identifying the etiology, we can categorize it into pharmacological and non-pharmacological management along with pain intervention (minimally invasive) or surgery. Multidisciplinary approach is the best for an effective outcome.
Pharmacological includes medication like NSAIDs, muscle relaxant, Collagen I & II, Vitamin C.
Non-pharmacological includes closed reduction with gentle traction, exercise, positioning, proper ergonomics, massage therapy, kinesio taping, shoulder support and brace, therapeutic modalities (heat and cold therapy, UST, TENS etc).
Pain intervention includes various injections like intra-articular injection, hydrodilatation of shoulder, interventional microadhesiolysis, trigger point injection, SNRB (Selective Nerve Root Block), PRP (Platelet Rich Plasma) etc.
Surgical intervention includes arthroscopic release (lysis of adhesion), repair of tendon tear (full thickness or partial thickness rotatory cuff tear) or labrum repair, total shoulder replacement etc.
Take home message: All shoulder pain is not frozen shoulder and therefore needs to be thoroughly evaluated by a physician for better care and outcome.
