No Longer Out of Joint
By Maureen Sangiorgio
Despite all the rough-and-tumble action sports Jim Macdonald played all his life, it was a mere whiffle ball that finally did his shoulder in. “I was playing ball with my kids, when I felt this sharp pain,” he recalls. “I ignored it for two years, but when I had to turn down fun activities like parasailing down the shore with my family, I knew I had to do something about it.” An MRI showed a torn labrum, which is the cartilage that forms a cup for the end of the arm bone (humerus) to move around in.
So What’s The Deal Here?
When you look at your shoulder, you’re looking at the most moveable yet one of the most troublesome joints in the body. Unlike your hip, which is more of a ball-and-socket joint, your shoulder joint is like a golf ball and tee, in which the ball can easily slip off the flat tee. No wonder about 14 million people seek medical care each year for shoulder problems, according to the Centers for Disease Control and Prevention.
Shoulder problems run the gambit of sprains, strains, dislocations, separations, tendonitis, bursitis, torn rotator cuffs, frozen shoulder, fractures, and arthritis. The shoulder is easily injured because the ball of the upper arm is larger than the shoulder socket that holds it. This article will focus on rotator cuff tendonitis and impingement, two of the most common causes of pain in the adult shoulder.
The rotator cuff is a group of muscles and tendons that cover your shoulder joint. The tendons and muscles keep the shoulder in place, and work together to lift and rotate the shoulder. Tendonitis is inflammation (redness, soreness, and swelling) of a tendon. In tendonitis 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 front edge of the shoulder blade (acromion). Squeezing of the rotator cuff is called impingement syndrome.
Does This Sound Familiar?
Here are the signs/symptoms of rotator cuff tendonitis and impingement:
Dull, aching shoulder pain; pain and difficulty reaching overhead; pain at night that can interfere with sleep; pain reaching behind your back; pain that gets worse with activity (especially overhead); pain with movement at or above shoulder level; a catching sensation as you lower your arm; weakness of the shoulder secondary to pain; limited range of motion secondary to pain, or feeling of stiffness; pain that is generally not related to one specific injury.
Impingement is common in both young athletes and middle-aged people, according to the American Academy of Orthopaedic Surgeons. Athletes who use their arms overhead for swimming, baseball, and tennis are particularly vulnerable. Workers who do repetitive lifting or overhead activities using the arm, such as paper hanging, construction, or painting are also at higher risk. Pain may also develop as the result of minor trauma, such as falling on an outstretched hand. The effects of the aging process on shoulder movement over many years can also irritate and wear down the tendons, muscles, and surrounding structures.
How Shoulder Problems Are Diagnosed
“First we take a medical history, followed by a thorough physical examination of the shoulder area,” says Dr. Godbout. “We determine the limits of movement, location of pain, shoulder strength, and extent of joint instability.” Your doctor may order one or more tests such as an X- ray which is useful for evaluating bony abnormalities, diagnosing fractures, or other problems of the bones. Soft tissues, such as muscles and tendons, do not show up on X-rays. Another test is an arthrogram, in which contrast fluid is injected 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.
An ultrasound is a noninvasive, patient-friendly procedure in which a small, hand-held scanner is placed on the skin of the shoulder. Just as ultrasound waves can be used to visualize the fetus during pregnancy, they can also be reflected off the rotator cuff and other structures to form a high quality image of them. The accuracy of ultrasound for the rotator cuff is particularly high.
MRI (magnetic resonance imaging) is another noninvasive procedure in which a machine with a strong magnet passes a force through the body to produce a series of cross-sectional images of the shoulder.
Shoulder Pain Treatment
“Treatment for rotator cuff tendonitis/impingement generally begins with conservative management such as rest, ice, and anti-inflammatory medicines like aspirin and ibuprofen,” says Dr. Godbout. “We can also use ultrasound to increase blood flow and reduce inflammation. Physical therapy, which consists of gentle stretching and strengthening exercises, are added gradually. If there is no improvement, our next step is cortisone injections.” If the pain is chronic and conservative treatment hasn’t helped after 6 to 12 months, the doctor may recommend either arthroscopic or open surgery to repair damage and relieve pressure on the shoulder tendons.
“In Jim’s case, we were able to perform arthroscopic surgery to repair his torn labrum, and relieve pressure in his shoulder,” says Dr. Godbout. Shoulder arthroscopy uses a tiny camera called an arthroscope to examine and/or repair the tissues in and around the shoulder joint. The arthroscope is inserted through a small incision in the skin, and is connected to a video monitor in the operating room. “We cleaned out the damaged and inflamed tissue in the upper part of the shoulder, then we repaired the torn labrum.” All this with four tiny incisions. With traditional, “open” surgery, you have a large incision so that the surgeon can get directly to the bones and tissues. According to Dr. Godbout, the benefit of arthroscopic surgery versus traditional “open” surgery is that recuperation is much quicker and easier on the patient. “We also get more predictable outcomes in terms of range of motion and shoulder joint stability.”
“I’m so glad I had the surgery done on my shoulder,” notes Jim. “My recovery was practically painless. Now I can play ball with my kids again, and I do plan on parasailing this summer!”