Shoulder

A rotator cuff tear is a common cause of pain and disability among adults. Each year, almost 2 million people in the United States visit their doctors because of a rotator cuff problem.

A torn rotator cuff will weaken your shoulder. This means that many daily activities, like combing your hair or getting dressed, may become painful and difficult to do.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder is a ball-and-socket joint: the ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade.

Normal shoulder anatomy

This illustration of the shoulder highlights the major components of the joint.

Your arm is kept in your shoulder socket by your rotator cuff. The rotator cuff is a group of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.

The rotator cuff tendons

The rotator cuff tendons cover the head of the humerus (upper arm bone), helping you to raise and rotate your arm.

There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.

Description

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus.

Illustration of a rotator cuff tendon torn away from bone

In most rotator cuff tears, the tendon is torn away from the bone.

Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be involved.

In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.

There are different types of tears.

  • Partial tear. This type of tear is also called an incomplete tear. It damages the tendon, but does not completely sever it.
  • Full-thickness tear. This type of tear is also called a complete tear. It separates all of the tendon from the bone. With a full-thickness tear, there is basically a hole in the tendon.

 

Rotator cuff tendons and a full-thickness tear in the supraspinatus tendon

(Left)  Overhead view of the four tendons that form the rotator cuff.
(Right) A full-thickness tear in the supraspinatus tendon.

Front view of rotator cuff and full-thickness tear in supraspinatus tendon

(Left) The front view of a normal rotator cuff. (Right) A full-thickness tear in the supraspinatus tendon.

Cause

There are two main causes of rotator cuff tears: injury and degeneration.

Acute Tear

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater likelihood of a rotator cuff tear in the opposite shoulder -- even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

  • Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.
  • Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body's natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
  • Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

Risk Factors

Because most rotator cuff tears are largely caused by the normal wear and tear that goes along with aging, people over 40 are at greater risk.

People who do repetitive lifting or overhead activities are also at risk for rotator cuff tears. Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers. Painters, carpenters, and others who do overhead work also have a greater chance for tears.

Although overuse tears caused by sports activity or overhead work also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall.

Symptoms

The most common symptoms of a rotator cuff tear include:

  • Pain at rest and at night, particularly if lying on the affected shoulder
  • Pain when lifting and lowering your arm or with specific movements
  • Weakness when lifting or rotating your arm
  • Crepitus or crackling sensation when moving your shoulder in certain positions

Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.

Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.

Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.

It should be noted that some rotator cuff tears are not painful. These tears, however, may still result in arm weakness and other symptoms.

Doctor Examination

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder. He or she will check to see whether it is tender in any area or whether there is a deformity. To measure the range of motion of your shoulder, your doctor will have you move your arm in several different directions. He or she will also test your arm strength.

Doctor testing patient's range of motion

Your doctor will test your range of motion by having you move your arm in different directions.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Your doctor will check for other problems with your shoulder joint. He or she may also examine your neck to make sure that the pain is not coming from a "pinched nerve," and to rule out other conditions, such as arthritis.

Imaging Tests

Other tests which may help your doctor confirm your diagnosis include:

  • X-rays. The first imaging tests performed are usually x-rays. Because x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur.
  • Magnetic resonance imaging (MRI) or ultrasound. These studies can better show soft tissues like the rotator cuff tendons. They can show the rotator cuff tear, as well as where the tear is located within the tendon and the size of the tear. An MRI can also give your doctor a better idea of how "old" or "new" a tear is because it can show the quality of the rotator cuff muscles.
Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move.

After a period of worsening symptoms, frozen shoulder tends to get better, although full recovery may take up to 3 years. Physical therapy, with a focus on shoulder flexibility, is the primary treatment recommendation for frozen shoulder.

Frozen shoulder most commonly affects people between the ages of 40 and 60, and occurs in women more often than men. In addition, people with diabetes are at an increased risk for developing frozen shoulder.

Anatomy

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.

To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

Shoulder anatomy

The shoulder capsule surrounds the shoulder joint and rotator cuff tendons.
Reproduced and modified from The Body Almanac. (c) American Academy of Orthopaedic Surgeons, 2003.

Description

In frozen shoulder, the shoulder capsule thickens and becomes stiff and tight. Thick bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint.

The hallmark signs of this condition are severe pain and being unable to move your shoulder -- either on your own or with the help of someone else. It develops in three stages:

Stage 1: Freezing

In the "freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

Stage 2: Frozen

Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

Stage 3: Thawing

Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

Inflamed joint capsule

In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.

Cause

The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

Diabetes. Frozen shoulder occurs much more often in people with diabetes. The reason for this is not known. In addition, diabetic patients with frozen shoulder tend to have a greater degree of stiffness that continues for a longer time before "thawing."

Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

Symptoms

Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.

Doctor Examination

Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder.

Your doctor will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called "passive range of motion." Your doctor will compare this to the range of motion you display when you move your shoulder on your own ("active range of motion"). People with frozen shoulder have limited range of motion both actively and passively.

Physical exam for frozen shoulder

Your doctor will test the range of motion in your shoulder.
Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010

Imaging Tests

Other tests that may help your doctor rule out other causes of stiffness and pain include:

X-rays. Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis.

Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of soft tissues. They are not required to diagnose frozen shoulder, however, they may help to identify other problems in your shoulder, such as a torn rotator cuff.

Biceps tendinitis is an inflammation or irritation of the upper biceps tendon. Also called the long head of the biceps tendon, this strong, cord-like structure connects the biceps muscle to the bones in the shoulder.

Pain in the front of the shoulder and weakness are common symptoms of biceps tendinitis. They can often be relieved with rest and medication. In severe cases, surgery may be needed to repair the tendon.

Anatomy

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

Biceps tendons

The biceps tendons attach the biceps muscle to the shoulder bone.

Glenoid. The head of your upper arm bone fits into the rounded socket in your shoulder blade. This socket is called the glenoid. The glenoid is lined with soft cartilage called the labrum. This tissue helps the head of the upper arm fit into the shoulder socket.

Rotator cuff. A combination of muscles and tendons keeps your arm centered in your shoulder socket. These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.

Biceps tendons. The biceps muscle is in the front of your upper arm. It has two tendons that attach it to bones in the shoulder. The long head attaches to the top of the shoulder socket (glenoid).

The short head of the biceps tendon attaches to a bump on the shoulder blade called the coracoid process.

Description

Biceps tendinitis is inflammation of the long head of the biceps tendon. In its early stages, the tendon becomes red and swollen. As tendinitis develops, the tendon sheath (covering) can thicken. The tendon itself often thickens or grows larger.

The tendon in these late stages is often dark red in color due to the inflammation. Occasionally, the damage to the tendon can result in a tendon tear, and then deformity of the arm (a "Popeye" bulge in the upper arm).

Normal shoulder anatomy.

Normal shoulder anatomy.

Biceps tendinitis

Biceps tendinitis causes the tendon to become red and swollen.

Biceps tendinitis usually occurs along with other shoulder problems. In most cases, there is also damage to the rotator cuff tendon. Other problems that often accompany biceps tendinitis include:

  • Arthritis of the shoulder joint
  • Tears in the glenoid labrum
  • Chronic shoulder instability (dislocation)
  • Shoulder impingement
  • Other diseases that cause inflammation of the shoulder joint lining

Cause

In most cases, damage to the biceps tendon is due to a lifetime of normal activities. As we age, our tendons slowly weaken with everyday wear and tear. This degeneration can be worsened by overuse — repeating the same shoulder motions again and again.

Many jobs and routine chores can cause overuse damage. Sports activities — particularly those that require repetitive overhead motion, such as swimming, tennis, and baseball — can also put people at risk for biceps tendinitis.

Repetitive overhead motion may play a part in other shoulder problems that occur with biceps tendinitis. Rotator cuff tears, osteoarthritis, and chronic shoulder instability are often caused by overuse.

Symptoms

  • Pain or tenderness in the front of the shoulder, which worsens with overhead lifting or activity
  • Pain or achiness that moves down the upper arm bone
  • An occasional snapping sound or sensation in the shoulder

Doctor Examination

Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder.

During the examination, your doctor will assess your shoulder for range of motion, strength, and signs of shoulder instability. In addition, he or she will perform specific physical examination tests to check the function of your biceps.

Physical examination for biceps tendinitis

Your doctor may press over the area where the biceps tendon attaches to the shoulder. Patients with tendinitis will have tenderness and swelling in this area.

Imaging Tests

Other tests that may help your doctor confirm your diagnosis include:

X-rays. Although they only visualize bones, x-rays may show other problems in your shoulder joint.

Magnetic resonance imaging (MRI) and ultrasound. These images can show soft tissues like the biceps tendon in greater detail.

One of the most common physical complaints is shoulder pain. Your shoulder is made up of several joints combined with tendons and muscles that allow a great range of motion in your arm. Because so many different structures make up the shoulder, it is vulnerable to many different problems. The rotator cuff is a frequent source of pain in the shoulder.

normal shoulder anatomy

This illustration of the shoulder highlights the major components of the joint.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

Your arm is kept in your shoulder socket by your rotator cuff. These muscles and tendons form a covering around the head of your upper arm bone and attach it to your shoulder blade.

There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm.

Description

The rotator cuff is a common source of pain in the shoulder. Pain can be the result of:

  • Tendinitis. The rotator cuff tendons can be irritated or damaged.
  • Bursitis. The bursa can become inflamed and swell with more fluid causing pain.
  • Impingement. When you raise your arm to shoulder height, the space between the acromion and rotator cuff narrows. The acromion can rub against (or "impinge" on) the tendon and the bursa, causing irritation and pain.

Cause

Rotator cuff pain is common in both young athletes and middle-aged people. Young athletes who use their arms overhead for swimming, baseball, and tennis are particularly vulnerable. Those who do repetitive lifting or overhead activities using the arm, such as paper hanging, construction, or painting are also susceptible.

Pain may also develop as the result of a minor injury. Sometimes, it occurs with no apparent cause.

Symptoms

Rotator cuff pain commonly causes local swelling and tenderness in the front of the shoulder. You may have pain and stiffness when you lift your arm. There may also be pain when the arm is lowered from an elevated position.

Beginning symptoms may be mild. Patients frequently do not seek treatment at an early stage. These symptoms may include:

  • Minor pain that is present both with activity and at rest
  • Pain radiating from the front of the shoulder to the side of the arm
  • Sudden pain with lifting and reaching movements
  • Athletes in overhead sports may have pain when throwing or serving a tennis ball

As the problem progresses, the symptoms increase:

  • Pain at night
  • Loss of strength and motion
  • Difficulty doing activities that place the arm behind the back, such as buttoning or zippering

If the pain comes on suddenly, the shoulder may be severely tender. All movement may be limited and painful.

Doctor Examination

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder. He or she will check to see whether it is tender in any area or whether there is a deformity. To measure the range of motion of your shoulder, your doctor will have you move your arm in several different directions. He or she will also test your arm strength.

Your doctor will check for other problems with your shoulder joint. He or she may also examine your neck to make sure that the pain is not coming from a "pinched nerve," and to rule out other conditions, such as arthritis.

physical exam of shoulder

Your doctor will test your range of motion by having you move your arm in different directions.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Imaging Tests

Other tests which may help your doctor confirm your diagnosis include:

X-rays. Becauses x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur. A special x-ray view, called an "outlet view," sometimes will show a small bone spur on the front edge of the acromion.

shoulder x-ray outlet views of normal and bone spur

(Left) Normal outlet view x-ray. (Right) Abnormal outlet view showing a large bone spur causing impingement on the rotator cuff.

Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of soft tissues like the rotator cuff tendons. They can show fluid or inflammation in the bursa and rotator cuff. In some cases, partial tearing of the rotator cuff will be seen.

A SLAP tear is an injury to the labrum of the shoulder, which is the ring of cartilage that surrounds the socket of the shoulder joint.

Anatomy

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. Surrounding the outside edge of the glenoid is a rim of strong, fibrous tissue called the labrum. The labrum helps to deepen the socket and stabilize the shoulder joint. It also serves as an attachment point for many of the ligaments of the shoulder, as well as one of the tendons from the biceps muscle in the arm.

shoulder labrum anatomy

The labrum deepens the socket of the shoulder joint, making it a stronger fit for the head of the humerus.

Description

The term SLAP stands for Superior Labrum Anterior and Posterior. In a SLAP injury, the top (superior) part of the labrum is injured. This top area is also where the biceps tendon attaches to the labrum. A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. The biceps tendon can be involved in the injury, as well.

SLAP tear

This cross-section view of the shoulder socket shows a typical SLAP tear.

Cause

Injuries to the superior labrum can be caused by acute trauma or by repetitive shoulder motion. An acute SLAP injury may result from:

  • A motor vehicle accident
  • A fall onto an outstretched arm
  • Forceful pulling on the arm, such as when trying to catch a heavy object
  • Rapid or forceful movement of the arm when it is above the level of the shoulder
  • Shoulder dislocation

People who participate in repetitive overhead sports, such as throwing athletes or weightlifters, can experience labrum tears as a result of repeated shoulder motion.

Many SLAP tears, however, are the result of a wearing down of the labrum that occurs slowly over time. In patients over 30 to 40 years of age, tearing or fraying of the superior labrum can be seen as a normal process of aging. This differs from an acute injury in a younger person.

Symptoms

The common symptoms of a SLAP tear are similar to many other shoulder problems. They include:

  • A sensation of locking, popping, catching, or grinding
  • Pain with movement of the shoulder or with holding the shoulder in specific positions
  • Pain with lifting objects, especially overhead
  • Decrease in shoulder strength
  • A feeling that the shoulder is going to "pop out of joint"
  • Decreased range of motion
  • Pitchers may notice a decrease in their throw velocity, or the feeling of having a "dead arm" after pitching

Doctor Examination

Medical History

Your doctor will talk with you about your symptoms and when they first began. If you can remember a specific injury or activity that caused your shoulder pain, it can help your doctor diagnose your shoulder problem — although many patients may not remember a specific event. Any work activities or sports that aggravate your shoulder are also important to mention, as well as the location of the pain, and what treatment, if any, you have had.

Physical Examination

During the physical examination, your doctor will check the range of motion, strength, and stability of your shoulder.

He or she may perform specific tests by placing your arm in different positions to reproduce your symptoms. Your doctor may also examine your neck and head to make sure that your pain is not coming from a "pinched nerve."

The results of these tests will help your doctor decide if additional testing or imaging of your shoulder is necessary.

testing shoulder range of motion

Your doctor will test your range of motion by having you move your arm in different directions.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Imaging Tests

X-rays. This imaging test provides clear pictures of dense structures, like bone. The labrum of the shoulder is made of soft tissue so it will not show up on an x-ray. However, your doctor may order x-rays to make sure there are no other problems in your shoulder, such as arthritis or fractures.

Magnetic resonance imaging (MRI) scans. This test can better show soft tissues like the labrum. To make a tear in the labrum show up more clearly on the MRI, a dye may be injected into your shoulder before the scan is taken.

MRI of SLAP tear

(Left) An MRI image of a healthy shoulder. (Right) This MRI image shows a tear in the labrum.

The shoulder is the most moveable joint in your body. It helps you to lift your arm, to rotate it, and to reach up over your head. It is able to turn in many directions. This greater range of motion, however, can cause instability.Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse.

Once a shoulder has dislocated, it is vulnerable to repeat episodes. When the shoulder is loose and slips out of place repeatedly, it is called chronic shoulder instability.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

Normal shoulder anatomy

Normal shoulder anatomy.

The head, or ball, of your upper arm bone fits into a shallow socket in your shoulder blade. This socket is called the glenoid. Strong connective tissue, called the shoulder capsule, is the ligament system of the shoulder and keeps the head of the upper arm bone centered in the glenoid socket. This tissue covers the shoulder joint and attaches the upper end of the arm bone to the shoulder blade.

Your shoulder also relies on strong tendons and muscles to keep your shoulder stable.

Description

Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.

Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Chronic shoulder instability is the persistent inability of these tissues to keep the arm centered in the shoulder socket.

Illustration of normal shoulder stability and shoulder dislocation

(Left)  Normal shoulder stability. (Right)  Head of the humerus dislocated to the front of the shoulder.

Cause

There are three common ways that a shoulder can become unstable:

Shoulder Dislocation

Severe injury, or trauma, is often the cause of an initial shoulder dislocation. When the head of the humerus dislocates, the socket bone (glenoid) and the ligaments in the front of the shoulder are often injured. The labrum — the cartilage rim around the edge of the glenoid — may also tear. This is commonly called a Bankart lesion. A severe first dislocation can lead to continued dislocations, giving out, or a feeling of instability.

Illustration of a Bankart lesion in the labrum

A Bankart lesion is a tear in the labrum—the cartilage rim around the edge of the shoulder socket.

Repetitive Strain

Some people with shoulder instability have never had a dislocation. Most of these patients have looser ligaments in their shoulders. This increased looseness is sometimes just their normal anatomy. Sometimes, it is the result of repetitive overhead motion.

Swimming, tennis, and volleyball are among the sports requiring repetitive overhead motion that can stretch out the shoulder ligaments. Many jobs also require repetitive overhead work.

Looser ligaments can make it hard to maintain shoulder stability. Repetitive or stressful activities can challenge a weakened shoulder. This can result in a painful, unstable shoulder.

Multidirectional Instability

In a small minority of patients, the shoulder can become unstable without a history of injury or repetitive strain. In such patients, the shoulder may feel loose or dislocate in multiple directions, meaning the ball may dislocate out the front, out the back, or out the bottom of the shoulder. This is called multidirectional instability. These patients have naturally loose ligaments throughout the body and may be "double-jointed."

Symptoms

Common symptoms of chronic shoulder instability include:

  • Pain caused by shoulder injury
  • Repeated shoulder dislocations
  • Repeated instances of the shoulder giving out
  • A persistent sensation of the shoulder feeling loose, slipping in and out of the joint, or just "hanging there"

Doctor Examination

Physical Examination and Patient History

After discussing your symptoms and medical history, your doctor will examine your shoulder. Specific tests help your doctor assess instability in your shoulder. Your doctor may also test for general looseness in your ligaments. For example, you may be asked to try to touch your thumb to the underside of your forearm.

Imaging Tests

Your doctor may order imaging tests to help confirm your diagnosis and identify any other problems.

X-rays. These pictures will show any injuries to the bones that make up your shoulder joint.

Magnetic resonance imaging (MRI). This provides detailed images of soft tissues. It may help your doctor identify injuries to the ligaments and tendons surrounding your shoulder joint.

The scapula, or shoulder blade, is a large triangular-shaped bone that lies in the upper back. The bone is surrounded and supported by a complex system of muscles that work together to help you move your arm. If an injury or condition causes these muscles to become weak or imbalanced, it can alter the position of the scapula at rest or in motion.

An alteration in scapular positioning or motion can make it difficult to move your arm, especially when performing overhead activities, and may cause your shoulder to feel weak. An alteration can also lead to injury if the normal ball-and-socket alignment of your shoulder joint is not maintained.

Treatment for scapular disorders usually involves physical therapy designed to strengthen the muscles in the shoulder and restore the proper position and motion of the scapula.

Anatomy

Your shoulder joint is a ball-and-socket joint. The head of the humerus (upper arm bone) is the ball and the scapula (shoulder blade) forms the socket where the humerus sits.

The scapula and arm are connected to the body by multiple muscle and ligament attachments. The front of the scapula (acromion) is also connected to the clavicle (collarbone) through the acromioclavicular joint.

As you move your arm around your body, your scapula must also move to maintain the ball and socket in normal alignment.

anatomy of the shoulder

(Left) The bones of the shoulder. The scapula serves as a site for the attachment of multiple muscles around the shoulder. (Right) The muscles and soft tissues of the shoulder.
Reproduced from JF Sarwak, ed: Essentials of Musculoskeletal Care, ed. 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Description

"winged" scapula

This photo shows a patient with a "winged" scapula (arrow). Note the prominence of the medial (inner) border of the bone.

Disorders of the scapula result in a deviation, or alteration, in the:

  • Normal resting position of the scapula, or
  • Normal motion of the scapula as the arm moves

The medical term for these alterations is scapular dyskinesis ("dys"= alteration of, "kinesis" = movement).

In most cases, alterations of the scapula can be seen by looking at the patient from behind. The medial (inner) border of the affected shoulder blade will appear more prominent than the one on the opposite side. This prominence will often be exaggerated as the patient moves his or her arm away from the body.

This is commonly called a "winged" scapula, and is sometimes associated with an audible crunching called a "snapping" scapula.

Cause

Causes of scapular dyskinesis include:

  • Weakness, imbalance, tightness, or detachment of the muscles that control the scapula
  • Injuries to the nerves that supply the muscles
  • Injuries to the bones that support the scapula or injuries within the shoulder joint

Symptoms

The most common symptoms of scapular dyskinesis include:

  • Pain and/or tenderness around the scapula, especially on the top and medial (inner) border
  • Weakness in the affected arm—your arm may feel "tired" or "dead" when you try to use it vigorously
  • Fatigue with repetitive activities, especially overhead movements
  • Limited range of motion—you may be unable to raise your arm above shoulder height
  • A "crunching" or "snapping" sound with shoulder movement
  • Noticeable protrusion or "winging" of the scapula
  • A drooped or forward tilted posture on the affected side

Home Remedies

In some cases, the symptoms of scapular dyskinesis may improve with simple home treatment that includes:

Restoring good posture. As you perform your everyday activities, try to stand and sit properly. To do this, pull your shoulder blades back together, and bend your elbows down and back as if you are trying to put them in your back pockets.

Balancing your exercise routine. If you are in a regular exercise program, make sure your upper body strength sessions are balanced. For every set of "presses" that you perform, you should do one set of "flys" and two sets of "rows." Your program should also include stretching exercises for your front shoulder muscles and for shoulder joint rotation.

Heat therapy. Soaking in a hot bath or using a heating pad may help alleviate tight shoulder muscles.

If your symptoms persist, it is important to contact your doctor. He or she can help determine the exact cause of your dyskinesis and provide treatment options.

Doctor Examination

Physical Examination

Your doctor will talk with you about your medical history and general health and ask about your symptoms. He or she will examine your entire shoulder and scapula, looking for injury, weakness, or tightness. In most cases, the physical exam will include the elements below.

Visual observation. Your doctor will look at your affected scapula from behind, comparing it to the noninvolved side. In order to see if scapular dyskinesis is present, your doctor may ask you to move your arms up and down 3 to 5 times, sometimes with light weights in your hands. This will usually reveal any weakness in the muscles and display the dyskinetic patterns.

Manual muscle testing. Your doctor will perform strength testing of your shoulder and scapular muscles to determine if muscle weakness is contributing to the abnormal scapular motion.

Corrective maneuvers. Specific tests involve corrective maneuvers that will help your doctor learn more about your condition. These tests include:

  • Scapular Assistance Test (SAT). In this test, the doctor will apply gentle pressure to your scapula to assist it upward as you elevate your arm. If your symptoms are relieved and the arc of motion is increased, it is an indication that your muscles are not strong enough to raise your arm.

scapular assistance test

In the Scapular Assistance Test, the doctor manually assists the scapula upward as the patient elevates his or her arm.
  • Scapular Retraction Test (SRT). In this test, the doctor will test your arm strength by pushing down on your extended arm. He or she will then manually place the scapula in a retracted position and test your strength again. In patients with scapular dyskinesis, muscle strength will improve when the shoulder blade is retracted.

scapular retraction test

In the Scapular Retraction Test, the doctor manually retracts the scapula while pushing down on the patient's extended arm.

Imaging Studies

Imaging studies are not always necessary to diagnose scapular dyskinesis. Your doctor may, however, order an imaging study, such as an x-ray, computerized tomography (CT) scan, or magnetic resonance imaging (MRI) scan, if he or she suspects a bony abnormality of the scapula (such as an osteochondroma) or an injury to another part of the shoulder.

In 2011, more than 50 million people in the United States reported that they had been diagnosed with some form of arthritis, according to the National Health Interview Survey. Simply defined, arthritis is inflammation of one or more of your joints. In a diseased shoulder, inflammation causes pain and stiffness.

Although there is no cure for arthritis of the shoulder, there are many treatment options available. Using these, most people with arthritis are able to manage pain and stay active.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff.

Illustration of normal shoulder anatomy

The bones and joints of the shoulder.
Reproduced with permission from J Bernstein, ed: Musculoskeletal Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003. 

There are two joints in the shoulder, and both may be affected by arthritis. One joint is located where the clavicle meets the tip of the shoulder blade (acromion). This is called the acromioclavicular (AC) joint.

Where the head of the humerus fits into the scapula is called the glenohumeral joint.

To provide you with effective treatment, your physician will need to determine which joint is affected and what type of arthritis you have.

Description

Five major types of arthritis typically affect the shoulder.

Osteoarthritis

Also known as "wear-and-tear" arthritis, osteoarthritis is a condition that destroys the smooth outer covering (articular cartilage) of bone. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. During movement, the bones of the joint rub against each other, causing pain.

Osteoarthritis usually affects people over 50 years of age and is more common in the acromioclavicular joint than in the glenohumeral shoulder joint.

Illustration and x-ray showing osteoarthritis of the shoulder

(Left) An illustration of damaged cartilage in the glenohumeral joint. (Right) This x-ray of the shoulder shows osteoarthritis and decreased joint space (arrow).
(Left) Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010. 

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic disease that attacks multiple joints throughout the body. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.

The joints of your body are covered with a lining — called synovium — that lubricates the joint and makes it easier to move. Rheumatoid arthritis causes the lining to swell, which causes pain and stiffness in the joint.

Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In RA, the defenses that protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and soften bone.

Rheumatoid arthritis is equally common in both joints of the shoulder.

Posttraumatic Arthritis

Posttraumatic arthritis is a form of osteoarthritis that develops after an injury, such as a fracture or dislocation of the shoulder.

Rotator Cuff Tear Arthropathy

Arthritis can also develop after a large, long-standing rotator cuff tendon tear. The torn rotator cuff can no longer hold the head of the humerus in the glenoid socket, and the humerus can move upward and rub against the acromion. This can damage the surfaces of the bones, causing arthritis to develop.

The combination of a large rotator cuff tear and advanced arthritis can lead to severe pain and weakness, and the patient may not be able to lift the arm away from the side.

Illustration of rotator cuff arthropathy

Rotator cuff arthropathy.

Avascular Necrosis

Avascular necrosis (AVN) of the shoulder is a painful condition that occurs when the blood supply to the head of the humerus is disrupted. Because bone cells die without a blood supply, AVN can ultimately lead to destruction of the shoulder joint and arthritis.

Avascular necrosis develops in stages. As it progresses, the dead bone gradually collapses, which damages the articular cartilage covering the bone and leads to arthritis. At first, AVN affects only the head of the humerus, but as AVN progresses, the collapsed head of the humerus can damage the glenoid socket.

Causes of AVN include high dose steroid use, heavy alcohol consumption, sickle cell disease, and traumatic injury, such as fractures of the shoulder. In some cases, no cause can be identified; this is referred to as idiopathic AVN.

Symptoms

Pain. The most common symptom of arthritis of the shoulder is pain, which is aggravated by activity and progressively worsens.

  • If the glenohumeral shoulder joint is affected, the pain is centered in the back of the shoulder and may intensify with changes in the weather. Patients complain of an ache deep in the joint.
  • The pain of arthritis in the acromioclavicular (AC) joint is focused on the top of the shoulder. This pain can sometimes radiate or travel to the side of the neck.
  • Someone with rheumatoid arthritis may have pain throughout the shoulder if both the glenohumeral and AC joints are affected.

Limited range of motion. Limited motion is another common symptom. It may become more difficult to lift your arm to comb your hair or reach up to a shelf. You may hear a grinding, clicking, or snapping sound (crepitus) as you move your shoulder.

As the disease progresses, any movement of the shoulder causes pain. Night pain is common and sleeping may be difficult.

Doctor Examination

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder.

During the physical examination, your doctor will look for:

  • Weakness (atrophy) in the muscles
  • Tenderness to touch
  • Extent of passive (assisted) and active (self-directed) range of motion
  • Any signs of injury to the muscles, tendons, and ligaments surrounding the joint
  • Signs of previous injuries
  • Involvement of other joints (an indication of rheumatoid arthritis)
  • Crepitus (a grating sensation inside the joint) with movement
  • Pain when pressure is placed on the joint

X-Rays

X-rays are imaging tests that create detailed pictures of dense structures, like bone. They can help distinguish among various forms of arthritis.

X-rays of an arthritic shoulder will show a narrowing of the joint space, changes in the bone, and the formation of bone spurs (osteophytes).

X-ray of severe osteoarthritis of the glenohumeral joint

This x-ray shows severe osteoarthritis of the glenohumeral joint.
Reproduced with permission from Crosby LA (ed): Total Shoulder Arthoplasty. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 18. 

To confirm the diagnosis, your doctor may inject a local anesthetic into the joint. If it temporarily relieves the pain, the diagnosis of arthritis is supported.

Overhand throwing places extremely high stresses on the shoulder, specifically to the anatomy that keeps the shoulder stable. In throwing athletes, these high stresses are repeated many times and can lead to a wide range of overuse injuries.

Although throwing injuries in the shoulder most commonly occur in baseball pitchers, they can be seen in any athlete who participates in sports that require repetitive overhand motions, such as volleyball, tennis, and some track and field events.

Anatomy

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. Surrounding the outside edge of the glenoid is a rim of strong, fibrous tissue called the labrum. The labrum helps to deepen the socket and stabilize the shoulder joint. It also serves as an attachment point for many of the ligaments of the shoulder, as well as one of the tendons from the biceps muscle in the arm.

Strong connective tissue, called the shoulder capsule, is the ligament system of the shoulder and keeps the head of the upper arm bone centered in the glenoid socket. This tissue covers the shoulder joint and attaches the upper end of the arm bone to the shoulder blade.

The bones of the shoulder

The bones of the shoulder.
Reproduced with permission from J Bernstein, ed: Musculoskeletal Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003.

The ligaments of the shoulder

The ligaments of the shoulder.
Reproduced with permission from J Bernstein, ed: Musculoskeletal Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003.

Your shoulder also relies on strong tendons and muscles to keep your shoulder stable. Some of these muscles are called the rotator cuff. The rotator cuff is made up of four muscles that come together as tendons to form a covering or cuff of tissue around the head of the humerus.

The biceps muscle in the upper arm has two tendons that attach it to the shoulder blade. The long head attaches to the top of the shoulder socket (glenoid). The short head attaches to a bump on the shoulder blade called the coracoid process. These attachments help to center the humeral head in the glenoid socket.

rotator cuff anatomy

This illustration shows the biceps tendons and the four muscles and their tendons that form the rotator cuff and stabilize the shoulder joint.
Reproduced and adapted with permission from The Body Almanac. (c) American Academy of Orthopaedic Surgeons, 2003.

In addition to the ligaments and rotator cuff, muscles in the upper back play an important role in keeping the shoulder stable. These muscles include the trapezius, levator scapulae, rhomboids, and serratus anterior, and they are referred to as the scapular stabilizers. They control the scapula and clavicle bones — called the shoulder girdle — which functions as the foundation for the shoulder joint.

Muscles in the upper back

Muscles in the upper back help to keep the shoulder stable, particularly during overhead motions, like throwing. (Note: this illustration has been drawn in such a way to show the many layers of muscle in the back.)
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Cause

When athletes throw repeatedly at high speed, significant stresses are placed on the anatomical structures that keep the humeral head centered in the glenoid socket.

baseball pitching phases

The phases of pitching a baseball.
Reproduced and adapted with permission from Poss R (ed): Orthopaedic Knowledge Update 3. Rosemont, IL. American Academy of Orthopaedic Surgeons, 1990, pp 293-302.

Of the five phases that make up the pitching motion, the late cocking and follow-through phases place the greatest forces on the shoulder.

  • Late-cocking phase. In order to generate maximum pitch speed, the thrower must bring the arm and hand up and behind the body during the late cocking phase. This arm position of extreme external rotation helps the thrower put speed on the ball, however, it also forces the head of the humerus forward which places significant stress on the ligaments in the front of the shoulder. Over time, the ligaments loosen, resulting in greater external rotation and greater pitching speed, but less shoulder stability.
  • Follow-through phase. During acceleration, the arm rapidly rotates internally. Once the ball is released, follow-through begins and the ligaments and rotator cuff tendons at the back of the shoulder must handle significant stresses to decelerate the arm and control the humeral head.

When one structure — such as the ligament system — becomes weakened due to repetitive stresses, other structures must handle the overload. As a result, a wide range of shoulder injuries can occur in the throwing athlete.

The rotator cuff and labrum are the shoulder structures most vulnerable to throwing injuries.

Common Throwing Injuries In the Shoulder

SLAP Tears (Superior Labrum Anterior to Posterior)

In a SLAP injury, the top (superior) part of the labrum is injured. This top area is also where the long head of the biceps tendon attaches to the labrum. A SLAP tear occurs both in front (anterior) and in back (posterior) of this attachment point.

Typical symptoms are a catching or locking sensation, and pain with certain shoulder movements. Pain deep within the shoulder or with certain arm positions is also common.

shoulder labrum and SLAP tear

(Left) The labrum helps to deepen the shoulder socket.

(Right) This cross-section view of the shoulder socket shows a typical SLAP tear.

Bicep Tendinitis and Tendon Tears

Repetitive throwing can inflame and irritate the upper biceps tendon. This is called biceps tendinitis. Pain in the front of the shoulder and weakness are common symptoms of biceps tendinitis.

Occasionally, the damage to the tendon caused by tendinitis can result in a tear. A torn biceps tendon may cause a sudden, sharp pain in the upper arm. Some people will hear a popping or snapping noise when the tendon tears.

biceps tendinitis

(Left) The biceps tendon helps to keep the head of the humerus centered in the glenoid socket. (Right) Tendinitis causes the tendon to become red and swollen.

Rotator Cuff Tendinitis and Tears

When a muscle or tendon is overworked, it can become inflamed. The rotator cuff is frequently irritated in throwers, resulting in tendinitis.

Early symptoms include pain that radiates from the front of the shoulder to the side of the arm. Pain may be present during throwing, other activities, and at rest. As the problem progresses, pain may occur at night, and the athlete may experience a loss of strength and motion.

Rotator cuff tears often begin by fraying. As the damage worsens, the tendon can tear. When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears in throwing athletes occur in the supraspinatus tendon.

rotator cuff tear

Rotator cuff tendon tears in throwers most often occur within the tendon. In some cases, the tendon can tear away from where it attaches to the humerus.

Problems with the rotator cuff often lead to shoulder bursitis. There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.

Internal Impingement

During the cocking phase of an overhand throw, the rotator cuff tendons at the back of the shoulder can get pinched between the humeral head and the glenoid. This is called internal impingement and may result in a partial tearing of the rotator cuff tendon. Internal impingement may also damage the labrum, causing part of it to peel off from the glenoid.

Internal impingement may be due to some looseness in the structures at the front of the joint, as well as tightness in the back of the shoulder.

The muscles and tendons of the rotator cuff

The muscles and tendons of the rotator cuff.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.
shoulder impingement

This illustration shows the infraspinatus tendon caught between the humeral head and the glenoid.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Instability

Shoulder instability occurs when the head of the humerus slips out of the shoulder socket (dislocation). When the shoulder is loose and moves out of place repeatedly, it is called chronic shoulder instability.

In throwers, instability develops gradually over years from repetitive throwing that stretches the ligaments and creates increased laxity (looseness). If the rotator cuff structures are not able to control the laxity, then the shoulder will slip slightly off-center (subluxation) during the throwing motion.

Pain and loss of throwing velocity will be the initial symptoms, rather than a sensation of the shoulder "slipping out of place." Occasionally, the thrower may feel the arm "go dead." A common term for instability many years ago was "dead arm syndrome."

Glenohumeral Internal Rotation Deficit (GIRD)

As mentioned above, the extreme external rotation required to throw at high speeds typically causes the ligaments at the front of the shoulder to stretch and loosen. A natural and common result is that the soft tissues in the back of the shoulder tighten, leading to loss of internal rotation.

This loss of internal rotation puts throwers at greater risk for labral and rotator cuff tears.

Scapular Rotation Dysfunction (SICK Scapula)

abnormal positioning of the scapula

This photograph shows abnormal positioning of the scapula on the right side.
Reproduced with permission from Kibler B, Sciascia A, Wilkes T: Scapular Dyskinesis and Its Relation to Shoulder Injury. J Am Acad Orthop Surg 2012; 20:364-372.

Proper movement and rotation of the scapula over the chest wall is important during the throwing motion. The scapula (shoulder blade) connects to only one other bone: the clavicle. As a result, the scapula relies on several muscles in the upper back to keep it in position to support healthy shoulder movement.

During throwing, repetitive use of scapular muscles creates changes in the muscles that affect the position of the scapula and increase the risk of shoulder injury.

Scapular rotation dysfunction is characterized by drooping of the affected shoulder. The most common symptom is pain at the front of the shoulder, near the collarbone.

In many throwing athletes with SICK scapula, the chest muscles tighten in response to changes in the upper back muscles. Lifting weights and chest strengthening exercises can aggravate this condition.

Doctor Examination

Medical History and Physical Examination

The medical history portion of the initial doctor visit includes discussion about your general medical health, symptoms and when they first began, and the nature and frequency of athletic participation

During the physicial examination, your doctor will check the range of motion, strength, and stability of your shoulder. He or she may perform specific tests by placing your arm in different positions to reproduce your symptoms.

The results of these tests help the doctor decide if additional testing or imaging of the shoulder is necessary.

Imaging Tests

Your doctor may order tests to confirm your diagnosis and identify any associated problems.

X-rays. This imaging test creates clear pictures of dense structures, like bone. X-rays will show any problems within the bones of your shoulder, such as arthritis or fractures.

Magnetic resonance imaging (MRI). This imaging study shows better images of soft tissues. It may help your doctor identify injuries to the labrum, ligaments, and tendons surrounding your shoulder joint.

Computed tomography (CT) scan. This test combines x-rays with computer technology to produce a very detailed view of the bones in the shoulder area.

Ultrasound. Real time images of muscles, tendons, ligaments, joints, and soft tissues can be produced using ultrasound. This test is typically used to diagnose rotator cuff tears in individuals who are not able to have MRI scans.

What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion in the arm — from scratching your back to throwing the perfect pitch.

Mobility has its price, however. It may lead to increasing problems with instability or impingement of the soft tissue or bony structures in your shoulder, resulting in pain. You may feel pain only when you move your shoulder, or all of the time. The pain may be temporary or it may continue and require medical diagnosis and treatment.

This article explains some of the common causes of shoulder pain, as well as some general treatment options. Your doctor can give you more detailed information about your shoulder pain.

normal shoulder anatomy

This illustration of the shoulder highlights the major components of the joint.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.

Cause

Most shoulder problems fall into four major categories:

  • Tendon inflammation (bursitis or tendinitis) or tendon tear
  • Instability
  • Arthritis
  • Fracture (broken bone)

Other much less common causes of shoulder pain are tumors, infection, and nerve-related problems.

Bursitis

Bursae are small, fluid-filled sacs that are located in joints throughout the body, including the shoulder. They act as cushions between bones and the overlying soft tissues, and help reduce friction between the gliding muscles and the bone.

Sometimes, excessive use of the shoulder leads to inflammation and swelling of the bursa between the rotator cuff and part of the shoulder blade known as the acromion. The result is a condition known as subacromial bursitis.

Bursitis often occurs in association with rotator cuff tendinitis. The many tissues in the shoulder can become inflamed and painful. Many daily activities, such as combing your hair or getting dressed, may become difficult.

Tendinitis

A tendon is a cord that connects muscle to bone. Most tendinitis is a result of inflammation in the tendon.

Generally, tendinitis is one of two types:

  • Acute. Excessive ball throwing or other overhead activities during work or sport can lead to acute tendinitis.
  • Chronic. Degenerative diseases like arthritis or repetitive wear and tear due to age, can lead to chronic tendinitis.

The most commonly affected tendons in the shoulder are the four rotator cuff tendons and one of the biceps tendons. The rotator cuff is made up of four small muscles and their tendons that cover the head of your upper arm bone and keep it in the shoulder socket. Your rotator cuff helps provide shoulder motion and stability.

Learn more: Biceps TendinitisShoulder Impingement/Rotator Cuff Tendinitis

Tendon Tears

Splitting and tearing of tendons may result from acute injury or degenerative changes in the tendons due to advancing age, long-term overuse and wear and tear, or a sudden injury. These tears may be partial or may completely separate the tendon from its attachment to bone. In most cases of complete tears, the tendon is pulled away from its attachment to the bone. Rotator cuff and biceps tendon injuries are among the most common of these injuries.

Learn more: Rotator Cuff TearsBiceps Tendon Tear at the Shoulder

Impingement

Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the underlying soft tissues when the arm is lifted away from the body. As the arm is lifted, the acromion rubs, or "impinges" on, the rotator cuff tendons and bursa. This can lead to bursitis and tendinitis, causing pain and limiting movement.

Learn more: Shoulder Impingement/Rotator Cuff Tendinitis

Instability

Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse.

Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.

Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Recurring dislocations, which may be partial or complete, cause pain and unsteadiness when you raise your arm or move it away from your body. Repeated episodes of subluxations or dislocations lead to an increased risk of developing arthritis in the joint.

Learn more: Chronic Shoulder Instability

Arthritis

Shoulder pain can also result from arthritis. There are many types of arthritis. The most common type of arthritis in the shoulder is osteoarthritis, also known as "wear and tear" arthritis. Symptoms such as swelling, pain, and stiffness, typically begin during middle age. Osteoarthritis develops slowly and the pain it causes worsens over time.

Osteoarthritis, may be related to sports or work injuries or chronic wear and tear. Other types of arthritis can be related to rotator cuff tears, infection, or an inflammation of the joint lining.

Often people will avoid shoulder movements in an attempt to lessen arthritis pain. This sometimes leads to a tightening or stiffening of the soft tissue parts of the joint, resulting in a painful restriction of motion.

Learn more: Arthritis of the Shoulder

Fracture

Fractures are broken bones. Shoulder fractures commonly involve the clavicle (collarbone), humerus (upper arm bone), and scapula (shoulder blade).

Shoulder fractures in older patients are often the result of a fall from standing height. In younger patients, shoulder fractures are often caused by a high energy injury, such as a motor vehicle accident or contact sports injury.

Fractures often cause severe pain, swelling, and bruising about the shoulder.

Doctor's Examination

In the case of an acute injury causing intense pain, seek medical care as soon as possible. If the pain is less severe, it may be safe to rest a few days to see if time will resolve the problem. If symptoms persist, see a doctor.

Your doctor will conduct a thorough evaluation in order to determine the cause of your shoulder pain and provide you with treatment options.

Medical History

The first step in the evaluation is a thorough medical history. Your doctor may ask how and when the pain started, whether it has occurred before and how it was treated, and other questions to help determine both your general health and the possible causes of your shoulder problem. Because most shoulder conditions are aggravated by specific activities, and relieved by specific activities, a medical history can be a valuable tool in finding the source of your pain.

Physical Examination

A comprehensive examination will be required to find the causes of your shoulder pain. Your doctor will look for physical abnormalities, swelling, deformity or muscle weakness, and check for tender areas. He or she will observe your shoulder range of motion and strength.

Tests

Your doctor may order specific tests to help identify the cause of your pain and any other problems.

  • X-rays. These pictures will show any injuries to the bones that make up your shoulder joint.
  • Magnetic resonance imaging (MRI) and ultrasound. These imaging studies create better pictures of soft tissues. MRI may help your doctor identify injuries to the ligaments and tendons surrounding your shoulder joint.
  • Computed tomography (CT) scan. This tool combines x-rays with computer technology to produce a very detailed view of the bones in the shoulder area.
  • Electrical studies. Your doctor may order a test, such as an EMG (electromyogram), to evaluate nerve function.
  • Arthrogram. During this x-ray study, dye is injected into the shoulder to better show the joint and its surrounding muscles and tendons. It may be combined with an MRI.
  • Arthroscopy. In this surgical procedure, your doctor looks inside the joint with a fiber-optic camera. Arthroscopy may show soft tissue injuries that are not apparent from the physical examination, x-rays, and other tests. In addition to helping find the cause of pain, arthroscopy may be used to correct the problem.
Thoracic outlet syndrome is a term used for several different conditions that can occur when nerves and/or blood vessels in the thoracic outlet are compressed or irritated.

The thoracic outlet is the space between your collarbone (clavicle) and your first rib. This narrow passageway is crowded with blood vessels, muscles, and nerves. If the shoulder muscles in your chest are not strong enough to hold the collarbone in place, it can slip down and forward, putting pressure on the nerves and blood vessels that lie under it. This causes a variety of symptoms which together are known as thoracic outlet syndrome.

Anatomy illustration, including the location of the thoracic outlet

The thoracic outlet is the space between your collarbone and first rib.
Reproduced and modified from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010. 

Cause

Thoracic outlet syndrome can result from injury, disease, or a congenital problem, such as an abnormal first rib. It is more common in women than in men, and poor posture and obesity can aggravate the condition.

Psychological changes are often seen in patients with thoracic outlet syndrome. It is not clear whether these changes are a cause or result of the syndrome.

Symptoms

Symptoms may vary, depending on which nerves or blood vessels are compressed. Symptoms from nerve compression are much more common than symptoms from blood vessel compression.

  • Pressure on the nerves (brachial plexus) may cause a vague, aching pain in the neck, shoulder, arm, or hand. It may also cause pain, numbness, or tingling on the inside of the forearm and the fourth and fifth fingers of the hand. Weakness may make your hand clumsy.
  • Pressure on the blood vessels can reduce the flow of blood out of your arm, resulting in swelling and redness of your arm. Less commonly, pressure can reduce the blood flow into your arm and hand, making them feel cool and easily fatigued.
  • Overhead activities are particularly difficult because they worsen both types of compression.
  • There may be a depression in your shoulder, or swelling or discoloration in your arm.
  • Your range of motion may be limited.

Doctor's Examination

Diagnosis of this condition can be more complicated than diagnosis of other more common shoulder conditions because there may be many symptoms to explain. Your doctor's evaluation will include an extensive medical history, physical examination, and diagnostic testing.

Medical History and Physical Examination

Your doctor will ask you about the history of your symptoms, perform a thorough physical examination, and try to reproduce your symptoms by examining your arm and hand in several positions.

Tests

Elevated arm stress test. A test doctors often use to help them identify thoracic outlet syndrome is the elevated arm stress test. Your doctor will have you raise your arms over your head, then open and close your fists for approximately 3 minutes. If this reproduces your symptoms, it is possible that you have thoracic outlet syndrome. However, people who do not have thoracic outlet syndrome may sometimes have a positive test.

Illustration of elevated arm stress test

Elevated arm stress test.
Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010. 

Imaging tests. To better see and evaluate the bones, muscles, tendons, and blood vessels, your doctor may order imaging tests. These may include x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and/or ultrasound.

Additional tests. Your doctor may order special blood circulation tests and nerve conduction tests to help make the diagnosis.

Treatment

If you have a rotator cuff tear and you keep using it despite increasing pain, you may cause further damage. A rotator cuff tear can get larger over time.

Chronic shoulder and arm pain are good reasons to see your doctor. Early treatment can prevent your symptoms from getting worse. It will also get you back to your normal routine that much quicker.

The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear you have.

There is no evidence of better results from surgery performed near the time of injury versus later on. For this reason, many doctors first recommend management of rotator cuff tears with physical therapy and other nonsurgical treatments.

Nonsurgical Treatment

In about 80% of patients, nonsurgical treatment relieves pain and improves function in the shoulder.

Nonsurgical treatment options may include:

  • Rest. Your doctor may suggest rest and limiting overhead activities. He or she may also prescribe a sling to help protect your shoulder and keep it still.
  • Activity modification. Avoid activities that cause shoulder pain.
  • Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.
  • Strengthening exercises and physical therapy. Specific exercises will restore movement and strengthen your shoulder. Your exercise program will include stretches to improve flexibility and range of motion. Strengthening the muscles that support your shoulder can relieve pain and prevent further injury.
  • Steroid injection. If rest, medications, and physical therapy do not relieve your pain, an injection of a local anesthetic and a cortisone preparation may be helpful. Cortisone is a very effective anti-inflammatory medicine; however, it is not effective for all patients.

Cortisone injection in the shoulder

A cortisone injection may relieve painful symptoms.

The chief advantage of nonsurgical treatment is that it avoids the major risks of surgery, such as:

  • Infection
  • Permanent stiffness
  • Anesthesia complications
  • Sometimes lengthy recovery time

The disadvantages of nonsurgical treatment are:

  • Size of tear may increase over time
  • Activities may need to be limited

Surgical Treatment

Your doctor may recommend surgery if your pain does not improve with nonsurgical methods. Continued pain is the main indication for surgery. If you are very active and use your arms for overhead work or sports, your doctor may also suggest surgery.

Other signs that surgery may be a good option for you include:

  • Your symptoms have lasted 6 to 12 months
  • You have a large tear (more than 3 cm) and the quality of the surrounding tissue is good
  • You have significant weakness and loss of function in your shoulder
  • Your tear was caused by a recent, acute injury

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). There are a few options for repairing rotator cuff tears. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

Treatment

Frozen shoulder generally gets better over time, although it may take up to 3 years. The focus of treatment is to control pain and restore motion and strength through physical therapy.

Nonsurgical Treatment

Most people with frozen shoulder improve with relatively simple treatments to control pain and restore motion.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.

Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint.

Hydrodilatation. If your symptoms are not relieved by other nonsurgical methods, your doctor may recommend hydrodilatation. This procedure involves gently injecting a large volume of sterile fluid into the shoulder joint to expand and stretch the shoulder joint capsule. Hydrodilatation is conducted by a radiologist who uses imaging to guide the placement of fluid.

Physical therapy. Specific exercises will help restore motion. These may be done under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before stretching. Below are examples of some of the exercises that might be recommended.

  • External rotation — passive stretch. Stand in a doorway and bend your affected arm's elbow to 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.

External Rotation - Passive Stretch

External Rotation - Passive Stretch
Reproduced and modified from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.
  • Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.

Forward Flexion - Supine Position

Forward Flexion - Supine Position
Reproduced and modified from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.
  • Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.

Crossover Arm Stretch

Crossover Arm Stretch
Reproduced and modified from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Surgical Treatment

If your symptoms are not relieved by therapy and other conservative methods, you and your doctor may discuss surgery. It is important to talk with your doctor about your potential for recovery continuing with simple treatments, and the risks involved with surgery.

Surgery for frozen shoulder is typically offered during "Stage 2: Frozen." The goal of surgery is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.

Manipulation under anesthesia. During this procedure, you are put to sleep. Your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of motion.

Shoulder arthroscopy. In this procedure, your doctor will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.

In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have good outcomes with these procedures.

Arthroscopic photos of shoulder joint

These photos taken through an arthroscope show a normal shoulder joint lining (left) and an inflamed joint lining affected by frozen shoulder.

Recovery. After surgery, physical therapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 6 weeks to 3 months. Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.

Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and improved range of motion. In some cases, however, even after several years, the motion does not return completely and some degree of stiffness remains. Diabetic patients often have some degree of continued shoulder stiffness after surgery.

Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.

Treatment

Your orthopedic surgeon will work carefully to identify any other problems in your shoulder and treat them along with your tendinitis.

Nonsurgical Treatment

Biceps tendinitis is typically first treated with simple methods.

Rest. The first step toward recovery is to avoid activities that cause pain.

Ice. Apply cold packs for 20 minutes at a time, several times a day, to keep swelling down. Do not apply ice directly to the skin.

Nonsteroidal anti-inflammatory medicines. Drugs like ibuprofen and naproxen reduce pain and swelling.

Steroid injections. Steroids such as cortisone are very effective anti-inflammatory medicines. Injecting steroids into the tendon can relieve pain. Your doctor will use these cautiously. In rare circumstances, steroid injections can further weaken the already injured tendon, causing it to tear.

Physical therapy. Specific stretching and strengthening exercises can help restore range of motion and strengthen your shoulder.

Surgical Treatment

If your condition does not improve with nonsurgical treatment, your doctor may offer surgery. Surgery may also be an option if you have other shoulder problems.

Arthroscopic surgery

During arthroscopy, your surgeon inserts the arthroscope and small instruments into your shoulder joint.

Surgery for biceps tendinitis is usually performed arthroscopically. This allows your doctor to assess the condition of the biceps tendon as well as other structures in the shoulder.

During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments.

Repair. Rarely, the biceps tendon can be repaired where it attaches to the shoulder socket (glenoid).

Biceps tenodesis. In some cases, the damaged section of the biceps is removed, and the remaining tendon is reattached to the upper arm bone (humerus). This procedure is called a biceps tenodesis. Removing the painful part of the biceps usually resolves symptoms and restores normal function.

Incision for biceps tenodesis.

A photograph and illustration showing the incision site for a biceps tenodesis.
Chalmers P, Sherman SL, Ghodadra N, Mather RC, Romeo AA: Biceps Tenotomy and Tenodesis, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 25-29.

Depending on your situation, your surgeon may choose to do this procedure arthroscopically or through an open incision.

Biceps tenodesis

In a tenodesis, the remaining tendon is attached to the humerus with a type of screw.
Chalmers P, Sherman SL, Ghodadra N, Mather RC, Romeo AA: Biceps Tenotomy and Tenodesis, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 25-29.

Tenotomy. In severe cases, the long head of the biceps tendon may be so damaged that it is not possible to repair or tenodese it. Your surgeon may simply elect to release the damaged biceps tendon from its attachment. This is called a biceps tenotomy. This option is the least invasive, but may result in a Popeye bulge in the arm.

Surgical complications. Overall, complication rates are low, and your surgeon can correct them without difficulty.

Infection, bleeding, stiffness, and other problems are possible complications. These are more likely to occur in open surgical procedures than in arthroscopic surgeries.

Rehabilitation. After surgery, your doctor will prescribe a rehabilitation plan based on the procedures performed. You may wear a sling for a few weeks to protect the tendon repair.

You should have immediate use of your hand for daily activities — writing, using a computer, eating, or washing. Your doctor may restrict certain activities to allow the repaired tendon to heal. It is important to follow your doctor's directions after surgery to avoid damage to your repaired biceps.

Your doctor will soon start you on therapeutic exercises. Flexibility exercises will improve range of motion in your shoulder. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.

Surgical outcome. Most patients have good results. They typically regain full range of motion and are able to move their arms without pain. People who play very high-demand overhead sports occasionally need to limit these activities after surgery.

Treatment

The goal of treatment is to reduce pain and restore function. In planning your treatment, your doctor will consider your age, activity level, and general health.

Nonsurgical Treatment

In most cases, initial treatment is nonsurgical. Although nonsurgical treatment may take several weeks to months, many patients experience a gradual improvement and return to function.

Rest. Your doctor may suggest rest and activity modification, such as avoiding overhead activities.

Non-steroidal anti-inflammatory medicines. Drugs like ibuprofen and naproxen reduce pain and swelling.

Physical therapy. A physical therapist will initially focus on restoring normal motion to your shoulder. Stretching exercises to improve range of motion are very helpful. If you have difficulty reaching behind your back, you may have developed tightness of the posterior capsule of the shoulder (capsule refers to the inner lining of the shoulder and posterior refers to the back of the shoulder). Specific stretching of the posterior capsule can be very effective in relieving pain in the shoulder.

Once your pain is improving, your therapist can start you on a strengthening program for the rotator cuff muscles.

Steroid injection. If rest, medications, and physical therapy do not relieve your pain, an injection of a local anesthetic and a cortisone preparation may be helpful. Cortisone is a very effective anti-inflammatory medicine. Injecting it into the bursa beneath the acromion can relieve pain.

cortisone injection into the shoulder

A cortisone injection may relieve painful symptoms.

Surgical Treatment

When nonsurgical treatment does not relieve pain, your doctor may recommend surgery.

The goal of surgery is to create more space for the rotator cuff. To do this, your doctor will remove the inflamed portion of the bursa. He or she may also perform an anterior acromioplasty, in which part of the acromion is removed. This is also known as a subacromial decompression. These procedures can be performed using either an arthroscopic or open technique.

Arthroscopic technique. In arthroscopy, thin surgical instruments are inserted into two or three small puncture wounds around your shoulder. Your doctor examines your shoulder through a fiberoptic scope connected to a television camera. He or she guides the small instruments using a video monitor, and removes bone and soft tissue. In most cases, the front edge of the acromion is removed along with some of the bursal tissue.

Your surgeon may also treat other conditions present in the shoulder at the time of surgery. These can include arthritis between the clavicle (collarbone) and the acromion (acromioclavicular arthritis), inflammation of the biceps tendon (biceps tendonitis), or a partial rotator cuff tear.

Open surgical technique. In open surgery, your doctor will make a small incision in the front of your shoulder. This allows your doctor to see the acromion and rotator cuff directly.

Rehabilitation. After surgery, your arm may be placed in a sling for a short period of time. This allows for early healing. As soon as your comfort allows, your doctor will remove the sling to begin exercise and use of the arm.

Your doctor will provide a rehabilitation program based on your needs and the findings at surgery. This will include exercises to regain range of motion of the shoulder and strength of the arm. It typically takes 2 to 4 months to achieve complete relief of pain, but it may take up to a year.

Treatment

Nonsurgical Treatment

In most cases, the initial treatment for a SLAP injury is nonsurgical.

Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.

Physical therapy. Specific exercises will restore movement and strengthen your shoulder. Flexibility and range-of-motion exercises will include stretching the shoulder capsule, which is the strong connective tissue that surrounds the joint. Exercises to strengthen the muscles that support your shoulder can relieve pain and prevent further injury. This exercise program can be continued anywhere from 3 to 6 months, and usually involves working with a qualified physical therapist.

Surgical Treatment

Your doctor may recommend surgery if your pain does not improve with nonsurgical methods.

Arthroscopy. The surgical technique most commonly used for treating a SLAP injury is arthroscopy. During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays pictures on a video monitor, and your surgeon uses these images to guide miniature surgical instruments.

shoulder arthroscopy

During arthroscopy, your surgeon inserts the arthroscope and small instruments into your shoulder joint.

Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.

arthroscopic images of SLAP tear and repair

(Left) An arthroscopic view of a healthy labrum. (Center) In this image, the surgeon uses a small instrument to evaluate a large SLAP tear. (Right) The labrum has been reattached with sutures.

Treatment options.There are several different types of SLAP tears. Your surgeon will determine how best to treat your SLAP injury once he or she sees it fully during arthroscopic surgery. This may require simply removing the torn part of the labrum, or reattaching the torn part using sutures. Some SLAP injuries do not require repair with sutures; instead, the biceps tendon attachment is released to relieve painful symptoms.

Your surgeon will decide the best treatment option based upon the type of tear you have, as well as your age, activity level, and the presence of any other injuries seen during the surgery.

Complications. Most patients do not experience complications from shoulder arthroscopy. As with any surgery, however, there are some risks. These are usually minor and treatable. Potential problems with arthroscopy include infection, excessive bleeding, blood clots, shoulder stiffness, and damage to blood vessels or nerves.

Your surgeon will discuss the possible complications with you before your operation.

Rehabilitation. At first, your shoulder needs to be protected while the repaired structures heal. To keep your arm from moving, you will most likely use a sling for 2 to 6 weeks after surgery. How long you require a sling depends upon the severity of your injury and the complexity of your surgery.

protective sling

Wearing a sling will protect your shoulder after surgery.

Once the initial pain and swelling has settled down, your doctor will start you on a physical therapy program that is tailored specifically to you and your injury.

In general, a therapy program focuses first on flexibility. Gentle stretches will improve your range of motion and prevent stiffness in your shoulder. As healing progresses, exercises to strengthen the shoulder muscles and the rotator cuff will gradually be added to your program. This typically occurs 6 to 10 weeks after surgery.

Your doctor will discuss with you when it is safe to return to sports activity. In general, throwing athletes can return to early interval throwing 3 to 4 months after surgery.

Outcomes

The majority of patients report improved shoulder strength and less pain after surgery for a SLAP tear.

Because patients have varied health conditions, complete recovery time is different for everyone.

In cases of complicated injuries and repairs, full recovery may take several months. Although it can be a slow process, following your surgeon's guidelines and rehabilitation plan is vital to a successful outcome.

Treatment

Chronic shoulder instability is often first treated with nonsurgical options. If these options do not relieve the pain and instability, surgery may be needed.

Nonsurgical Treatment

Your doctor will develop a treatment plan to relieve your symptoms. It often takes several months of nonsurgical treatment before you can tell how well it is working. Nonsurgical treatment typically includes:

Activity modification. You must make some changes in your lifestyle and avoid activities that aggravate your symptoms.

Non-steroidal anti-inflammatory medication. Drugs like aspirin and ibuprofen reduce pain and swelling.

Physical therapy. Strengthening shoulder muscles and working on shoulder control can increase stability. Your therapist will design a home exercise program for your shoulder.

Surgical Treatment

Surgery is often necessary to repair torn or stretched ligaments so that they are better able to hold the shoulder joint in place.

Surgical repair of a Bankart lesion

Bankart lesions can be surgically repaired. Sutures and anchors are used to reattach the ligament to the bone.

Arthroscopy. Soft tissues in the shoulder can be repaired using tiny instruments and small incisions. This is a same-day or outpatient procedure. Arthroscopy is a minimally invasive surgery. Your surgeon will look inside the shoulder with a tiny camera and perform the surgery with special pencil-thin instruments.

Open Surgery. Some patients may need an open surgical procedure. This involves making a larger incision over the shoulder and performing the repair under direct visualization.

Rehabilitation. After surgery, your shoulder may be immobilized temporarily with a sling.

When the sling is removed, exercises to rehabilitate the ligaments will be started. These will improve the range of motion in your shoulder and prevent scarring as the ligaments heal. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.

Be sure to follow your doctor's treatment plan. Although it is a slow process, your commitment to physical therapy is the most important factor in returning to all the activities you enjoy.

Treatment

shoulder stretch

Physical therapy exercises will focus on strengthening and stretching the muscles around the shoulder.

Nonsurgical Treatment

In almost all cases, the symptoms of scapular dyskinesis will improve with nonsurgical treatment.

Nonsurgical treatment may include:

Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen and naproxen, can help relieve pain and swelling.

Physical therapy. Your doctor or physical therapist will provide an exercise program that targets the specific causes of your dyskinesis. Physical therapy usually focuses on:

  • Strengthening the muscles that stabilize and move the scapula, and
  • Stretching the muscles that are tight and limiting scapular motion

Surgical Treatment

Most patients who have general dyskinesis due to muscle weakness or tightness do not need surgery.

However, if your dyskinesis is being caused by an injury to your shoulder joint, your doctor may perform a procedure to repair or reconstruct the injured tissues. This will be followed by rehabilitation to restore the scapula's normal motion.

Long-Term Outcomes

Once the causes for your dyskinesis have been addressed and normal scapular position and motion are restored, your doctor may recommend a maintenance conditioning program of flexibility and strengthening. This is especially important if your job or recreational activities involve vigorous or repetitive shoulder and arm movements. These exercises should be done 3 times a week or as recommended by your doctor.

Treatment

Nonsurgical Treatment

As with other arthritic conditions, initial treatment of arthritis of the shoulder is nonsurgical. Your doctor may recommend the following treatment options:

  • Rest or change in activities to avoid provoking pain. You may need to change the way you move your arm to do things.
  • Physical therapy exercises may improve the range of motion in your shoulder.
  • Nonsteroidal anti-inflammatory medications (NSAIDs), such as aspirin or ibuprofen, may reduce inflammation and pain. These medications can irritate the stomach lining and cause internal bleeding. They should be taken with food. Consult with your doctor before taking over-the-counter NSAIDs if you have a history of ulcers or are taking blood thinning medication.
  • Corticosteroid injections in the shoulder can dramatically reduce the inflammation and pain. However, the effect is often temporary.
  • Moist heat
  • Ice your shoulder for 20 to 30 minutes two or three times a day to reduce inflammation and ease pain.
  • If you have rheumatoid arthritis, your doctor may prescribe a disease-modifying drug, such as methotrexate.
  • Dietary supplements, such as glucosamine and chondroitin sulfate may help relieve pain. (Note: There is little scientific evidence to support the use of glucosamine and chondroitin sulfate to treat arthritis. In addition, the U.S. Food and Drug Administration does not test dietary supplements. These compounds may cause negative interactions with other medications. Always consult your doctor before taking dietary supplements.)

Surgical Treatment

Your doctor may consider surgery if your pain causes disability and is not relieved with nonsurgical options.

Arthroscopy. Cases of mild glenohumeral arthritis may be treated with arthroscopy, During arthroscopy, the surgeon inserts a small camera, called an arthroscope, into the shoulder joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.

During the procedure, your surgeon can debride (clean out) the inside of the joint. Although the procedure provides pain relief, it will not eliminate the arthritis from the joint. If the arthritis progresses, further surgery may be needed in the future.

Shoulder joint replacement (arthroplasty). Advanced arthritis of the glenohumeral joint can be treated with shoulder replacement surgery, in which the damaged parts of the shoulder are removed and replaced with artificial components, called a prosthesis.

Replacement surgery options include:

  • Hemiarthroplasty. Just the head of the humerus is replaced by an artificial component.
  • Total shoulder arthroplasty. Both the head of the humerus and the glenoid are replaced. A plastic "cup" is fitted into the glenoid, and a metal "ball" is attached to the top of the humerus.
  • Reverse total shoulder arthroplasty. In a reverse total shoulder replacement, the socket and metal ball are opposite a conventional total shoulder arthroplasty. The metal ball is fixed to the glenoid and the plastic cup is fixed to the upper end of the humerus. A reverse total shoulder replacement works better for people with cuff tear arthropathy because it relies on different muscles — not the rotator cuff — to move the arm.
Illustrations of total shoulder replacement and reverse total shoulder replacement

(Left) A conventional total shoulder replacement (arthroplasty) mimics the normal anatomy of the shoulder. (Right) In a reverse total shoulder replacement, the plastic cup inserts on the humerus, and the metal ball screws into the shoulder socket.

Resection arthroplasty. The most common surgical procedure used to treat arthritis of the acromioclavicular joint is a resection arthroplasty. Your surgeon may choose to do this arthroscopically.

In this procedure, a small amount of bone from the end of the collarbone is removed, leaving a space that gradually fills in with scar tissue.

Recovery. Surgical treatment of arthritis of the shoulder is generally very effective in reducing pain and restoring motion. Recovery time and rehabilitation plans depend upon the type of surgery performed.

Pain management. After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Complications. As with all surgeries, there are some risks and possible complications. Potential problems after shoulder surgery include infection, excessive bleeding, blood clots, and damage to blood vessels or nerves.

Your surgeon will discuss the possible complications with you before your operation.

Future Developments

Research is being conducted on shoulder arthritis and its treatment.

  • In many cases, it is not known why some people develop arthritis and others do not. Research is being done to uncover some of the causes of arthritis of the shoulder.
  • Joint lubricants, which are currently being used for treatment of knee arthritis, are being studied in the shoulder.
  • New medications to treat rheumatoid arthritis are being investigated.
  • Much research is being done on shoulder joint replacement surgery, including the development of different joint prosthesis designs.
  • The use of biologic materials to resurface an arthritic shoulder is also being studied. Biologic materials are tissue grafts that promote growth of new tissue in the body and foster healing.

SOURCE: Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; January 2013. Based on data from the National Health Interview Survey, 2008-2011; U.S. Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics.

Treatment

Left untreated, throwing injuries in the shoulder can become complicated conditions.

Nonsurgical Treatment

In many cases, the initial treatment for a throwing injury in the shoulder is nonsurgical. Treatment options may include:

  • Activity modification. Your doctor may first recommend simply changing your daily routine and avoiding activities that cause symptoms.
  • Ice. Applying icepacks to the shoulder can reduce any swelling.
  • Anti-inflammatory medication. Drugs like ibuprofen and naproxen can relieve pain and inflammation. They can also be provided in prescription-strength form.
  • Physical therapy. In order to improve the range of motion in your shoulder and strengthen the muscles that support the joint, your doctor may recommend specific exercises. Physical therapy can focus on muscles and ligament tightness in the back of the shoulder and help to strengthen the structures in the front of the shoulder. This can relieve some stress on any injured structures, such as the labrum or rotator cuff tendon.
  • Change of position. Throwing mechanics can be evaluated in order to correct body positioning that puts excessive stress on injured shoulder structures. Although a change of position or even a change in sport can eliminate repetitive stresses on the shoulder and provide lasting relief, this is often undesirable, especially in high level athletes.
  • Cortisone injection— If rest, medications, and physical therapy do not relieve your pain, an injection of a local anesthetic and a cortisone preparation may be helpful. Cortisone is a very effective anti-inflammatory medicine. Injecting it into the bursa beneath the acromion can provide long-term pain relief for tears or other structural damage.

cortisone injection in shoulder

A cortisone injection may relieve painful symptoms.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

 

Your doctor may recommend surgery based on your history, physical examination, and imaging studies, or if your symptoms are not relieved by nonsurgical treatment.

The type of surgery performed will depend on several factors, such as your injury, age, and anatomy. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

Arthroscopy. Most throwing injuries can be treated with arthroscopic surgery. During arthroscopy, the surgeon inserts a small camera, called an arthroscope, into the shoulder joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.

During arthroscopy, your doctor can repair damage to soft tissues, such as the labrum, ligaments, or rotator cuff.

shoulder arthroscopy

During arthroscopy, your surgeon inserts the arthroscope and small instruments into your shoulder joint.

Open surgery. A traditional open surgical incision (several centimeters long) is often required if the injury is large or complex.

Rehabilitation. After surgery, the repair needs to be protected while the injury heals. To keep your arm from moving, you will most likely use a sling for for a short period of time. How long you require a sling depends upon the severity of your injury.

As soon as your comfort allows, your doctor may remove the sling to begin a physical therapy program.

In general, a therapy program focuses first on flexibility. Gentle stretches will improve your range of motion and prevent stiffness in your shoulder. As healing progresses, exercises to strengthen the shoulder muscles and the rotator cuff will gradually be added to your program. This typically occurs 4 to 6 weeks after surgery.

Your doctor will discuss with you when it is safe to return to sports activity. If your goal is to return to overhead sports activities, your doctor or physical therapist will direct a therapy program that includes a gradual return to throwing.

It typically takes 2 to 4 months to achieve complete relief of pain, but it may take up to a year to return to your sports activities.

Prevention

In recent years, there has been a great deal of attention on preventing throwing injuries of the shoulder.

Proper conditioning, technique, and recovery time can help to prevent throwing injuries. Throwers should strive to maintain good shoulder girdle function with proper stretches and upper back and torso strengthening.

In the case of younger athletes, pitching guidelines regarding number of pitches per game and week, as well as type of pitches thrown, have been developed to protect children from injury.

Treatment

Activity Changes

Treatment generally involves rest, altering your activities, and physical therapy to help you improve shoulder strength and flexibility. Common sense solutions such as avoiding overexertion or overdoing activities in which you normally do not participate can help to prevent shoulder pain.

Medications

Your doctor may prescribe medication to reduce inflammation and pain. If medication is prescribed to relieve pain, it should be taken only as directed. Your doctor may also recommend injections of numbing medicines or steroids to relieve pain.

Surgery

Surgery may be required to resolve some shoulder problems. However, the large majority of patients with shoulder pain will respond to simple treatment methods such as altering activities, rest, exercise, and medication.

Certain types of shoulder problems, such as recurring dislocations and some rotator cuff tears, may not benefit from exercise. In these cases, surgery may be recommended fairly early.

Surgery can involve arthroscopy to remove scar tissue or repair torn tissues, or traditional open procedures for larger reconstructions or shoulder replacement.

Treatment

Treatment for thoracic outlet syndrome usually does not include surgery.

Nonsurgical Treatment

Physical therapy. Exercises can help strengthen the muscles surrounding the shoulder so that they are better able to support the collarbone. Postural exercises can help you stand and sit straighter, which lessens the pressure on the nerves and blood vessels.

Nonsteroidal anti-inflammatory medications. Drugs like naproxen and ibuprofen can ease the pain and reduce swelling.

Weight loss. If you are overweight, your doctor may recommend that you begin a weight loss program. Being overweight can stress the shoulder muscles that support your collarbone.

Lifestyle changes. You may need to change your workstation layout, avoid strenuous activities, and even modify everyday activities that aggravate your symptoms.

Surgical Treatment

If nonsurgical treatment does not relieve your symptoms, your doctor may offer surgery.

Surgery for thoracic outlet syndrome may involve removing a portion of an abnormal first rib, releasing a muscle that joins the neck and chest, or sometimes both.

Prevention

If you have symptoms of thoracic outlet syndrome, avoid carrying heavy bags over your shoulder because this depresses the collarbone and increases pressure on the important structures in the thoracic outlet.

You should also do some simple exercises to keep your shoulder muscles strong. Here are four that you can try—10 repetitions of each exercise should be done twice daily:

  • Corner Stretch - Stand in a corner (about 1 foot from the corner) with your hands at shoulder height, one on each wall. Lean into the corner until you feel a gentle stretch across your chest. Hold for 5 seconds.
  • Neck Stretch - Put your left hand on your head, and your right hand behind your back. Pull your head toward your left shoulder until you feel a gentle stretch on the right side of your neck. Hold for 5 seconds. Switch hand positions and repeat the exercise in the opposite direction.
  • Shoulder Rolls - Shrug your shoulders up, back, and then down in a circular motion.
  • Neck Retraction - Pull your head straight back, keeping your jaw level. Hold for 5 seconds.

As with all exercise programs, if any of these movements cause pain, stop immediately.

corner stretch for thoracic outlet syndrome

Corner stretch. You should feel this stretch in the front of your shoulder, your chest, and upper back.