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How is shoulder pain diagnosed?

As with any medical issue, a shoulder problem is generally diagnosed using a three-part process;

Medical history – the patient tells the doctor about any injury or other condition that might be causing the pain. Time line of the shoulder pain. Exacerbating and remitting factors…How does the pain get worse? How does the pain get better? This will give many clues to the physician about what might be causing this.

Keep in mind the differential diagnosis for shoulder pain is long. Many different things can cause it. The second part of the process is physical examination. The doctor examines the patient to feel for injury and discover the limits of movement, location of pain, extent of joint instability. Many times this will be enough and medical history and physical exams do a very accurate diagnosis about what exactly is going on with the shoulder. If the doctor still has more questions, the doctor may order more imaging tests to help make a specific diagnosis.

A standard x-ray in which low level radiation is passed through the body to produce a picture called a radiograph. This type of x-ray is useful for diagnosing fractures or other problems with the bones. Soft tissue such as muscles and tendons do not show up on x-rays. Ultrasound is a different non-evasive technique in which ultrasound waves can be used to visualize some structures in the shoulder particularly the ones closer to the surface. Many times the problems with the rotator cuff are due to some of the structures located close to the surface and therefore is very helpful in making this diagnosis.

Finally, a frequently used imaging technique is the magnetic residence imaging (MRI) which is another non-evasive procedure in which a machine with a strong magnet passes a force through the body to produce a series of cross-sectional images of the shoulder. This allows the doctor to look at the soft tissues and help make a more definitive diagnosis. Most certainly before a surgery is proposed, an MRI will likely be available for the doctor to review to plan surgery.

At its very basic level, rotator cuff tendonitis is a muscle imbalance problem. Scientific research states that 90% of shoulder pain has at least something to do with the rotator cuff. To understand what is going on there, you need to understand the role of the rotator cuff.

The rotator cuff acts as a counterbalance to the larger muscles that are trying to move the arm. If not for the rotator cuff, as the deltoid, trapezius, or pectoralis muscles move the arm, the head of the round ball on top of the arm bone would slip out of the very shallow dish that it is in. This is called the glenoid fossa.

All movements require a very complex system of essentially muscles moving in two different directions to keep this big ball sitting on a tiny dish. The one thing you notice about shoulder pain as a practicing physician is it can happen to people who are in bad shape, people who are in good shape – it just happens.

One thing that we often see in our office is what we call a “high-riding shoulder”. This process is the result of a relative weakening of the floor muscles of the rotator cuff when compared to the overlying muscles of the deltoid, pectoralis, and trapezius muscle groups.

The muscles involved lead to an upward migration of the humerus and the humeral head (the big ball), that compresses the supraspinatus, one of the muscles of the rotator cuff up against the roof of the shoulder, which is very hard, and this compromises its blood flow, leading to significant stress and disease within the rotator cuff.

This process occurs to many people on a daily basis. The main reason for this problem is that people continue this muscle imbalance. There are great exercises for the larger muscle groups and for the small muscle groups as well. However, the small muscle exercise groups are not as well-known, but are actually very easy to do.

I think when people come to understand that it is a muscle imbalance problem more than anything is when we will start to make some inroads into solving the nearly universal problem of shoulder pain and rotator cuff tendonitis.

Best Way To Help Prevent Shoulder Injuries

One of the most gratifying and mind-expanding aspects of this project is in talking with other health providers, health professionals, out of the traditional medicine realm. I have talked with probably 500 chiropractors and have spoken with dozens of athletic trainers, and one thing I have really come to appreciate about their input is that it is coming from a framework of wellness. I am a traditional medical doctor, and we fix problems when they arise. We do give some, what I would call, lip service to wellness, but it is not our outlook, frankly. We are trained to fix disease, which is a fantastic and great talent to have. Coming to learn about wellness and keeping people well is something that has given me insight into a powerful tool.

With that in mind, I would like to think about the shoulder and the muscles of the shoulder and how people might be able to get stronger and remain more functional with their shoulder by exercising in the right way. One thing that I see a lot of people do is basically get stronger, get bigger in the upper chest and the back. This is, of course, great. I think that muscle mass is, generally speaking, good for your health. I think there is overall a deficiency of muscles in the population, particularly the aging population, but even when we are talking about young and healthy people, I am definitely supportive of getting stronger. One problem I see is that people are trying to get stronger without a great understanding of muscle balance.

In particular in how it relates to the shoulder, muscle balance is critical. Keep in mind that the muscle balance will allow the shoulder to function. The shoulder is a remarkably complex joint with a 270° range of motion. When you move your shoulder, you need complex interactions between muscle groups; some muscles moving your arm and the other muscles working in the opposite direction trying to keep basically the ball in the socket. What I see a lot of people doing is essentially working on the overlying muscles including the pectoralis, the deltoid, and the trapezius without appropriately exercising the rotator cuff. Let’s think about this. It’s like building on sand. If you do not have a sound underpinning for your shoulder in the form of a very strong rotator cuff, several things are going to happen.

Firstly, the overlying muscles are going to outstrip the counterforce of a relatively weak rotator cuff.

Secondly, you are going to have pain because the easiest way to think about it is that the shoulder is going to start to slip out of its joint because the rotator cuff dynamically stabilizes the ball on the tee, if you will.

Thirdly, your shoulder won’t get as strong. To get a stronger shoulder, and all the muscles of the shoulder girdle, you should first have a strong rotator cuff. How does one get a strong rotator cuff? I think this is trickier than most people think. I think that people are doing the wrong exercises that engage the wrong muscles. I would take a look at the RotatoReliever and consider that as the gold standard, the best form of dynamic stabilization. If you want to get really strong in the upper body, start with a strong base. Start with a strong rotator cuff and then you will be able to bulk up much easier, much faster, and with much less pain.

Understanding the Causes of Shoulder Pain

The shoulder is easily injured because the ball of the upper arm is larger than the shoulder socket that holds it. To remain stable, the shoulder must be anchored by its muscles, tendons, and ligaments.

Shoulder pain may be localized or may be felt in areas around the shoulder or down the arm. Although the shoulder is easily injured during sporting activities and physical activity, the primary causes of shoulder problems may be the natural age-related degeneration of the surrounding soft tissues such as those found in the rotator cuff. The incidence of rotator cuff problems rises dramatically as a function of age and is generally seen among individuals who are more than 60 years old. Often, the dominant and non-dominant arm will be affected to a similar degree. Overuse of the shoulder can lead to more rapid age-related deterioration of the shoulder muscles, tendons, and ligaments.

Brace To Treat Rotator Cuff Tendonitis

Given that 90 + percent of shoulder pain is due to rotator cuff tendonitis it is worthwhile to consider those therapies set focusing on rotator cuff tendonitis. A recent study presented at The American College of Sports Medicine showed impressive results with using a nighttime brace to treat rotator cuff and tendonitis.

The study started with all patients receiving traditional care, which included hands on anti-inflammatory medications and physical therapy. However, half the patients then received an additional treatment of a nighttime brace that they wore for one month. The study was blinded. The results showed remarkable 100% improvement in those people who used the brace on a regular basis.

The patients did not need to wear the brace for more than three weeks. Only 50% of those in the group not using the brace got better over a one month period. This small but powerful study did reach statistical significance. This brace does represent new and exciting therapy to deal with this incredibly common problem of rotator cuff tendonitis.

Shoulder Steroid Injections

Steroid injection represents a useful tool in the management of chronic shoulder pain. The doctor will typically use a lateral approach to inject the subchromial space, particularly with rotator cuff problems. At different times, the doctor may use an anterior approach or a posterior approach to actually put steroid in the shoulder joint. This would be less common. Ideally steroid should be thought of as providing temporary relief and when used appropriately, and when used in conjunction with physical therapy, shoulder steroid injections will almost act as a band-aid. They’ll give people a temporary period of time where the physical therapy can really start working. This is primarily because the steroid is a very effective anti-inflammatory, and for a short period of time will relieve pain.

Steroids have multiple actions. They act as anti-inflammatory, and therefore, frequently will reduce pain in an area with inflammation. Also and essentially a side effect is that they will cause destruction of protein. Certainly steroids do have a complication and you can get too many steroid injections into a shoulder. There has been research to suggest that if someone were to get more than 3 steroid injections into the shoulder that the subsequent repair of the rotator cuff that may need to happen is more difficult. Shoulder steroid injections are a beneficial tool when used appropriately. It is again recommended that it is used in conjunction with physical therapy. The doctor will perform the steroid injection under sterile conditions as to not introduce germs into the joint space. Steroids are actually produced by the body in small amounts.

The steroids injected into the joint are generally safe and do not have systemic side affects unlike steroid pills. Steroid injections typically will not rise up blood sugars to a significant degree. Possible side affects/adverse affects of shoulder steroid injection would include an infection, bleeding into the joint if the needle goes through a significant blood vessel, skin can ulcerate if too much steroid is injected closely underneath the skin. Also there can be fat trephine under the skin and essentially leaving a dent in the contour of where the steroid was injected. Additionally, there can be tendon rupture and overall weakening of the structure receiving the steroid.

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Helping Shoulder Pain With Ice

Honestly, patients think I am blowing them off when I tell them ice helps and they should ice twice daily for the joints that are hurting.

Why does it work? Well at some point in the inflammatory process starts working against in the joint. Inflammation is the response to damage and initially is part of the healing process. Unfortunately the inflammatory process can become a bit of a train out of control. It is in your bests interests shut down the inflammatory process in your joints.

Ice shuts down inflammation. Inflammation is a series of chemical reactions involving many different enzymes and cells. This mesh work of inflammation requires a certain temperature to work well. Ice lowers the temperature and decreased the speed of chemical reactions and overall decreases the amount of inflammation.

A key is to do it. Generally making it easier is a good idea. I love the products at Coldone.com very convenient and keep your joints plenty cold.

Surgery for Shoulder Arthritis

Shoulder arthritis is an affliction affecting millions of Americans. Frequently we hear about knee replacement, hip replacement. More rarely is it suggested that patients undergo shoulder replacement. Primarily there is a lack of expertise that causes this. Also it has been cited that shoulder surgery has more risk. A recent study by the led by Doctor Edward McFarland, MD, director of the division of adult orthopedics at Johns Hopkins Hospital analyzed a series of hip replacement versus knee replacement versus shoulder replacement procedure. After looking at how the patients fair, researchers concluded that comparatively total shoulder replacement was just as safe and effective as other types of joint replacement.

According to a nationwide 2003 Medicare figure, 6700 people had shoulder joints replaced that year compared with 107,000 hip replacements and nearly 200,000 knee replacements. It is interesting that patients in the study who had shoulder surgery, had far fewer in hospital post-surgical complications compared to those who had their hips and knees replaced. This includes a risk of death. Additionally, despite the fewer numbers, the shoulder replacement surgery also called arthroplasty was also less expensive according to the researcher. Shoulder replacements total cost on average were just over $10,000 where hip replacement was $15,000 and knee replacement was nearly $15,000.

The conclusion of this article is that shoulder replacement surgery should be performed more frequently noting that 99% of people who have had shoulder replacement for arthritis get pain relief and say they wish they had done it sooner. The study indicates there may be little reason to wait.

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There is an interesting study that came out of Henry Ford Hospital in Detroit that used new technology to compare the shoulders of 22 patients. These patients had arthroscopic surgical repair of tendons and rotator cuff tears in one shoulder, and the study compared the injured shoulder to the other, non-injured shoulder. Interestingly, they found that long-term shoulder function, in particular shoulder strength and joint stability, are not fully restored after surgical repair, and there are significant differences when compared to the opposite shoulder, and that the differences persist over time.

This is interesting. Orthopedic surgeons will frequently cite how their patient satisfaction after a rotator cuff repair is high, in spite of the prolonged six-month recovery from the surgery. Of course this is in contrast to the recent research that shows these shoulders appear to be permanently not as strong, and in general not as functional, as they were at baseline. This needs to be looked at, particularly in comparison to some of the research suggesting that physical therapy in an organized, specific fashion or daily therapy at home with something such as the RotatoReliever, may be just as good if not better than long-term outcomes from surgery.

I think that given the amount of pain, suffering, and generally disabling aspect of this surgery for a period of time, typically about four to six months, that we need to have high standards on what the results of the surgery are. Shoulder pain remains common in 40 million Americans suffering from it. Many of these people have rotator cuff tears, and we need to do further research to find out how we can best serve them.

In today’s challenging economic environment, many people have to foot the bill for some of their own costs of procedures and treatment. Many times it’s difficult to follow the dollar in medicine. Recently some researchers have put together an interesting cost analysis of rotator cuff repair, and I think it’s important for patients to know about the actual cost of the surgery prior to going in. Keep in mind that a cost of the surgery in this study which was performed through Columbia University in New York did analyze the cost of the surgery and all the associated costs and then the six month follow-up costs that included some rehab. Keep in mind it did not include any of the doctor visits and attend said physical therapy prior to the surgery. In any case, the total cost of a rotator cuff surgery averaged $12,464, a figure driven largely by physician’s fees which were on average $2,392, operating room costs average $3001, and a total per diem hospital cost average $2,122. The remainder of the costs were largely physical therapy. Again, sometimes the cost of medicine is difficult for people to track down. The other costs that this study did not take into account is wages lost. Keep in mind every, there of course, the hospital days, there’s a few days after the surgery where most people are unable to go to work, and there’s all the missed time from work in regards to the physical therapy appointments.