Shoulder

Adhesive capsulitis, commonly called frozen shoulder, involves pain, loss of motion, inflammation, and adhesions or scarring of the capsule that surrounds the shoulder joint. Frozen shoulder may occur following an injury or immobilization of the shoulder joint, such as after surgery. The bone, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule becomes inflamed, thickens and tightens around the shoulder joint, restricting its movement and causing pain. This pain often leads to avoiding movement of the arm. This lack of movement leads to stiffness, and then to even less motion. Over time, it will become difficult or painful to perform movements like reaching over head or behind your back.

A shoulder separation is an injury to the acromioclavicular (AC) joint on the top of the shoulder. A shoulder separation occurs where the clavicle and the top of the scapula (acromion) come together. AC separation results in moderate to severe pain at the site of the injury, swelling, inflammation, and deformity at the joint. A loss of function, due to the pain and instability, often occurs with high grade separations.

The two most common causes of a shoulder separation are either a direct blow to the shoulder (often seen in football, rugby, or hockey), or a fall on to an outstretched hand (commonly seen after falling off a bicycle or horse). These forces injure the ligaments that surround and stabilize the AC joint. If the force is severe enough, the ligaments attaching to the underside of the clavicle are torn. This causes the “separation” of the clavicle from the scapula. In the case of torn ligaments, surgical repair may be required. In less severe cases, or following surgical repair, the shoulder muscles need to be specifically strengthened so that they can help to prevent future separation.

An AC joint separation injury can range from mild to severe:

• Grade 1 – A mild shoulder separation involves a sprain of the AC ligament that does not move the collarbone and looks normal on X-rays.
• Grade 2 – A more serious injury tears the AC ligament and sprains or slightly tears the coracoclavicular (CC) ligament, putting the collarbone out of alignment to some extent.
• Grade 3 – The most severe shoulder separation completely tears both the AC and CC ligaments and puts the AC joint noticeably out of position.

The head of your upper arm bone, the humerus, 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. Labral tears can occur from acute trauma, such as falling on an outstretched arm, sudden pull or violent overhead reach, or from repetitive shoulder motions, such as throwing sports or weightlifting.

The symptoms of a labral tear are very similar to other shoulder injuries and include: pain, usually with overhead activities; catching, locking, popping, or grinding; occasional night pain or pain with daily activities; a sense of instability in the shoulder; decreased range of motion; and loss of strength. Although surgery may be necessary, it is often recommended that conservative treatment to reduce inflammation and strengthen the rotator cuff muscles should be attempted first in order to manage symptoms and stabilize the joint.

Thoracic Outlet Syndrome (TOS) occurs when the nerves and vascular structures from the neck are compressed as they run through the shoulder into the upper arm. Many times, there may also be compression in the spine or further down the shoulder, elbow, arm or hand. Symptoms may include numbness, tingling, weakness, pain or blanching of any of the fingers.
The thoracic outlet is the space between your clavicle (collarbone) and your first rib. If the shoulder muscles in your chest are not strong enough to hold the clavicle in place, it can slip down and forward, putting pressure on the nerves and blood vessels that lie under it. Additionally, if certain muscles in the neck or chest are tight they can also compress the nerves going down the arm. TOS can result from injury, disease, or a congenital problem, such as an abnormal first rib. Poor posture can aggravate the condition.

Bicipital tendonitis, also called biceps tendonitis, is inflammation in the main tendon that attaches the top of the biceps muscle to the shoulder. It often causes a deep ache directly in the front and top of the shoulder. The ache may spread down into the main part of the biceps muscle and pain usually increases with overhead activities. The most common cause is overuse from certain types of work or sports activities. Biceps tendonitis may develop gradually from the effects of wear and tear, or it can happen suddenly from a direct injury. The tendon may also become inflamed in response to other problems in the shoulder, such as rotator cuff tears, impingement, or instability.

Bursitis is caused by inflammation of a bursa, a small fluid-filled sac that functions as a gliding surface to reduce friction between muscles, tendons, and joints during movement. There are 160 bursae located throughout the body. The major bursae are adjacent to the tendons near the large joints, such as the shoulders, elbows, hips, knees, and heels.

In the shoulder there are three bursae, and each of these can become inflamed and swell with more fluid. The most common causes of bursitis are repetitive motions or positions that irritate the bursae such as throwing or lifting overhead repeatedly, leaning on your elbows or kneeling for long periods, or prolonged sitting, particularly on hard surfaces. Symptoms of bursitis include joint pain and tenderness when you press around the joint, stiffness and aching when you move the affected joint, or swelling, warmth or redness over the joint.

Calcific tendonitis is the name given to a shoulder condition in which there is a slow accumulation of calcium, usually in the body of the supraspinatus tendon. As the calcification builds up over time, it becomes chalk-like.

If spontaneous resorption of the calcium occurs, the condition progresses to the acute stage, and the calcium will be removed by macrophages and giant cells. During this phase, there is extremely acute pain, and the calcific deposit develops a thick, white, toothpaste-like consistency.There is vascular proliferation and an increase in cells, which raises the intratendinous pressure, causing pain as the tendon impinges on the surrounding bursa. Interestingly, during the chronic stage, the presence of calcium is usually painless, and as it dissipates, the pain increases. Excruciating pain may last from one to 14 days, but the condition is self-limited. If the deposit ruptures spontaneously, the patient will experience immediate relief. However, if the excruciating, acute pain persists, the patient may have to be referred for needling or aspiration.

Treatment in the acute stage may require an arm sling, ice and various modalities. Techniques such as ART, Graston Technique and friction massage are contraindicated. The calcium deposit will be tender under direct pressure. In the chronic stage, the above techniques may be useful if there is not severe tenderness over the area.

Burners and stingers are common injuries in contact sports. A burner or a stinger is an injury to the brachial plexus, the nerve supply of the upper arm, either at the neck or shoulder. This often happens when the head is forcefully pushed sideways and down, or twisted. This bends the neck and compresses, or pinches, the surrounding nerves. The injury is named for the stinging or burning pain that spreads from the base of the skull, to the shoulder or along the neck and to the hand. This can feel like an electric shock or lightning bolt down the arm.