Shoulder Pain

Hello, I’m Joel Baumgartner, M.D. from Rejuv Medical; shoulder pain can be cause by a lot of different things. Often shoulder pain is caused by a rotator cuff injury, tendonosis, breakdown of the joint, wear and tear, or arthritis. At Rejuv Medical we are going to focus on getting your shoulder either rehabbed and getting the muscles balanced so that the shoulder is not impinging. Or if there are tears or actual breakdown of the tissues in the joint, Rejuv Medical has different treatments we can actually use to regenerate, heal and repair those ligaments, joints and tendons.

Bursitis of the Shoulder and Impingement Syndrome

Bursitis

     “My shoulder hurts and I think I may have bursitis.” Is a common comment heard in a Sports Medicine Clinic like Rejuv Medical.  This statement may only scrape the surface of what is really the underlying cause of the shoulder pain.  Bursitis is an inflammation or swelling of the bursa sac, a fluid filled tissue balloon filled with a thick lubricating fluid.  A bursa is a common structure all over the body.  The one in the shoulder frequently causing a portion of the shoulder pain commonly experienced is the sub-acromial bursa.  It is named for the place it lives, under the acromion process of the shoulder blade (scapula).

Shoulder Anatomy

     The shoulder  anatomy begins with the bony structures.  These include the shoulder blade (scapula), the upper arm bone (humerous), and the collar bone (clavicle).  The shoulder blade is a relatively flat bone with a ridge(scapular spine)  that runs along its upper third.  At the end of the spine of the scapula is a curved piece called the acromion process.  Also a part of the shoulder blade is a projection that makes a very shallow socket for the ball and socket joint of the shoulder (glenoid).  The end of the upper arm bone (humerous) has a ball like structure called the humeral head.  This is the ball of the ball and socket.  The ball is quite a bit larger than the socket.  Imagine a basketball on a golf tee.

     To keep the ball aligned in such a shallow socket is a tissue extension of the socket called the labrum.  There are also muscles that surround the ball and socket joint of the shoulder that help keep the joint together.  These muscles are called the rotator cuff.  Some people mistakenly call this the rotator cup, but they are more like a cuff on a shirt sleeve that surrounds.  The rotator cuff is a group of four small muscles and their tendons.  (Tendons are at the end of a muscle and attach the muscle to bone.)  Names of the rotator cuff musculature include the Supraspinatus, Infraspinatus, Teres Minor, and the Subscapularis.  There are also other muscles that attach the shoulder blade or scapula to the spinal column and the ribs.

     The subacromial space is like a tunnel above the ball and socket joint of the shoulder.  It is an area under the acromion process that comes off the spine of the shoulder blade and acts as a roof over the tunnel.  The ball and socket makes up the floor of the tunnel.  What lives in the tunnel?  One of the rotator cuff muscles, the supraspinatus lies within the tunnel as well as the subacromial bursa. 

 Impingement Syndrome

     Think of someone  pinching your arm.  It hurts! It may bruise.  Your arm may be sore for several days from just that one pinching episode.  Now think of the structures in the tunnel above the shoulder’s ball and socket joint (glenohumeral joint or GH joint).  Imagine how they may hurt when they get pinched.  How can that happen?

     As we age the acromioclavicular (AC) joint –the area where you would separate your shoulder --  begins to deteriorate and a wear and tear type of arthritis called osteoarthritis begins.  Sometimes there are spurs that grow down from the AC joint into the tunnel from the roof.  Other times a ligament may calcify with this process or the end of the acromion process (roof of tunnel) may begin to hook. 
All these conditions decreases the space in the tunnel and the rotator cuff begins to be pinched.  Other times an injury may cause the bursa sac to swell (bursitis) and that may further decrease the space in the tunnel.  When any or all of these occur it causes the structures in the tunnel to get pinched.  That is called Impingement Syndrome of the shoulder.  Of course this is a simplification of the actual physiological process, but it gives one an idea of the process.

     Once the tunnel space is narrowed, the rotator cuff musculature begins to swell (inflammation).  This swelling may lead to chronic conditions like tendinitis or tendinosis.  As these progress, the cuff may begin to thin and eventually holes may develop leading to significant rotator cuff disease or rotator cuff tears.

    When we have shoulder pain, the muscles surrounding the shoulder blade begin to shut down causing a condition where the shoulder blade rides in a less than optimal position often causing the space in the tunnel (subacromial space) to further narrow.  This creates a vicious circle of pain, muscle shut down and scapular mal-positioning (scapular dyskinesis or winging).

     To help fix this condition, specific exercises are necessary.  A cautious approach under the guidance of a Physical Therapist or Athletic Trainer should be used.  Occasionally injections may be needed to help the patient through the rehabilitation process.  Depending on certain factors, there may be times when rehabilitation exercises and injections are not enough.  At these times an arthroscopic surgery may be necessary and then a decompression procedure may be performed to increase the space in the tunnel.

    To determine what is the driving force or root cause of shoulder pain, the first step is an accurate diagnosis.  Call the Rejuv Medical Clinic to schedule an appointment for one of our providers to examine your shoulder.  The number is 320.217.8480.

Rotator Cuff Injury

Rotator Cuff

      When a patient comes to the Orthopedic and Sports Medicine Department of the Rejuv Medical Center with shoulder pain, occasionally the pain may be coming from a structure in the shoulder called the rotator cuff.  What is the rotator cuff?  It is a group of muscles that attach the shoulder blade to the upper arm bone called the humerous.    Let’s review some anatomy of the shoulder then discuss the various injuries / conditions involving the rotator cuff.

Shoulder Anatomy

     The shoulder  anatomy begins with the bony structures.  These include the shoulder blade (scapula), the upper arm bone (humerous), and the collar bone (clavicle).  The shoulder blade is a relatively flat bone with a ridge(scapular spine)  that runs along its upper third.  At the end of the spine of the scapula is a curved piece called the acromion process.  Also a part of the shoulder blade is a projection that makes a very shallow socket for the ball and socket joint of the shoulder (glenoid).  The end of the upper arm bone (humerous) has a ball like structure called the humeral head.  This is the ball of the ball and socket.  The ball is quite a bit larger than the socket.  Imagine a basketball on a golf tee.

     To keep the ball aligned in such a shallow socket is a tissue extension of the socket called the labrum.  There are also muscles that surround the ball and socket joint of the shoulder that help keep the joint together.  These muscles are called the rotator cuff.  Some people mistakenly call this the rotator cup, but they are more like a cuff on a shirt sleeve that surrounds.  The rotator cuff is a group of four small muscles and their tendons.  (Tendons are at the end of a muscle and attach the muscle to bone.)  Names of the rotator cuff musculature include the Supraspinatus, Infraspinatus, Teres Minor, and the Subscapularis.  There are also other muscles that attach the shoulder blade or scapula to the spinal column and the ribs.

     The subacromial space is like a tunnel above the ball and socket joint of the shoulder.  It is an area under the acromion process that comes off the spine of the shoulder blade and acts as a roof over the tunnel.  The ball and socket makes up the floor of the tunnel.  What lives in the tunnel?  One of the rotator cuff muscles, the supraspinatus lies within the tunnel as well as the subacromial bursa.

 Rotator cuff tears

     So then, how do we get rotator cuff tears?  There are basically two ways.  One is called an acute rotator cuff tear.  The other is a more chronic slower progressing degeneration called rotator cuff disease.  Acute cuff tears occur suddenly and quite often forcefully.  For example, a 20 year old college football player – while a strong healthy athlete – can still have an acute rotator cuff tear from a sudden injury when falling in a pile up onto an outstretched arm when the pile collapses.  In this instance, the rotator cuff tendon can tear in a splitting fashion or be pulled (or avulsed) from the bone.  It happens suddenly and in a fast and forceful manner.  Another example is a 30 year old starting their mower for the first time of the season expecting the rope to pull the full distance.  If the engine has seized and the piston is frozen in place, the rope will not pull much at all with a sudden stop at the end.  Again, this is a sudden and forceful injury.  The tear in the rotator cuff tendon can be complete and rupture the tendon (structure that connects muscle to bone).  It could also be what is known as a partial thickness rotator cuff tear and be like cutting part way through a steak to see how well done it may be.  Other times, rotator cuff tears can be full thickness tears without going all the way across the width of the tendon and are more like a hole through the entire thickness of the tendon.  These various types of tears most commonly occur to the top most of the rotator cuff tendons, the supraspinatus.  However, they can also occur to the infraspinatus, the subscapularis or teres minor.  There can also be tears in multiple tendons from the same injury.

Rotator cuff disease

     Another  type of rotator cuff tear comes from a process known as rotator cuff disease.  Rotator cuff disease is more common in individuals who are 40 years old and beyond.  It is basically a degenerative process where the tendon begins to breakdown.  Initially the tendon thins until a small hole may develop.  Think of the sole of a leather dress shoe.  As the shoe is worn more, the sole may thin in one place until a small full thickness hole appears.  This pinpoint hole will grow into a dime sized hole and continue to get wider across.  The size of these holes vary.  They can be small if caught early.  Massive tears may occur if ignored or one tries to push through the pain.  Another size tear is called an irreparable tear.  These tears are not able to be repaired with surgery.  Often this person has a decrease in the ability to lift the arm over head and is unable to reach back behind with that arm.  This is a good reason to get a good diagnosis as soon as possible.

Treating rotator cuff tears

     The treatment of rotator cuff tears varies depending on the type of tear that has occurred.  For a partial thickness rotator cuff tear, Physical Therapy may be the solution many times.  Very specific therapeutic exercises, and  manual therapy can often be very helpful.  Occasionally a combination of injections and Physical Therapy may be the solution for this type of cuff tear.  For a full thickness tear these often require a surgical repair.  Whether the surgery is performed by an arthroscope or with an open incision may depend on what all is seen by the surgeon on the MRI or based on the surgeon’s preference.  This may also depend on which tendon is injured and to what extent.  For massive tears that cannot be repaired, then a combination of injections and Physical Therapy are often prescribed.

     To determine what is the driving force or root cause of shoulder pain, the first step is an accurate diagnosis.  Call the Rejuv Medical Clinic to schedule an appointment for one of our providers to examine your shoulder.  The number is 320.217.8480.

Common phrases associated with shoulder pain include:

Osteoarthritis               Bursitis

Frozen Shoulder          Rotator Cuff Injury

Dislocated Shoulder     Broken Collarbone