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We NOW have Saturday morning clinic hours in our Ashburn office from 8-12. Walk-in visits are accepted.
Shoulder pain is common at all ages, in both active and sedentary people. There are numerous causes of shoulder pain, but as with most things, there are a handful of sources that account for most of the diagnoses. Often the diagnoses can be grouped according to age and cause, resulting from trauma or arising without an injury.
In this post, I’d like to focus on shoulder pain arising in middle aged and older folks that occurs without trauma.
One would think that without an injury, pain in the shoulder would be rare. But this, unfortunately, is not the case. Shoulder pain as we age is common. Much of the time, the causes are at least in part, degenerative (wear and tear over one’s life), or from the accumulation of effects of other health factors over time.
Although the causes may differ, many of the symptoms are alike or at least overlap – often making the specific diagnoses a little difficult to pin down – at least initially. Fortunately, early on, the non-surgical treatment for most of these diagnoses is very similar. So except in protracted cases or if treatment has failed, and we are considering surgery, knowing the exact diagnosis is not always critical.
Often the symptoms in these cases are pain on the side of the shoulder, particularly with lifting your arm overhead and at night. This pain is often described as “throbbing” but can be sharp. It also often radiates to the elbow. Frequently it feels better with rest and seems to come out of the blue.
It is essential to understand how the shoulder works if you are to understand why pain develops. The shoulder is a ball and socket joint. The ball is at the top of your arm (humerus), and the socket (glenoid) is the most outer part of your shoulder blade. The humerus sits directly on the glenoid like a ball on a tee. The capsule, a tissue that contains ligaments within it, helps hold the ball to the cup. Surrounding this capsule are muscles that originate from the shoulder blade or collarbone. These muscles ultimately become tendons that end on your arm. When the muscles shorten, the contraction force passes to the tendons. The pull of the tendons is what moves your arm.
Your shoulder is a complex system that must work like an orchestra. All the parts of your shoulder have specifically defined roles and timing of action. If there is any alteration from this pattern, then pain, dysfunction, and injury can occur.
Although this is a very complex system, six diagnoses are responsible for most of the issues in these non-traumatic cases. Let’s review these.
This process is traditionally known as Impingement Syndrome. It may also be called rotator cuff tendinitis or tendinosis or subacromial pain syndrome. In fact, there is a slew of titles that describe this same process. Some in medicine take offense to the term impingement syndrome since it implies an incorrect mechanism of causation.
The common symptoms seen with this problem are as described above. Pain on the side of your shoulder or upper arm is frequent. This discomfort is worse with overhead activities and sleeping. It often follows overuse, as may occur with swimming, throwing, or doing overhead chores, such as painting a ceiling.
The exact cause of these symptoms is somewhat controversial. Many believed the primary source of this issue was a spur on the undersurface of the overlying bone, the acromion, pressing down on the rotator cuff from above. Most now agree that a spur is not needed to develop these symptoms, nor is the primary problem pressure on the rotator cuff from above. The thinking now is that the pain likely arises from either isolated degeneration (tendinosis) of the rotator cuff or tendinosis, along with a reactive inflammation of the overlying bursa (bursitis) and, on occasion, the underlying joint lining, the synovium (synovitis). In other cases, it may also arise from bursitis alone.
Frequently there is an associated disruption of normal shoulder function. The shoulder dysfunction can either arise from the pain and subsequent disuse or precede the problem and, at least in part, be a causative factor.
Although this problem often presents in isolation, it also frequently occurs along with many other shoulder problems. Bursitis and impingement symptoms often accompany almost all of the common shoulder problems on this list. Impingement symptoms are often the predominant symptoms in many of these issues.
When in isolation, treatment for this problem is nearly always non-operative. When occurring as a result of another problem, the initial treatment may be similar. However, the prognosis is dependent on that of the primary issue.
The treatment focuses on correcting the three main pathological issues: overuse, bursal inflammation, and shoulder dysfunction.
At least initially, the treatment consists of “relative rest”, avoiding painful activities as much as possible to let the injured tendon “heal.” Often you will be given medications to reduce pain and inflammation. Physical therapy is frequently needed as well to get the shoulder functioning correctly. Typically the medicines consist of anti-inflammatories, usually by mouth. An injectable steroid (“cortisone”) is also often used. Cortisone is somewhat controversial as it may cause some injury to the rotator cuff tendons itself. But if used sparingly and not injected directly into the tendon, the additional damage is likely minimal, if at all.
The prognosis for recovering from this problem is excellent. If given enough time, most recover fully with the above prescription. We do operate, however, in two scenarios. Those rare cases that don’t improve and those in which the patient is unable or does not want to wait long enough for recovery.
Nearly every time I see a working-aged and older patient with shoulder pain, they almost always blame their pain on their darn rotator cuff. Often they believe the symptoms may be arising from a rotator cuff tear. Although people in these age groups may have a rotator cuff tear, it doesn’t mean that the tear is the source of their pain – but it can be.
Whereas the tendinosis we discussed above is at the earlier stages of rotator cuff degeneration, rotator cuff tears occur in the later stages. Going from a healthy tendon, to tendinosis and subsequently to a rotator cuff tear is similar to going from baby smooth skin to rougher skin to wrinkles. It is a normal part of the aging process for many.
The rotator cuff is a group of four tendons usually attached to the top of your arm bone. These tendons arise from muscles originating on your shoulder blade. They contribute significantly to your arm motion. When they are not working correctly – or torn – pain, weakness, and overall poor shoulder function may arise.
It is critical to understand, however, that this is not always the case. Rotator cuff tears can exist and your shoulder can function and feel perfectly healthy. As a result, they can be present when you have shoulder pain and not be the source of your pain.
There are many types of rotator cuff tears. For purposes of explaining this, it is only necessary for you to understand about two of them. There are traumatic and degenerative tears. Degenerative tears occur slowly over time. As a result, your body has time to adjust to the tendon changes. This adaption can enable your shoulder to function and feel normal despite the tear. Traumatic tears occur abruptly. As a result, pain and functional changes occur suddenly. The sudden injury doesn’t allow for accommodation by your shoulder.
This concept of accommodation is essential. To understand better, think of how we react when going from a dark environment to a light one. When this occurs slowly – say during a sunrise – no problem. Not so when walking outside from a dark room on a very bright day. In the first case, our eyes have time to accommodate. In the second, they do not. The same amount of light but a different reaction.
Unfortunately, the distinction between degenerative and traumatic may not always be clear. Almost all of us can relate some “trauma” to our shoulder pain. But is it a coincidence or causation? The first clue is if you have to try hard to remember the injury, it probably didn’t cause the problem.
Making this distinction can even be further complicated by MRI imaging. Although there are some classic characteristics for both chronic and acute tears, traumatic tears sometimes look chronic and degenerative tears can sometimes look acute on MRIs.
To further complicate things, some can have chronic tears that were previously unknown and asymptomatic, have an injury, and now have symptoms. In this case, the prognosis may mirror either the expected outcome of degenerative tears or traumatic tears. Only time will tell.
Degenerative tears may be the source of your pain or may just be an asymptomatic finding noted because you have pain – but not your pain’s cause.
As a result, nearly always, when there is a known chronic degenerative rotator cuff tear or a suspected tear without trauma, the initial treatment is non-operative. Like the other sources of pain discussed here, there is often pain and abnormal function that is likely contributing to your symptoms. Therefore treatment usually consists of rest and medications to control the pain and potential inflammation and physical therapy to address any dysfunction. Importantly this treatment isn’t likely to resolve your symptoms in a couple of weeks. As we get older, things take time.
If this doesn’t work, then surgery may be needed. The exact operation recommended will depend on specific factors regarding your age, activity level, function, characteristics of your tear, and overall shoulder health.
The Biceps is a muscle with two tendons attaching to its top and one to its bottom. One of the top tendons runs through a groove under a ligament in the front of your upper arm. It then takes an abrupt turn into your shoulder joint, where it attaches to the top of your glenoid.
This tendon can have problems anywhere throughout this circuitous course. There are common problems seen with the biceps tendon when there is no trauma. These are tendinitis with or without degeneration (tendinosis), excessive motion in and out of the groove (subluxation), and partial tears.
Often with biceps issues, the pain will be in front of your shoulder. If something is getting caught, as with a partial tear or subluxation, there may be a periodic click or “pop.”
At least initially, treatment is often non-operative. Like for impingement symptoms, usually, treatment focuses on rest, anti-inflammatory medications, and physical therapy. An injection in the bicep’s sheath may help biceps tendinitis or when inflammation occurs due to early biceps tendon degeneration or mild tearing. It can also sometimes be useful from a diagnosis perspective. Unfortunately, in cases in which this treatment is unsuccessful, for tendon subluxation or when tearing is more significant, surgery may be required.
Frozen shoulder is common and appears to becoming even more so. If you develop frozen shoulder, you will notice progressive pain and stiffness. For many, there are specific stages of the disorder that mark initiation to cure. Often people will progress through this process with or without treatment. Frozen shoulder is a problem that doctors rarely cure but rather one in which we help you get through as you heal on your own.
The exact cause of the problem is unknown. What is known, and seen in all cases is the joint’s lining, the capsule, shortens and becomes severely inflamed. These capsular changes are responsible for much of the two predominant symptoms: stiffness and pain. There also is resultant subacromial bursitis that leads to classic impingement symptoms, at least early on. Before significant stiffness develops, this can confuse the diagnosis. Loss of motion in all directions as the process progresses along with normal x-rays, distinguishes this entity from the other shoulder problems discussed here.
Frozen shoulder is seen more commonly in certain groups. Those with diabetes are the most common to develop this problem. Also, frozen shoulder more commonly afflicts middle-aged women over the young, the elderly, and males. Other groups that more frequently develop this problem are those with thyroid disorders, women after breast cancer surgery, and those after shoulder injuries and surgery.
Treatment often starts with pain and inflammation control with medications or injections. As pain settles down and pain tolerance increases, physical therapy may be helpful. Usually, this is not productive initially as the pain is often significant and the loss of motion is progressive, no matter the treatment. Frustratingly, in the early stages, it is often like swimming against the current. No matter what we do, the symptoms seem to progress.
Fortunately, for most, this process resolves over time. Those with diabetes or who develop a frozen shoulder after trauma or surgery often have a protracted case.
In those who fail to respond to non-operative treatment, surgery followed by aggressive therapy can often be helpful. For diabetic patients with poorly controlled disease, getting better blood sugar control also appears to be beneficial.
The shoulder can get arthritis like any other joint. There are two main types of arthritis: Inflammatory and degenerative. Examples of inflammatory arthritis are Rheumatoid arthritis, psoriasis, lupus, gout, etc. In this type of arthritis, the underlying problem is an autoimmune issue. Something triggers your cells to mistakenly view your joints’ structures as foreign and attack them. This response leads to the destruction of the affected joint. Multiple joints, and even other organ systems, may be involved.
Degenerative arthritis (osteoarthritis or degenerative joint disease) is somewhat different. It is a more local process. Although it may affect multiple joints simultaneously, the source of destruction for the various joints is usually unrelated. The degree of involvement also often differs from joint to joint. Because this is the more common form of arthritis occurring as we age, traditionally it has been thought of solely as a “wear and tear” phenomenon. Recently, we have come to understand that there is more likely a biomechanical cause of the problem. Trauma such as a joint fracture or infection, or even microtrauma over a sustained period, may initiate the process. However, a cascade of enzymes and other biological factors is involved in the progression of the joint’s destruction.
The common symptoms of shoulder arthritis are deep and diffuse pain, limited motion, a grinding sensation, and overall poor shoulder function. Different people are affected differently. Some may have only a few of these symptoms and have them mildly. Others may have many or all of these symptoms and have them severely.
Most of the time, plain x-rays are all that is needed to confirm the diagnosis. Advanced studies, like MRIs, are usually only required for surgical planning. The exact type of inflammatory arthritis that exists often involves a review of the various symptoms, an assessment of your medical and family medical history, and lab tests.
There is no present confirmed way to reverse the damage caused by arthritis. In the case of early inflammatory arthritis of the shoulder, there are medications that may slow the development of more severe symptoms and joint destruction. For both forms of arthritis, some treatments may help reduce symptoms, but a “cure” in the traditional sense is impossible. Only by surgically replacing the joint, can the arthritis be eradicated.
Non-operative treatment is the usual suggestion for newer or less severe cases. Your doctor will likely offer various treatments depending on your willingness, medical profile, symptoms, and specifics of your arthritis symptoms and severity. Among the therapeutic options are things like modifying or eliminating painful activities, over the counter or prescribed medications, physical therapy, and injections.
On occasion, arthroscopy may be beneficial. In arthroscopy, your surgeon can remove things such as loose bodies, torn pieces of tissue, or cartilage that may be contributing to inflammation and pain. They cannot replace the injured or missing cartilage. It is important to note that although it may seem to make sense that “cleaning out the joint” with arthroscopy would be helpful, it often is not. Typically the pain and reduced function come from many sources. Not all of which are amenable to arthroscopy. So arthroscopy should only be used to treat shoulder arthritis sparingly.
For those with more symptomatic arthritis, mainly when adequate control of your symptoms by non-surgical or lesser operative means is not possible, is a shoulder replacement. There are different types of replacements. The decision about which would be right for you depends on various individual factors, such as age, activity level, the status of your rotator cuff, and other anatomical characteristics.
For reasons not fully understood, calcifications can develop in our tendons. This phenomenon is particularly common in the rotator cuff tendons. Women between the ages of 40-60 are effected most commonly.
Calcifications in your tendon can cause pain for two main reasons. First, just the calcification’s presence within the tendon can cause increased pressure and pain, not unlike the pain one may get from a large pimple. Additionally, The tendon calcifications are often in a semi-liquid or crystal form. Calcifications of this type can escape the tendon into the adjacent bursa. They can then be viewed as foreign by your body. In response, your cells may “attack” the crystals. The response leads to a severe inflammatory reaction. This reaction can be extremely painful.
There tend to be three symptom patterns for calcific tendinitis. In the first, the calcifications are hard, like small pebbles, and relatively benign. For these cases, although x-rays can quickly identify the calcification, it is rarely symptomatic and usually requires no treatment. In the second form, there is an acute, severe painful inflammatory reaction. The overlying skin may be warm. Due to pain, any motion will be difficult. People with this type of calcific tendonitis are very uncomfortable until this is under better control. The third type is a more chronic, lower level of near-constant pain. Often patients will describe the pain as “gnawing.” People with this form are usually able to carry on with normal activities. Still, they can’t seem to escape the chronic discomfort.
It is often best to treat the acute form, at least initially, non-operatively. Potent prescription-strength oral anti-inflammatories and local steroid injections are often very helpful in reducing or eliminating these severe symptoms. Because the pain can be so severe, sometimes pain medications may be needed in the short-term. Physical therapy is helpful to regain lost range of motion and improve function.
I have found that there are three paths that non-operatively treated calcific tendinitis takes. The first is resolution. The inflammatory reaction is a war in which your body is battling the crystals. Sometimes your body wins the battle, removing the crystals and the symptoms, along with them. On some occasions, the acute symptoms will resolve, only to come back again. This pattern can repeat itself over and over again. Finally, the severe symptoms can resolve, and more chronic low-level symptoms persist.
If non-operative treatment cannot cure your calcific tendinitis, it can be treated effectively with arthroscopic surgery.
The vast majority of nontraumatic shoulder pain results from one of the six diagnoses above. There are other causes not discussed here. That is why it is always helpful to see a shoulder specialist when you have worrisome or protracted symptoms.
Advanced imaging studies, such as MRIs, are rarely needed initially. First, they do not help to dictate treatment. Second, they can confuse the diagnosis. MRIs in middle age are seldom normal. There are many findings on a middle-agers’ shoulder MRI that are normal for age but sound worrisome. Take it from me, it is tough for a worried and uncomfortable patient to disregard these findings. As a result, their presence in your report can often lead to unnecessary surgery.
Most of the time, when there has not been trauma, you have time on your side. So non-operative treatment is usually the initial recommendation. Furthermore, non-operative treatment is generally successful—more reason to start with this treatment.
If you’re in those golden middle-age years and have shoulder pain that began without trauma, you can relax. Your symptoms and problem are likely treatable – and curable.
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