The diagnosis and rehabilitation of shoulder injuries continues to be a primary skill set for the doctors of the Soft Tissue Center. The shoulder is very complex which is the reason is it has been a focus of research and care.
Shoulder Impingement and Rotator Cuff Tears
The shoulder has two most common sets of pathologies, which can overlap each other. The most common is impingement (most frequently subacromial impingement), which is often associated with rotator cuff tears. The other major set of pathologies of the shoulder is instability (including pseudoinstability) and tears of the labrum (cartilage ring around the socket or glenoid).
Impingement can occur between the ball and the roof over the socket. As the name implies, tendons and a bursa are pinched or impinged which cause inflammation and swelling in the early stages. Over time, this mechanical impingement can start to erode the tendons and lead to partial tears or complete tears. The tendons that are most frequently eroded are one of the rotator cuff tendons (supraspinatus) and also one of the biceps tendons. Research in 2003 revealed a contributing factor that had been previously unrecognized – tightness of the posterior shoulder capsule. This tightness is easily remedied with simple, but specific stretches.
Shoulder Instability and Labral Tears
The shoulder is often described as a golf ball sitting on a golf tee to illustrate the shallow joint, which allows a great deal of motion. Overhead athletes and people who perform a great deal of weight training can overstretch the ligaments/capsule of the shoulder. This can cause the ball to slide back and forth too much in the socket. This can cause pain. This excessive motion can also tear the cartilage ring (labrum) in predictable locations. The labral tears may or may not cause pain.
The same research in 2003, which identified posterior capsule tightness, also concluded that this problem could contribute to labrum tears. The tightness can also create a false appearance of looseness in the shoulder in young overhead athletes, which is known as pseudolaxity. Pseudolaxity will result in shoulder injuries if not corrected.
Looseness of the shoulder can also cause the ball to move too far and impact against the bundle of nerves that supply the upper extremity. The symptoms include tingling, numbness and sometimes pain in the upper extremity. This problem can be confused with symptoms from the neck, or with carpal tunnel syndrome or similar nerve entrapments.
Cervical Spine Related Shoulder Pain
The neck (cervical spine) pathologies can refer pain to the shoulder or can make shoulder muscles excessively weak, which in turn can cause pain in the shoulder. These pathologies need to be considered in patients who have apparent shoulder pathology.
Tests for the Shoulder
At the Soft Tissue Center a thorough history and physical examination of the shoulder and neck will determine the likely source of the pain and other symptoms. Tests may be indicated. These tests may include an MRI to evaluate the extent of a rotator cuff tear or a cervical disc injury, which of course is determined on a case-by-case basis; a special test, known as an MR arthrogram, is performed to best visualize the tear of the labrum in patients with labral and instability symptoms; or nerve studies to determine the extent of nerve injury. If the cervical spine is the origin of the shoulder as determined by the history and clinical examination, an MRI of the cervical spine may be in order, as well as nerve studies.
Shoulder Pain Management
This information along with the history and clinical examination will determine which path of care is best. Many patients do not need these tests and simply need a clinical diagnosis and rehabilitation to improve the rotator cuff strength, improve shoulder range-of-motion, and improve posture to protect the shoulder. It is important to understand that anatomy and function do not always correlate. It is important to “treat the patient and not treat the film”.
The doctors at the Soft Tissue Center at DISC are knowledgeable in the diagnosis and management of shoulder pathologies. Soft Tissue Center doctors have presented papers on various aspects of clinical diagnosis of shoulder pathologies at conferences. A lay book, The 7-Minute Rotator Cuff Solution 1st edition was published 20 years ago by Dr. Horrigan. Simple, evidence-based exercises can help the shoulder tremendously. Exercise or training modification of popular gym exercises may be required as well. A referral to a specialist to consult about joint injections, which contain growth factors, may be in order. This approach can be combined with conservative care. A referral to an orthopedic surgeon with experience in shoulder arthroscopy may be indicated. If the shoulder pain is arising from the neck and there is progressive nerve damage is occurring, a referral to a spine surgeon may be required. Again, these decisions are made on a case-by-case basis.
The doctors at the Soft Tissue Center can be your first step and help guide you through the process of diagnosis and the treatment plan whether the plan is rehabilitation with our group or if we need to refer you to another specialist for co-management of your shoulder pain.