Shoulder pain is a common cause of disability and functional loss. The shoulder joint is a ball and socket joint surrounded by a capsule, muscles and ligaments. One in four suffer from shoulder pain some time in their life. This may be acute in nature particularly following trauma. In younger patients, this normally occurs in the context of sports and athletics and may range from a sprain to a fracture of the clavicle and occasionally a dislocation of the joint itself. In older patients with osteoporosis, fractures are a common occurrence.
On the other hand, chronic conditions, which I encounter on a regular basis in my clinic, usually develop slowly over weeks and months and worsen with time. These are mostly insidious in nature and normally degenerative.
Patients typically experience pain on the lateral aspect of the arm. This pain may radiate to the neck or elbow. The pain is worse with rotatory movements of the arm particularly while undertaking mundane activities like putting on a jacket or getting something off a shelf.
At times, the pain may even wake the patient at night. This is thought to be related to the physical pressure exerted due to sleeping on the shoulder as well as the slowing of metabolism during this time which causes the natural pain-relieving hormones or endorphins to drop.
Other common causes of severe shoulder pain, besides trauma, are calcific tendonitis and adhesive capsulitis also known as frozen shoulder.
Calcific tendonitis is a manifestation of the degeneration of the shoulder joint. As wear and tear progresses, excess bone projections known as osteophytes develop. This is associated with inflammation of the tendons around the shoulder joint known as the rotator cuff. The tendons also thicken and deposit calcium in their substance.
Occasionally, the bursa between the tendon and overlying bone may get inflamed. The calcium deposit may be as flecks or as large chunks and may incite an acute inflammatory reaction when it eludes into the joint.
Chronic conditions usually develop slowly over weeks and months and worsen with time
The condition may be confirmed using an X-ray or ultrasound scan. In adhesive capsulitis or frozen shoulder, the capsule and ligaments around the shoulder joint become stiff and contracted.
There are three different stages - the freezing, the frozen and the thawing stage where pain and stiffness initially worsen. One can wait for this condition, which is more common in females, to improve or resolve itself but this may take several months. Frozen shoulder, in which the X-rays appear as showing no abnormality, is typically idiopathic which means that no underlying cause can be identified.
Most cases occur in the context of trauma which, at times, may be a simple jarring or sprain, essentially an episode which the patient might not even remember. A patient with an endocrine condition such as diabetes is more prone to develop this condition.
Treatments of both these conditions involve a concoction of painkillers as well as a programme of physiotherapy and exercises. I have developed a robust pathway for managing these conditions.
Physiotherapy is important and it helps reduce pain levels, improves mechanics and the range of movement and relieves stiffness. It also strengthens the muscles around the shoulder girdle.
At times, patients may also require steroid injections for either condition. In calcific tendonitis, barbotage of the joint, which is a procedure in which the calcium deposits are needled, and joint distension in the case of frozen shoulder are also options. If, however, there is no progress, then surgery becomes a very effective way forward.
As a shoulder specialist, I perform these procedures arthroscopically or through a keyhole intervention. This reduces the damage to the surrounding soft tissues and hence reduces morbidity, with an improvement of recovery time and a quicker return to work and play.
This surgery is performed as a day-case. In calcific tendonitis, both the excess bone and inflammation are removed as are the calcium deposits. In frozen shoulder, the thickened capsule and ligaments are carefully cut through by making very small portal incisions. The previously popular manipulation under anaesthetic for frozen shoulder has now become obsolete in view of the associated damage this procedure may cause.
The patient will require intense physiotherapy after these arthroscopic procedures to allow them to gain full benefit. The pain levels and range of movements will then steadily improve over the subsequent weeks following the operation.
Alistair Pace is a consultant orthopaedic surgeon at St Thomas Hospital, Qormi, St James Hospital, Sliema and Da Vinci Hospital, Birkirkara. He is also a senior lecturer at the University of Malta.