Shoulder Disorders

Frozen Shoulder

Frozen shoulder is a painful shoulder condition that limits movement and causes stiffness in the joint. It is also called adhesive capsulitis and may progress to the state where you may find it very hard to move your arm. Frozen shoulder is more common in older adults between 40 and 60 years, and occurs more often in women than men.

The condition is caused by the inflammation of the shoulder capsule, the tissue that surrounds the joint. The shoulder capsule becomes thick, tight and forms stiff bands of tissue called adhesions. The risk of a frozen shoulder increases with immobilization for long periods of time following injury or surgeries, and may be associated with other disease conditions such as diabetes, Parkinson’s disease, hypothyroidism, hyperthyroidism or cardiac diseases.

The condition can be diagnosed by the presenting symptoms and radiological diagnostic tools such as X-rays or MRI scans. Treatment for frozen shoulder may include non-steroidal anti-inflammatory drugs and steroid injections for pain, treatment of the underlying risk factors or shoulder arthroscopy surgery. During surgery, the scar tissue is removed and tight ligaments are dissected. Following surgery, physical therapy is advised to bring full range of motion and strengthen the muscles.

Shoulder Pain

Pain in the shoulder suggests a shoulder injury which is more common in athletes participating in sports such as swimming, tennis, pitching and weightlifting. The injuries are caused due to the over usage or repetitive motion of the arms.

In addition to pain, shoulder injuries also cause stiffness, restricted movements, difficulty in performing routine activities and popping sensation.

Some of the common shoulder injuries that cause pain and restrict the movement of shoulders, include sprains and strains, dislocations, tendinitis, bursitis, rotator cuff injury, fractures and arthritis.

  • Sprains and strains: A sprain is stretching or tearing of ligaments (tissues that connect adjacent bones in a joint). It is a common injury and usually occurs when you fall or suddenly twist. A strain is stretching or tearing of muscle or tendon (tissues that connect muscle to bone). It is common in people participating in sports. Strains are usually caused by twisting or pulling of the tendons.
  • Dislocations: A shoulder dislocation is an injury that occurs when the end of the bone is forced out of its position. It is often caused by a fall or direct blow to the joint while playing contact sport.
  • Tendinitis: It is an inflammation of a tendon, a tissue that connect muscles to bone. It occurs because of injury or overuse.
  • Bursitis: It is an inflammation of a fluid-filled sac called bursa that protects and cushions your joints. Bursitis can be caused by chronic overuse, injury, arthritis, gout or infection.
  • Rotator cuff injury: The rotator cuff consists of tendons and muscles that hold the bones of the shoulder joint together. Rotator cuff muscles allow you to move your arm up and down. Rotator cuff injuries often cause a decreased range of motion.
  • Fractures: A fracture is a break in the bone that commonly occurs because of injury, such as a fall or a direct blow to the shoulder.
  • Arthritis: Osteoarthritis is the most common type of shoulder arthritis, characterized by progressive wearing away of the cartilage of the joint.

Early treatment is necessary to prevent serious shoulder injuries. The immediate mode of treatment recommended for shoulder injuries is rest, ice, compression and elevation (RICE). Your doctor may also prescribe anti-inflammatory medications to help reduce the swelling and pain.

Your doctor may recommend certain exercises to prevent stiffness and improve range of motion and strength. Passive manipulation and massage therapy to improve blood circulation and healing are also administered. Other techniques such as acupuncture, TENS, and ultrasound therapy may additionally be recommended.

Subluxation

The shoulder is a highly mobile ball and socket joint. The ball of the upper arm bone (humerus) is held in place at the socket (glenoid) of the shoulder blade (scapula) by a group of ligaments. A partial dislocation of the shoulder joint is termed as a subluxation. This means the ball has partially moved out of the glenoid as opposed to a dislocation, where the ball completely moves out of the glenoid. Subluxation usually occurs from falls or a direct blow to your shoulder. It can also be caused due to a previous shoulder injury or if the ligaments in your shoulder are loose. Subluxations tend to reoccur due to laxity in the ligaments.

Subluxation of the shoulder includes the following symptoms:

  • A feeling that your shoulder has moved out of place
  • Pain, numbness or weakness of the injured shoulder
  • A feeling of looseness of the shoulder

Subluxation of the shoulder is diagnosed by checking your medical history and symptoms and performing a physical examination of your shoulder. Your doctor may also recommend X-rays to confirm diagnosis and check for any fractures of the shoulder joint.

Subluxation of the shoulder is treated with rest, ice packs and NSAID’s to reduce the pain and inflammation. You may be referred to physical therapy for shoulder strengthening exercises to help prevent recurrence. Surgery may be required to repair the ligaments if conservative treatment measures do not prevent further subluxations.

Shoulder Impingement

Shoulder impingement is the condition of inflammation of the tendons of the shoulder joint. It is one of the most common causes of pain in the adult shoulder. The shoulder is a 'ball-and-socket' joint. A ‘ball' at the top of the upper arm bone, humerus, fits neatly into a 'socket’, called the glenoid, which is part of the shoulder blade, scapula. Shoulder impingement is also called as swimmer’s shoulder, tennis shoulder, or rotator cuff tendinitis.

Causes

Impingement results from pressure on the rotator cuff from part of the shoulder blade (scapula) as the arm is lifted. It is more likely to occur in young and middle aged people who engage in physical activities that require repeated overhead arm movements. The pain may be due to a "bursitis" or inflammation of the bursa overlying the rotator cuff or a "tendonitis" of the cuff itself. In some circumstances, a partial tear of the rotator cuff may cause impingement pain.

Symptoms

Individuals with shoulder impingement may experience severe pain at rest and during activities, weakness of the arm and difficulty in raising the hand overhead.

Diagnosis

Diagnosis involves physical examination by the doctor where in the doctor checks for the possible range of movements with the affected shoulder. X-rays and MRI scans may be ordered to see the injury and inflammation.

Conservative Treatment Options

Shoulder impingement can be treated with rest, ice packs, anti-inflammatory drugs, and avoiding the activities involving the shoulder. Physical therapy may be advised to strengthen the muscles and steroid injections may be given if pain persists.

Surgery

Arthroscopic surgery is recommended if the rotator cuff tendons are torn and to remove the bony spurs.

SLAP Tears

The shoulder joint is a ball and socket joint. A 'ball' at the top of the upper arm bone (the humerus) fits neatly into a 'socket', called the glenoid, which is part of the shoulder blade (scapula). The term SLAP (superior –labrum anterior-posterior) lesion or SLAP tear refers to an injury of the superior labrum of the shoulder. The labrum is a ring of fibrous cartilage surrounding the glenoid for stabilization of the shoulder joint. The biceps tendon attaches inside the shoulder joint at the superior labrum of the shoulder joint. The biceps tendon is a long cord-like structure which attaches the biceps muscle to the shoulder and helps to stabilize the joint.

Causes

The most common causes include falling on an outstretched arm, repetitive overhead actions such as throwing, and lifting a heavy object. Overhead and contact sports may put you at a greater risk of developing SLAP tears.

Symptoms

The most common symptom is pain at the top of the shoulder joint. In addition, catching sensation and pain most often with activities such as throwing may also occur.

Diagnosis

Diagnosis is made based on the symptoms and physical examination. A regular MRI scan may not show up a SLAP tear and therefore an MRI with a contrast dye injected into the shoulder, is ordered. The contrast dye helps to highlight SLAP tears.

Treatment

Your doctor may recommend anti- inflammatory medications to control pain. In athletes who want to continue their sports, arthroscopic surgery of the shoulder may be recommended. Depending on the severity of the lesion, SLAP tears may simply require debridement or some may need to be repaired. A SLAP repair can be done using arthroscopic techniques that require only two or three small incisions.

Regular exercises that make the shoulder muscles strong should be done. Adequate warm-up exercises before activities and avoiding high contact sports can help prevent injuries that cause instability.

Arthritis of the Shoulder

The term arthritis literally means inflammation of a joint, but is generally used to describe any condition in which there is damage to the cartilage. Damage of the cartilage in the shoulder joint causes shoulder arthritis. Inflammation is the body's natural response to injury. The warning signs that inflammation presents are redness, swelling, heat and pain.

The cartilage is a padding that absorbs stress. The proportion of cartilage damage and synovial inflammation varies with the type and stage of arthritis. Usually the pain early on is due to inflammation. In the later stages, when the cartilage is worn away, most of the pain comes from the mechanical friction of raw bones rubbing on each other.

Types of Arthritis

There are over 100 different types of rheumatic diseases. The most common are osteoarthritis and rheumatoid arthritis.

Osteoarthritis: Osteoarthritis is also called as degenerative joint disease; this is the most common type of arthritis, which occurs often in older people. This disease affects cartilage, the tissue that cushions and protects the ends of bones in a joint. With osteoarthritis, the cartilage starts to wear away over time. In extreme cases, the cartilage can completely wear away, leaving nothing to protect the bones in a joint, causing bone-on-bone contact. Bones may also bulge, or stick out at the end of a joint, called a bone spur.

Osteoarthritis causes joint pain and can limit a person's normal range of motion (the ability to freely move and bend a joint). When severe, the shoulder joint may lose all movement, making a person disabled.

Rheumatoid Arthritis: This is an auto-immune disease in which the body's immune system (the body's way of fighting infection) attacks healthy joints, tissues, and organs. Occurring most often in women of childbearing age (15-44), this disease inflames the lining (or synovium) of joints. It can cause pain, stiffness, swelling, and loss of function in joints. When severe, rheumatoid arthritis can deform, or change, a joint.

Rheumatoid arthritis affects mostly joints of the hands and feet and tends to be symmetrical. This means the disease affects the same joints on both sides of the body (both the hands or both feet) at the same time and with the same symptoms. No other form of arthritis is symmetrical. About two to three times as many women as men have this disease.

Causes

Osteoarthritis is caused by the wearing out of the cartilage covering the bone ends in a joint. This may be due to excessive strain over prolonged periods of time, or due to other joint diseases, injury or deformity. Primary osteoarthritis is commonly associated with ageing and general degeneration of joints.

Secondary osteoarthritis is generally the consequence of another disease or condition, such as repeated trauma or surgery to the affected joint, or abnormal joint structures from birth.

Rheumatoid arthritis is often caused when the genes responsible for the disease is triggered by infection or any environmental factors. With this trigger body produce antibodies, the defense mechanism of body, against the joint and may cause rheumatoid arthritis.

Symptoms

There are several forms of arthritis and the symptoms vary according to the form of arthritis. Each form affects the body differently. Arthritic symptoms generally include swelling and pain or tenderness in joints for more than two weeks, redness or heat in a joint, limitation of motion of a joint, and early morning stiffness.

In an arthritic shoulder

  • The cartilage lining is thinner than normal or completely absent. The degree of cartilage damage and inflammation varies with the type and stage of arthritis
  • The capsule of the arthritic shoulder is swollen
  • The joint space is narrowed and irregular in outline; this can be seen in an X-ray image.
  • Bone spurs or excessive bone can also build up around the edges of the joint

Diagnosis

Doctors diagnose arthritis with a medical history, physical exam and X-rays of the affected part. Computed tomography (CT) scans and magnetic resonance imaging (MRI) scans are also performed to diagnose arthritis.

Treatment Options

There is no cure for arthritis, so beware of 'miracle cures'. Your doctor may prescribe anti-inflammatory medicine. They may recommend occupational therapy or physiotherapy, which includes exercises and heat treatment. In severe cases, surgery may be suggested. The type of surgery will depend on your age and severity of the disease. In the elderly with severe arthritis, joint replacement can give good results. Common surgery for treatment of shoulder arthritis arthroplasty (replacement of the damaged joint) may be total shoulder arthroplasty or hemiarthroplasty.

Shoulder Instability

Shoulder instability is a chronic condition that causes frequent dislocations of the shoulder joint.

Causes

A dislocation occurs when the end of the humerus (the ball portion) partially or completely dislocates from the glenoid (the socket portion) of the shoulder. A partial dislocation is referred to as a subluxation whereas a complete separation is referred to as a dislocation.

Risk Factors

The risk factors that increase the chances of developing shoulder instability include:

  • Injury or trauma to the shoulder
  • Falling on an outstretched hand
  • Repetitive overhead sports such as baseball, swimming, volleyball, or weightlifting
  • Loose shoulder ligaments or an enlarged capsule

Symptoms

The common symptoms of shoulder instability include pain with certain movements of the shoulder; popping or grinding sound may be heard or felt, swelling and bruising of the shoulder may be seen immediately following subluxation or dislocation. Visible deformity and loss of function of the shoulder occurs after subluxation or sensation changes such as numbness or even partial paralysis can occur below the dislocation because of pressure on nerves and blood vessels.

Conservative Treatment

The goal of conservative treatment for shoulder instability is to restore stability, strength, and full range of motion. Conservative treatment measures may include the following:

  • Closed Reduction: Following a dislocation, your surgeon can often manipulate the shoulder joint, usually under anesthesia, realigning it into proper position. Surgery may be necessary to restore normal function depending on your situation
  • Medications: Over the counter pain medications and NSAID’s can help reduce the pain and swelling. Steroidal injections may also be administered to decrease swelling
  • Rest: Rest the injured shoulder and avoid activities that require overhead motion. A sling may be worn for 2 weeks to facilitate healing
  • Ice: Ice packs should be applied to the affected area for 20 minutes every hour

Surgery

When the conservative treatment options fail to relieve shoulder instability, your surgeon may recommend shoulder stabilization surgery. Shoulder stabilization surgery is done to improve stability and function to the shoulder joint and prevent recurrent dislocations. It can be performed arthroscopically, depending on your situation, with much smaller incisions. Arthroscopy is a surgical procedure in which an arthroscope, a small flexible tube with a light and video camera at the end, is inserted into a joint to evaluate and treat of the condition. The benefits of arthroscopy compared to the alternative, open shoulder surgery are smaller incisions, minimal soft tissue trauma, less pain leading to faster recovery.

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