Within the last several weeks, I have had two friends telling me about the pain they were experiencing with one of their shoulders. One of the few injuries from which I have suffered (from playing tennis) was tendinitis in my right shoulder. This lasted for nearly two years before spontaneously ending. Shoulder pain often comes on without warning and for no apparent reason. There are a number of conditions that may cause the pain, but the most common is shoulder tendinitis. In addition to the pain that results − especially when moving the arm − limitation in the range of movement often occurs, making it more difficult to perform overhead functions such as brushing hair, fastening a bra and lifting.
The shoulder joint is comprised of a group of muscles called the rotator cuff that keeps the upper arm (humerus) within the socket of the shoulder blade (scapula). When one or more of the tendons of these muscles (the rotator cuff) becomes inflamed, rotator cuff tendinitis occurs and, if the muscle is the large biceps muscle, it results in biciptal tendinitis. Shoulder tendinitis is usually attributed to some repetitive stress on the shoulder tendons as seen in tennis, pickle ball, golfing and baseball, and overhead activity. Sometimes, it can arise from a more obvious injury or fall and, in those cases, there may actually be a rotator cuff tear wherein the tendon actually separates partially or totally from its bony attachment. Symptoms of tendinitis include pain at rest − aggravated by movement, especially in the extremes. As the initial pain is usually mild, anti-inflammatory drugs such as aspirin and ibuprofen along with topical analgesic compounds are often used but, with persisting or increasing pain, consultation with your physician is recommended.
In the area below the tip of the shoulder (the acromion) lies a bursa, a fluid-filled sac that cushions the tendons. This sac may become inflamed (shoulder bursitis) and may or may not be associated with tendinitis.
In some cases, the tendinitis may be associated with the deposit of calcium within one or more rotator tendons. This condition, calcific tendinitis, is associated with more intense pain − often worse in the morning − and is more common in diabetics and older adults.
Shoulder disorders and the limitation of movement over a period of time can lead, in some cases, to a “frozen shoulder” or adhesive capsulitis. In this condition, there is a thickening and stiffening of the tissues around the joint and the range of movement of the arm may be severely compromised. This occurs more frequently where there has been insufficient treatment of the tendinitis, in women and persons between the ages of 40 and 60. Medical treatment, including physiotherapy, is necessary.
Occasionally, shoulder pain may be from a disorder in the neck but felt in the shoulder. This referred pain can be caused by a number of conditions. Cervical osteoarthritis, commonly occurring in people over the age of 60, is caused by deterioration in the discs between the bony vertebrae. As the vertebrae move closer together, the joints may become affected with osteoarthritis including joint surface damage and bony spurs. If there is pressure on the nerves exiting the spine at the site of arthritic changes, or from effects of a herniated disc, the nerve(s) that supply the arm can become ‘pinched’ and the resulting pain can appear to be a shoulder problem. In such cases, there may be associated pain that radiates down the arm and movement of the neck can sometimes either relieve or intensify the symptoms.
Osteoarthritis of the shoulder joint is an uncommon cause of symptoms but, on rare occasions, may be found to be the cause. In this condition in which there is destruction of cartilage, the cushioning material on the joint surfaces is eroded, causing the bare bone surfaces to rub against each other. Hips and knees are the most common sites for this condition.
Most people beginning to experience shoulder discomfort begin home treatment before seeking medical attention. This should include stopping any repetitive motion or sport that may be suspected as causing or aggravating the symptoms. In the first 24-48 hours following any mild shoulder injury, symptoms can be treated with ice or cold packs. After that, heat often relieves discomfort, as well as mild over-the-counter anti-inflammatory medications. Pain-relieving topical creams may also help. Although exercises are not recommended in these initial few days, the arm should be moved regularly to its full range to help prevent stiffness.
If there is obvious injury or if pain is severe, more immediate medical attention is needed. During the pandemic, this has usually been an emergency room visit. For milder cases, an initial consult by phone or in person with your family physician is warranted. Doctors will take a history to identify any precipitating causes and may order some initial investigation, such as an X-ray. Ultrasound examination is now being used to diagnose rotator cuff tears. A physical examination is the most helpful and can suggest more specific medications and diagnostic tests.
If there is still doubt about the cause of the pain or failure to respond to conservative treatment, more sophisticated testing may be indicated and an orthopaedic specialist may be recommended. Further imaging from MRI or CT scans, blood tests and even surgical examination of the shoulder (arthroscopy) may be necessary.
Treatment will be based on the diagnosis. For acute injuries to the shoulder, hospitalization and surgery may be indicated. For the more chronic conditions, home treatment will be most important, with other medical measures and physiotherapy warranted if symptoms become more severe or persistent.
More than 80% of cases of shoulder tendinitis get better over time without the need for surgical intervention. During that time, the physician may recommend an injection of cortisone in the joint − but this can be done only a few times at most. Physiotherapy is recommended for almost every shoulder problem, especially rotator cuff tendinitis and frozen shoulder. It helps to ensure continued range of motion − thereby reducing the risk of developing a frozen shoulder – as well as to help with pain. Physiotherapy also helps maintain strength and function in the shoulder muscles. Home exercises will be taught by the physiotherapist and should be followed diligently. Some individuals claim relief with acupuncture.
Surgery is often urgently needed for severe shoulder injuries such as fractures or certain dislocations, but is rarely indicated with other causes of shoulder pain. Where there is more serious damage to the rotator cuff tendons and when medical management and physiotherapy have made no improvement, the orthopaedic surgeon may recommend surgical repair. This operation should be considered carefully before being done, as it is not always successful.
As cases of shoulder tendinitis are far more common in seniors, it is important to be aware of the precipitating factors in many of the cases. This is especially important for snowbirds who, once arriving in the sunny south, often participate more actively in activities such as golfing, pickle ball and swimming. It is recommended that such activities be initiated slowly, with modifications in the type or intensity of the actions involving the shoulder if symptoms of discomfort arise.
Overuse of the shoulder in any activity may increase the likelihood of symptoms. Nevertheless, good posture, daily physical exercise, avoiding heavy lifting and keeping your arms moving in a full range of motion will help avoid − as well as manage − shoulder tendinitis.