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General Issues

Impingement

Impingement occurs when there is excessive friction between tissues in a joint. In the shoulder, impingement often occurs when the rotator cuff rubs against the acromion. The rotator cuff is a group of tendon that sits between the humerus and acromion bones, and it is susceptible to be impinged if the space between tendon and bone decreases. 

 

Shoulder impingement is often a result of overuse. Lots of use of the shoulder can cause the tendons of the rotator cuff to swell, decreasing the joint space, causing the cuff to rub against the acromion, leading to pain, irritation, and inflammation. Shoulder impingement can also be caused by bursitis (inflammation of the bursa). Bursa provides the lubrication for the cuff to slide freely during motion, so inflammation of this tissue can lead to issues.

 

Risk factors for shoulder impingement include overhead athletes, certain occupations, age, previous injuries, and structural issues. Athletes in sports involving repetitive overhead motion like volleyball, swimming, tennis, and baseball, as well as occupations like construction, painting, and window washing may be at increased risk for this injury. Previous shoulder injuries, old age, and an abnormally shaped acromion also factor into impingement.

Symptoms of this injury include pain, weakness, and stiffness at the joint. This pain may be present during a variety of overhead activities, and may even ache at night. This injury can be diagnosed with a physical exam, X-Ray, and MRI.

Impingement can firstly be treated with rest, ice, and generally avoiding motions that aggravate pain in the shoulder. Physical therapy can help improve strength and range of motion, while non steroidal anti inflammatory drugs like ibuprofen and aspirin can help relieve pain and reduce inflammation. If these methods are unsuccessful, steroid injection and surgery could help. 

 

There are a few methods of surgery for this issue. Surgeons may widen the subacromial space so the cuff no longer catches on bone, remove an inflamed part of the bursa, or perform an anterior acromioplasty, where part of the acromion is removed. Surgery can be performed arthroscopically or via open surgery. 

To prevent this injury, avoid overhead lifting and perform exercises that strengthen the rotator cuff. Check out the “Physical Therapy Recommendations” section of our website to learn more about rotator cuff exercises.

Separation

The acromioclavicular joint is where the acromion (shoulder blade) meets the clavicle (collarbone). Separation of the AC joint occurs when the ligaments connecting these bones together are injured. This is normally caused by either a sudden blow to the outside of the shoulder or falling directly on the shoulder. The acute force from these blows that tears the ligaments can then cause the collarbone and shoulder blade to be separated. AC separation can range from a mild sprain of the ligaments to a complete tear that comes with complete joint separation.

 

Separation commonly occurs in athletes, especially those that play contact sports like football, soccer, and basketball. They also occur in sports that involve falls, like gymnastics and downhill skiing.

 

The symptoms of an AC separation include pain, weakness, bruising and swelling, limited range of motion, and a bump at the top of the shoulder. This bump, which is more obvious in more serious injuries, makes it easier to diagnose a separation.

 

The initial treatment for this injury involves taking care of pain, with rest, ice, non steroidal anti-inflammatory medication, and immobilization via a sling. Then, exercises to improve range of motion and physical therapy are helpful. Maintaining motion after a shoulder injury is important in preventing frozen shoulder, which is a condition of immense stiffness and pain and the joint. Surgery for AC separation consists of either cutting back the acromion so it doesn’t rub against the acromion or repairing the ligaments beneath the acromion.

 

Recovery for AC separation depends largely on the classification of injury, and if the AC and coracoclavicular ligaments are intact. It also depends on the age and activity level of the patient, as surgery is more likely to be considered for younger, more active patients. Nonsurgical treatment is typically considered for grade 1 or 2 fractures, but ample discourse exists regarding the treatment of other classifications of injuries. Overall, the AC joint is a complex joint that can be injured in many different ways and severities.

Fracture

Fractures of the shoulder joint involve breaking one of the three bones of the shoulder:  the clavicle, humerus, or scapula. Clavicle and proximal humerus fractures are often caused by a direct blow from an accident, fall, or collision. The scapula is harder to fracture than these two bones, so fractures of it are usually caused by high energy trauma.

 

The symptoms of a shoulder fracture include pain while moving the arm, swelling, bruising, limited range of motion, and “grinding” feeling when moving. Additionally, a bump on the shoulder is characteristic of a fractured clavicle.

 

The nonsurgical treatment for shoulder fractures initially includes rest and immobilization. A sling or figure 8 strap is used for the first 3-8 weeks after surgery. After the immobilization period, physical therapy and home exercises can help improve strength and motion. Most shoulder fractures can be treated without surgery.

 

Surgery is needed for more serious injuries, and often involves fixation with plates and screws. For more severe cases partial shoulder replacement surgery, reverse shoulder replacement nonunion fracture surgery, and malunion shoulder fracture surgery are options.

 

After surgery, you may need assistance with daily functions for 5-10 days, but can return to school or work after this period. When pain in the shoulder resides, you can resume shoulder movement, and exercises will be helpful for recovery. You can return to sports or regular activity once full strength is regained, which typically occurs about six months after surgery.

Cartilage Tear

Articular cartilage is a type of connective tissue on the ends of long bones. It facilitates movement, making it easier for bones to slide past each other at the joint. The cartilage can be torn from acute trauma like a dislocation, or as a result of wear and tear over time. It can also be injured following certain issues like osteochondritis, which occurs when decreased blood flow to a bone under cartilage causes part of the bone to die, causing both the bone and cartilage to crack and break off.

 

You may have a cartilage tear if you experience pain lifting the arm over the head, weakness, a decreased range of motion, night pain, or a clicking or grinding sensation at the shoulder joint. To treat this injury, rest the shoulder, and try physical therapy or over the counter pain medications. If pain persists, steroid injections or surgery are possibilities. 

 

One surgical procedure for this issue is arthroscopic debridement, where a surgeon will employ small incisions and a camera to clear the joint of damaged tissue. Surgeons can also opt to repair the cartilage, or perform a shoulder replacement if the injury is severe enough.

 

Though cartilage tears can be difficult to predict, some aspects of prevention are in the patient’s control. A family history of arthritis or cartilage problems can put one at risk for cartilage tears, but other risk factors are more preventable. Avoiding repetitive overhead movements and heavy lifting can help decrease the risk of a cartilage tear. Properly stretching and warming up to exercise and practicing good posture can help avert one of these injuries.

Patient Resources

Impingement 

AC Separation

Fracture

Cartilage Tear

Bursitis​

References

Impingement

  1. https://my.clevelandclinic.org/health/diseases/7079-shoulder-impingement-syndrome

  2. https://shoulderelbow.org/2017/07/19/terrible-triad-elbow-fracture-dislocation/

  3. https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-impingementrotator-cuff-tendinitis

  4. https://www.hss.edu/condition-list_shoulder-impingement.asp

  5. https://www.healthline.com/health/shoulder-impingement

 

AC Separation

  1. https://my.clevelandclinic.org/health/diseases/7079-shoulder-impingement-syndrome

  2. https://shoulderelbow.org/2017/07/19/terrible-triad-elbow-fracture-dislocation/

  3. https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-impingementrotator-cuff-tendinitis

  4. https://www.hss.edu/condition-list_shoulder-impingement.asp

  5. https://www.healthline.com/health/shoulder-impingement

 

Fracture

  1. https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-trauma-fractures-and-dislocations/

  2. https://my.clevelandclinic.org/health/diseases/17470-shoulder-fractures

  3. https://www.pennmedicine.org/for-patients-and-visitors/find-a-program-or-service/orthopaedics/shoulder-pain/shoulder-fracture-diagnosis-and-treatment

  4. https://www.hopkinsmedicine.org/health/conditions-and-diseases/humerus-fracture-upper-arm-fracture

  5. https://nyulangone.org/conditions/shoulder-elbow-fractures/treatments/nonsurgical-treatment-for-shoulder-elbow-fractures

  6. https://www.hss.edu/condition-list_fractures-shoulder.asp

Cartilage Tear

  1. https://sportsmedicine.mayoclinic.org/condition/shoulder-cartilage-and-arthritis/

  2. https://www.hopkinsmedicine.org/health/conditions-and-diseases/shoulder-labrum-tear

  3. https://mydoctor.kaiserpermanente.org/ncal/structured-content/Condition_Shoulder_Cartilage_Tendon_Injuries_-_PMR.xml?co=%2Fregions%2Fncal

  4. https://orthoinfo.aaos.org/en/treatment/articular-cartilage-restoration

  5. https://orthoinfo.aaos.org/en/diseases--conditions/osteochondritis-dissecans/

  6. https://www.mayoclinic.org/diseases-conditions/osteochondritis-dissecans/symptoms-causes/syc-20375887

  7. https://my.clevelandclinic.org/health/diseases/21073-osteochondritis-dissecans

  8. https://orthoinfo.aaos.org/en/treatment/arthroscopy/

  9. https://orthoinfo.aaos.org/en/treatment/shoulder-arthroscopy/

Bursitis

  1. https://www.healthline.com/health/bursitis-shoulder

  2. https://www.mayoclinic.org/diseases-conditions/bursitis/symptoms-causes/syc-20353242

  3. https://www.hopkinsmedicine.org/health/conditions-and-diseases/shoulder-bursitis

  4. https://my.clevelandclinic.org/health/diseases/21530-bursitis-in-shoulder

CC Healthwise, Incorperated

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Bursitis

Bursa are fluid filled sacs that reduce friction and cushion the tissues within a joint. The bursa of the shoulder are called the subacromial bursa, and they cushion the area between the rotator cuff and the acromion (shoulder blade). Bursitis is the inflammation of the bursa.

 

There are three types of bursitis: chronic, infected, and traumatic. Chronic is the most common, and is caused by repetitive overhead movements that increase friction between tissues, that can in turn irritate and inflame the bursa. Infected bursitis is caused by bacterial infection, and traumatic bursitis is caused by acute trauma, which often occurs in sports.

 

Some common symptoms of bursitis are pain with movement, stiffness, and swelling. Chronic bursitis is characterized by swelling, while infected bursitis involves more severe symptoms like pain, inflammation, tenderness, fever and swelling spreading throughout the body. Traumatic bursitis can be characterized by the immediate onset of swelling and tenderness.

 

All types of bursitis can be treated with rest, ice, immobilization and over the counter pain medication for the pain and inflammation. Antibiotics can help with infected bursitis, and compression and padding can help with traumatic bursitis. If the bursitis is severe, steroids, an aspirate, or arthroscopy may be helpful. An aspirate is removing fluid from the bursa. Most bursitis can be treated nonsurgically, as it is mostly a chronic issue that flares up occasionally. Finding out what aggravates the pain and avoiding or modifying those activities can help prevent further pain.

 

People that do a lot of repetitive overhead motion are at risk for bursitis, as well as older people. Illnesses like diabetes, rheumatoid arthritis, kidney disease, and thyroid diseases are also associated with bursitis. 

 

To prevent subacromial bursitis, avoid or modify behaviors that put pressure on the shoulders. Wheel heavy loads, and take lots of breaks during activities involving heavy lifting. Exercise to strengthen the muscles of the shoulder joint, and warm up and stretch before activity of the shoulder.

Tendonitis

Shoulder tendonitis is a condition where the tendons of the shoulder are inflamed (either the rotator cuff or biceps tendon.

 

Tendons are tissues that connect muscle to bone. The rotator cuff consists of four tendons in the shoulder that help stabilize, lift, and rotate the arm. The biceps tendon connects the biceps muscle to the bones of the shoulder. It has two “heads” that connect to different bones of the shoulder. The biceps tendon long head connects to the glenoid (the socket of the shoulder) and goes through a very narrow space to do so. This can lead to the irritation and inflammation of the tendon.

 

Anything that causes the tendons of the shoulder to be pinched by surrounding structures can lead to shoulder tendonitis, from years of overhead activity to acute injuries. Years of overhead sports and jobs, or just doing a new repetitive overhead movement can cause this condition. It can also be caused by impingement syndrome, which occurs when the rotator cuff rubs against the bones of the shoulder.

 

Common symptoms of tendonitis include pain, stiffness, and swelling. If you have this condition, you may also experience a limited range of motion, tenderness, and night pains. These symptoms are similar to bursitis, which is another inflammatory condition. 

 

To diagnose these different inflammatory conditions that affect the joints, a medical history and physical examination will be performed. A physician can assess your pain and range of motion to rule out arthritis or other joint problems, as well as examine for swelling, redness, warmth. Tissue may be extracted from swollen bursa to check for gout or infection, while blood tests and imaging (X-Ray/MRI) may be taken to check for other conditions. A variety of conditions can factor into arthritis and bursitis, such as rheumatoid arthritis, diabetes, and gout, making the diagnosis complex. 

 

If untreated, tendonitis can develop into more serious conditions. It can increase the risk of tendon rupture, and if it continues for months it can lead to tenodesis, which is the chronic degeneration of the tendon. So, diagnosing the cause of shoulder pain can be important to preventing further issues.

 

The initial treatment for shoulder tendonitis includes, rest, ice, compression, NSAIDS, physical therapy, and activity modification. If these are unsuccessful, a cortisone injection or, in rare cases, surgery is considered. The surgery performed on rotator cuff tendonitis is arthroscopy, or open surgery in more severe cases. The surgical options for bicipital tendonitis include repair, biceps tenodesis (damaged part of tendon is removed and remaining part is attached to the humorous), and tenotomy. Tenotomy is reserved for severe cases, and is performed by releasing the biceps tendon from its attachment site.

 

Shoulder tendonitis is often caused by overuse. To prevent this issue, either avoid or modify repetitive overhead activities. Make sure you have good technique and posture during activities, stretch, and stop if an abnormal pain persists.

Bone Spurs

Osteophytes, also called bone spurs, are smooth, bony projections from bone that form near joints. They often develop over time with the onset of joint damage and arthritis, and result in pain and other symptoms when they impinge on other tissues of the body.

 

Arthritis, old age, and a family history of spurs can result in osteophyte formation. In osteoarthritis, the cartilage on the edges of bones breaks down over time, causing bones to rub against each other. In response to this damage, the body may compensate by making bone spurs. Rotator cuff tendonitis is also associated with bone spurs. As the tendons of the rotator cuff rub against the normal subacromial space, bone spurs can form, further pitching the rotator cuff and causing rotator cuff tendonitis.

 

Many people don’t know that they have bone spurs, as they only cause problems when they impinge on other tissues. For example, they can pinch nerves, causing weakness, numbness, and sharp pains. They can also cause tendonitis or tendon tears when they rub on the rotator cuff or biceps tendon. Other common symptoms of bone spurs include pain, swelling, stiffness, and reduced range of motion.

 

Most bone spurs are found when X-Rays are taken for other reasons. Bone spurs can be diagnosed through physical examination, as well as other imaging techniques such as CT scans and MRIs.

 

Bone spurs can be initially treated with rest, ice, NSAIDS or over the counter pain relievers, and physical therapy. In addition to exercises to strengthen the muscles and improve range of motion, physical therapists can use ultrasound therapy or a deep tissue massage. Lifestyle changes like doing lower impact activities and weight loss can help relieve stress on the joints. Bone spurs can be surgically removed by themselves, or as part of another surgery like debridement.

 

To prevent bone spurs, eat a well rounded diet and exercise to keep your bones healthy and prevent them from stress. Practice good posture and ergonomics during daily activities, and practice stretching and good technique when exercising.

CC Healthwise, Incorperated

Patient Resources

References

Tendonitis

  1. https://my.clevelandclinic.org/health/diseases/13203-shoulder-tendinitis

  2. https://www.hopkinsmedicine.org/health/conditions-and-diseases/shoulder-tendonitis

  3. https://www.mayoclinic.org/diseases-conditions/tendinitis/symptoms-causes/syc-20378243

  4. https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-impingementrotator-cuff-tendinitis

  5. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&contentid=p01387

  6. https://www.health.harvard.edu/pain/what-to-do-about-rotator-cuff-tendinitis

  7. https://www.pennmedicine.org/for-patients-and-visitors/find-a-program-or-service/orthopaedics/shoulder-pain/shoulder-tendinitis-diagnosis-and-treatment

  8. https://uvahealth.com/services/sports-medicine/shoulder-tendinopathy

  9. https://nyulangone.org/conditions/bursitis-tendinitis-in-adults/diagnosis

  10. https://www.cedars-sinai.org/health-library/diseases-and-conditions/b/bursitis-and-tendinitis.html

  11. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Tendinitis-Bursitis

  12. https://my.clevelandclinic.org/treatment-guides/22-0070-shoulder-pain-guide?_gl=1*1lupfqf*_ga*MzM0MDczMDYyLjE2MjIxNDMyNjg.*_ga_HWJ092SPKP*MTYyNjI4MDg5Ni4xMy4xLjE2MjYyODI1NDUuMA..&_ga=2.74187282.1681809008.1626280896-334073062.1622143268#replacement-options-tab

  13. https://my.clevelandclinic.org/health/diseases/17449-rotator-cuff-tendonitis

  14. https://www.uofmhealth.org/health-library/uh2113

Bone Spurs