What’s Going on with My Shoulder?

There is no body part that people come into therapy for that causes as much confusion as the shoulder. The worry and confusion is palpable from the first day of physical therapy. BUT Why?

The worry and confusion is very understandable for many reasons.

1. Shoulders hurt in every position, whether sitting, standing, moving, not moving, sleeping, eating…you name it. You just can’t seem to find a comfortable position when your shoulder is bothering you, and it is incredibly frustrating.
2. Shoulders “pop” and no one can understand “why?”
3. Shoulder pain wakes you up, or doesn’t let you get the sleep in the first place (which just makes EVERYTHING worse).
4. When the shoulder hurts, you can’t DO anything. There is difficulty getting washed, difficulty getting dressed, difficulty eating, and worst of all…you can’t reach your coffee cup.
5. Finally, just when you thought it was getting better…the pain and popping comes back.

Let’s see if I can clear up any lingering confusion about that Shoulder pain.

The shoulder joint is a very complicated joint which is actually made up of 4 joints: The Sternoclavicular joint (where your collar bone meets your chest), the acromioclavicular joint (where your collar bone meets your shoulder blade at the top of the “shoulder”), the scapulothoracic joint (your shoulder blade on your ribs) and your Gleno-humeral joint (the part of the body people call the “shoulder”—where the arm bone meets the rest of the body). All 4 joints must work together in concert to allow the others to do there jobs correctly. If just 1 of the 4 joints doesn’t move enough, at least one of the other joints has to make up the motion so you can wash your back, reach for your coffee, or throw a ball.

Beyond the 4 joints working perfectly together, there are 11 muscles that cross the gleno-humeral joint with another 15 muscles that directly attach and move the shoulder blade and collarbone to allow the shoulder to work correctly. 26 muscles working together with 4 joints perfectly is like trying to get the offense and defense of a football team to try to get along and not blame each other for the problems that happen.

The cause of the vast majority of shoulder problems is the ROTATOR CUFF. The rotator cuff is actually 4 muscles that wrap around the shoulder to hold the gleno-humeral joint together. The gleno-humeral joint is a ball and socket joint, but the socket is too shallow to really keep the shoulder together. Most people think of a ball and socket as the socket wrapping around the ball to create a nice stable three dimensional moving structure (like the Hip), but in the shoulder the socket is about one third the size of the ball (which allows the large range of movement that exists in the shoulder). The shoulder ball and socket is akin to a golf ball on a tee…but on its side, so without any support the ball would fall right to the ground, so the 4 muscles of the rotator cuff wrap around the ball (the humerus) and are able to hold the ball in the reference point of the socket and still move the arm.

So with a basic understanding of how the shoulder works, it’s easy to see how so much can go wrong. There are an infinite number of diagnoses that cause shoulder pain due to the high risk caused by the large motion and intricate play of forces at the shoulder, but here are the most common (with a brief description so you will know what your doctor means when your friend tells you what is wrong with his/her shoulder).

• Rotator cuff tear/tendonitis: A swelling or tear in the muscles that hold the shoulder in place. When there is a rotator cuff tear the pain tends to be on the outside part of the upper arm just below the shoulder, and it is very difficult lifting the arm and may even look like you are shrugging the whole shoulder to allow more lifting.
• Impingement syndrome: The rotator cuff is pinched under the acromio-clavicular arch (which is where the collar bone and a piece of the scapula go over the top of the humerus-the upper arm bone). The rotator cuff then rubs on the arch and causes pain. This can cause or be caused by a rotator cuff tendinitis or tear.
• Bicep tendonitis: A swelling of the bicep as it crosses in front of the shoulder and often causes pain and popping. Yes…your bicep runs all the way up in front of the shoulder. A bicep tendinitis is usually caused by an impingement syndrome, the rotator cuff not doing its job correctly or a labral injury.
• Labral injuries: The labrum is a small piece of tissue that is really an extension of the cartilage of the socket that extends past the socket’s edge and creates a suction cup effect and helps the rotator cuff hold the shoulder together. At times, the labrum is pinched between the ball and socket and either inflames or tears, creating pain and popping.
• AC joint sprains or arthritis: AC sprains or arthritis are a ligament injury or wear and tear of the acromio-clavicular joint that cause pain on the top of the shoulder and usually are described as a pinching pain with certain movements, reaching and while sleeping on that shoulder, and no pain with rest. Pain is especially with reaching across the body and is sometimes accompanied by grinding.
• Arthritis: Arthritis is due to wear and tear that grinds down the cartilage of the joint, causing a deep achy pain especially first thing in the morning and last thing at night, pain with a lot of activity or with weightbearing.

All of these diagnoses occur on a varied spectrum from a little achy to completely debilitating. The treatment for these are as widely varied as the intensity and presentation of the symptoms—most are treatable conservatively with physical therapy and maybe some medications, to treated with an injection and physical therapy, to needing surgery in the worst cases.

All of the shoulder problems can be helped with therapy and prevention if caught early enough.

This list is by no means comprehensive and by no means does everyone have the exact same symptoms with same diagnosis. Everyone needs to be treated individually and each solution is customized, but it is always true that the sooner you find help for your shoulder injury the better.