Shoulder Pain / frozen shoulder


Shoulder pain


The shoulder joint is a ball-and-socket joint. The ball is the round shape at the top of the bone in the upper arm (humerus bone), which fits into the socket, the cup-shaped outer part of the scapula. The shoulder has a wide range of motion with three degrees of freedom. When something goes wrong in the shoulder, it affects your ability to move freely and can cause a great deal of pain and stiffness.

The bones in the shoulder are cushioned by a layer of cartilage. There are two main joints. The acromioclavicular joint is between the highest part of the scapula and the clavicle. The glenohumeral joint is made up of the top, ball-shaped part of the humerus bone and the outer edge of the scapula.

This joint is also known as the shoulder joint. The shoulder joint is the most mobile joint in the entire body. It moves the shoulder forward and backward. It also allows the arm to move in a circular motion and to move up and away from the body.
Causes of shoulder joint

There are many pathological conditions in the shoulder that can cause shoulder pain, we will describe some common conditions in this article. These are as follows:

Shoulder dislocation

When the top of the humerus moves out of its normal location in the shoulder joint that means the shoulder is dislocated. When it is only partially displaced and not totally out of its socket, it is called a subluxation.

What are the causes?

Causes will be related to injuries, these include;

  • When an arm is pulled or twisted with extreme force in an outward, upward, or backward direction.
  • Fall on an outstretched arm, a direct forceful blow to the shoulder can cause a shoulder dislocation.
  • Seizures and shock can cause shoulder dislocations because they produce extreme, unbalanced muscle contractions that can cause the humerus out of the glenoid cavity.

Types of dislocation

There are 3 types of shoulder dislocation anterior, posterior, and inferior.

Anterior dislocation– when the humerus head displaced forward, toward the front of the body. This is the most common type of dislocation, in young people, most of the time the cause is typically sports-related. In older people, it usually caused by a fall on an outstretched arm.

Posterior dislocation-when the humerus is displaced toward the back of the body. Posterior dislocations account for 2% to 5% of all shoulder dislocations. It is related to seizures and shock and it also can happen because of a fall on an outstretched arm.

Inferior dislocation-when the humerus is displaced downward. This is a rare case and it can be caused by various types of trauma in which the arm is pushed downward.

Symptoms of shoulder dislocation

  • Limited range of motion of the shoulder
  • Severe pain in shoulder joint
  • Swelling over the shoulder and pain gets worse with movement.
  • Not able to touch another shoulder.
  • Shoulder bruising or abrasions if dislocation caused by the injury.

Diagnosis of shoulder dislocation

Your doctor will ask you to move your shoulder and will ask if this ever happened before, what other symptoms you have experienced, how you injured your shoulder, and how long your shoulder has been hurting to make a diagnosis.

In most cases, you will be asked for an x-ray to see the exact position of your bones.

Frozen shoulder

Frozen shoulder is characterized by pain and stiffness in the shoulder joint as a result of inflammation and fibrosis of the shoulder capsule. It is common after 40 years of age and women are at higher risk than men. It is also called adhesive capsulitis; some people think that its arthritis but both conditions are unrelated. In most of the cases, there is less synovial fluid in the joints, pain can be severe that person cannot even able to move the shoulder. There are three stages of frozen shoulder;

Freezing- this is the first stage of frozen shoulder, this stage starts with slight pain in the shoulder and pain gets worsen, up to the level of joint range restriction. This stage typically lasts from 8 weeks to 9 months.

Frozen- in the second stage pain becomes less but the stiffness remains the same or it increases more. Major daily life activities can be difficult because of so much restriction of joint range of motion. The frozen stage lasts from 4 to 6 months.

Thawing- in the last stage symptoms start getting improve but for a full recovery, it can take 6 months to 2 years.

What are the causes of frozen shoulder?

There is no specific cause for frozen shoulder, but some factors can increase the risk of developing frozen shoulder for example;

  • Immobilization- if you are having any injury, fracture, or dislocation to shoulder joint, and you are prescribed to not move your arm or you have to immobilize your arm and shoulder for more than 1 month. Then you can develop a frozen shoulder because of no movement at the shoulder joint. Patients are prescribed to move shoulder and arm to reduce the risk of frozen shoulder.
  • Diabetes-it has been seen that diabetic patients are more prone to have a frozen shoulder, although the reason is unknown. Stiffness and pain continue for a longer time before the thawing stage.
  • Other disease-some other medical conditions are also associated with a frozen shoulder for example; cardiac diseases, hypothyroidism, hyperthyroidism, and Parkinson’s disease.

Symptoms of frozen shoulder

  • Pain in the shoulder joint, it can go to the arm also.
  • Limitation in joint range of motion.
  • Not able to perform overhead activities.
  • When it’s severe you might not able to perform daily activities like dressing and combing your hair.

Diagnosis of frozen shoulder

Diagnosis is depending on symptoms and physical examination. If you have pain and stiffness, you will go to your physiotherapist then your physiotherapist will assess your range of motion and specific movement. If you are not able to perform up to the normal range then it can be diagnosed as a frozen shoulder.

There is one important thing for differential diagnosis that you cannot move your shoulder passively also because in some other conditions of the shoulder a person cannot move his shoulder but if someone else is moving his shoulder the range can go up to normal but he cannot move actively.

So, if there is both active and passive range is restricted then it is confirmed for frozen shoulder.

Your doctor can ask for magnetic resonance imaging to rule out rotator cuff tear and x-ray for other bony abnormalities.

Impingement syndrome

In this condition, there is an impingement of rotator cuff muscles under acromion process of the shoulder joint. It is also called swimmer’s shoulder since it is very common in swimmers.

It is also common in some athletes who use their shoulders a lot for example; baseball or softball players. It is characterized by inflammation in rotator cuff muscles and pain in the shoulder joint. There are four rotator cuff muscles

(supraspinatus, infraspinatus, teres minor, and subscapularis) these muscles originate from the scapular bone and insert into the humerus upper end. These are helping in overhead activities and rotation of the shoulder joint. These muscles are more prone to have injuries in comparison to other muscles of the shoulder joint.

Risk factors

There are some factors which can increase the risk of developing shoulder impingement such as swimming, baseball, and tennis. Occupations that require heavy lifting are also at higher risk. These include; constructor workers, painting, moving boxes and other types of heavy lifters.

Some people are having unusual acromion shapes from birth those are also at higher risk.

Symptoms of shoulder impingement syndromes

The symptoms of shoulder impingement are as follows;

  • Pain in the shoulder joint and it can go to the side of the arm also.
  • Pain aggravates in overhead activities.
  • Weakness in shoulder muscles.
  • Difficulty in daily life activities.
  • In case of severe pain, a person is not able to move the shoulder against gravity.
  • Pain can be minor but it is constant and it can get worse at night.

Diagnosis of shoulder impingement

There are many physical tests that can help to diagnose it these are; neer’s impingement test, supraspinatus test, and drop arm test.

In some cases, you may need an x-ray to rule out arthritis and any bone anomaly in shoulder bones. MRI may be needed to see the severity of inflammation.

Subacromial bursitis

In this condition, there is intense pain in the shoulder and it gets worse when you move your shoulder. It often happens in the case of overuse and repetitive movement of the shoulder.

What is it?

In our body, there are small sacs all over and that is filled with a fluid called a bursa. These are thin cushions between your bones and the moving parts of your body like muscles and tendons.

If a bursa gets swollen and fills up with more fluid than it should, then there will be inflammation in that specific bursa and this condition is called bursitis. This is most commonly happening in bursa near joints like shoulder, hips, elbows, and knees.

The subacromial (subdeltoid) bursa in each shoulder helps rotator cuff muscles to function. If it gets swollen because of overuse, you have subacromial bursitis.

Causes of subacromial bursitis

Causes are as follows;

  • Overuse of shoulder muscles.
  • Overhead lifting.
  • Forceful pulling of shoulder muscles.
  • The shape of your shoulder can also be a factor.
  • Being very active may also harm your bursa, especially if you do throw or pitching.
  • Inflamed joint.
  • Any trauma or injury to the shoulder joint.

Other factors are chronic irritation, shoulder muscle weakness, calcium deposits, and any type of shoulder arthritis.

Symptoms of subacromial bursitis

Symptoms would be as pain and stiffness in the shoulder, pain is typically on the lateral and anterior side of the shoulder and there might be swelling and redness over the shoulder. Tenderness (pain in touch) in front of the shoulder.

How to diagnose?

Your doctor will check your range of motion and physical examination to diagnose subacromial bursitis. Magnetic imaging resonance can show your bursa is filled with fluid.

There is a difference between frozen shoulder and subacromial bursitis, in frozen shoulder restriction of active and passive movements, and in acromial bursitis, only active movements are restricted. Speed’s test is specific to diagnose subacromial bursitis

Rotator cuff tendinitis

Tendons of the rotator cuff are susceptible to tendonitis, due to relatively poor blood supply near the insertion of muscles. The rotator cuff is a group of four tendons (supraspinatus, infraspinatus, teres minor, and subscapularis) that covers the humeral head and function of these muscles are arm rotation and elevation.

These muscles and their tendons work together with the deltoid muscle to provide motion and strength to the shoulder for all overhead and waist level activities.

This condition is often caused by overuse of these muscles in repetitive overhead activities such as throwing, raking, washing cars or windows, and many other types of repetitive activities. It may also occur as a result of an injury.

Rotator cuff injuries are the most common cause of shoulder pain and limitation of shoulder range of motion. Rotator cuff tendonitis is the mildest form of rotator cuff tear.

Symptoms of rotator cuff tendinitis

The classic symptoms include a ‘toothache’ like pain in the shoulder joint. Sometimes the pain is going to the arm and front and lateral side of the shoulder. It may interfere with sleeping comfortably.

Pain can be minor nut it is constant and it can get worse at night. Difficulty in daily life activities and in severe cases, a person is not able to move the shoulder against gravity.

The symptoms get aggravated by raising the arms overhead or in activities. Furthermore, reaching behind the back to fasten underclothing or to pass a belt can aggravate the arm and shoulder pain. Weakness in shoulder and arm muscles is also significant in this condition.

Diagnosis of rotator cuff tendinitis

Diagnostic tests utilized: MRI may be used, but sometimes not sensitive enough for an accurate assessment.

Clinical examination including the following special tests will be useful to make diagnose:

  • Supraspinatus test

Neer’s impingement test

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