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Shoulder Pain
Introduction
The shoulder joint is the most vulnerable joint in the body as it is very exposed and very mobile. The bony support is quite limited and this consists of the acromion process of the shoulder blade and the clavicle with the acromioclavicular joint. This is helped by some supportive ligaments and several bursae, which are slime filled pockets that help to allow different tissue levels to move around easily .
There are also the supportive shoulder girdle muscles and the muscles and tendons that are part of the rotator cuff mechanism. With all of these support mechanisms for the shoulder joint it becomes possible to forward flex 180° and abduct 180°as well. The first 90°of this range of motion is done within the acromiohumeral joint (the articulation between the acromion and the humeral head). The 90°to 180°motion takes place in the "subscapular joint". This is the summation of tissues underneath the shoulder blade, situated between the chest wall and the shoulder blade. This very soft connective tissue in cooperation with the subscapular bursa enables us to reach up high, to throw and pitch baseballs, to play tennis, golf, to swim with a breast stroke. Normally we have no pain. But when the shoulder is painful, then we need to know why. This chapter explains to you why, and what structure could be responsible for this pain.
Treatment of shoulder strain/ supraspinatus tendinitis/ subacromial tendinitis:
Various physiotherapy treatment modalities such as TENS, ultrasound, laser treatments and range of motion anbd strengthening exercises will help with the recovery from the painful shoulder. Within the first 6 to 8 weeks anti-inflammatories by mouth or by local application (see below) are useful in getting the swellijng and pain under control. Pain medication may have to be given in addition for a short period of time (a few days). As anti-inflammatories are hard on the stomach, the use of topical medications is very useful.
At a recent conference (Ref.7) Dr. Taunton, Professor at the Univeresity of BC, Vancouver, and Sportsmedicine Director of the Allan McGavin Sports Medicine Centre in Vancouver, talked about the use of topical non-steroidal anti-inflammatories in tendinitis cases. Pennsaid is such a commercially available preparation that is applied to the skin and penetrates considerably deep to reach the inflamed tendon. This preparation is a mixture of the anti-inflammatory Diclofenac (1.5%) and the vehicle DMSO, which also has anti-inflammatory properties. The doctor can even order copounded medicine that the pharmacist mixes with Lecithin, 5 to 10% Diclofenac and use this as cream or patch (saran wrap).
Shoulder Strain/Sprain
Most physicians use "strain" and "sprain" synonymously. Either term simply means "soft tissue injury" of the shoulder. In other words, when you bang your shoulder and it gets bruised for a few days, it's that sort of injury. There may be a hematoma of the subcutaneous tissue and within the muscles of the shoulder, but all of this resolves without any trace of injury within 1 to 3 weeks. In the more serious strains where there is a loss of range of motion and strength in the shoulder, a few physiotherapy visits make a big difference in the recovery rate. Eventually, even in these cases, most patients have a satisfactory recovery.
Supraspinatus Tendinitis
As I explained above under "shoulder impingement" and "rotator cuff tendinitis" when the tendon of the supraspinatus muscle rubs repetitively from impingement or from overuse, the supraspinatus tendon gets inflamed. This condition is called "supraspinatus tendinitis". It can lead to a rotator cuff tear at the insertion of the supraspinatus tendon into the rotator cuff. This is a common injury in baseball players (pitchers) or tennis players.
Subacromial Bursitis
Underneath the acromion is a bursa, which will get inflamed with shoulder impingement and often becomes the cause of a chronic irritation and decreased range of motion and loss of strength. For shoulder decompression to take care of the shoulder impingement, this abnormally swollen and inflamed bursa has to also be taken out and technically this often means that an open surgical decompression procedure needs to be done.
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