Shoulder problems include pain, is one of the most common reasons for a doctor's visit for musculoskeletal symptoms. Shoulders are the most movable joints in the body. However, this is an unstable joint because of the range of motion that is allowed. This instability increases the likelihood of joint injury, often resulting in a degenerative process in which tissue is damaged and no longer functioning properly.
Shoulder pain may be localized or may be referred to the area around the shoulder or down the arm. Other areas of the body (such as the gall bladder, liver, or heart disease, or cervical spine collar disease) can also cause pain that the brain may interpret as arising from the shoulder.
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The shoulder joint is made up of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (the upper arm bone) (see diagram). Two joints facilitate shoulder movement. The acromioclavicular joint (AC) is located between the acromion (the part of the scapula that forms the highest point of the shoulder) and the clavicle. The glenohumeral joint, often called the "shoulder joint", is a ball-and-socket joint that allows the arms to rotate in a circle or to hang out and away from the body. The "ball" is the top and round of the upper arm bone or the humerus; "socket," or glenoid, is a plate-shaped portion of the outer edge of the scapula where the ball fits. The arm movement is further facilitated by the ability of the scapula itself to slide along the ribs. The capsule is a soft tissue envelope that surrounds the glenohumeral joint. It is coated by a thin and fine synovial membrane.
The shoulder bone is held by muscles, tendons, and ligaments. Tendons are the hard tissue straps that bind the shoulder muscles to the bone and help the muscles in moving the shoulders. Ligaments attach the shoulder bones to each other, providing stability. For example, the front of the joint capsule is anchored by three glenohumeral ligaments.
The rotator cuff is a structure consisting of a tendon which, with associated muscles, holds the ball at the top of the humerus in the glenoid socket and provides mobility and strength to the shoulder joint.
Four structures such as pockets called bursa allow smoothness between bones, muscles, and tendons. They protect and protect rotator cuff from bony acromion arches.
Maps Shoulder problem
Diagnosis
Here are some ways doctors diagnose shoulder problems:
Medical history and physical examination
- Medical history (patient informs doctor about injury). For shoulder problems, medical history including patient age, dominant hand, if injury affects normal work/activity as well as details on actual shoulder issues including acute versus chronic and shoulder arrest, instability, locking, pain, parasesi (burning) sensation), stiffness , swelling, and weakness. Other useful information include OPQRST (onset, palliative/provocation, quality, radiation, severity, timing) and history of problems that may cause referred pain (pain felt on the shoulder but actually originating from other parts of the body) including cervical spine disturbances, heart attack, peptic ulcer disease, and pneumonia. Standardized questionnaires such as the Penn Shoulder Score that assess shoulder pain and function may help elicit the history needed to make the diagnosis and monitor the progress of the condition.
- Physical examination of the shoulder to feel the injury and find the limit of movement, location of pain, and degree of joint instability. The steps to obtaining this information are inspection (searching), palpation (feeling), testing the range of motion, and performing specific maneuvers. Information collected on the inspection is asymmetry, atrophy, ecchymosis, scarring, swelling, and venous distention. Palpation can help find pain and disability, and should specifically include the anterior glenohumeral joint, acromioclavicular joints, biceps tendon, cervical spine, coracoid process, shoulder blades, and sternoclavicular joints. Various external and internal rotation motion tests, abduction and adduction, passive and active weakness, and true weakness versus weakness due to pain. Apley scratch tests are the most useful: scapular touch opposite to reach behind the head for adduction and external rotation and behind the back for abduction and internal rotation. Finally, there are more specific maneuvers that can be used for diagnosis, but the accuracy is limited.
Diagnostic test
- Test to confirm the diagnosis of certain conditions. Some of these tests include:
- X-ray
- Arthrogram - A diagnostic record that can be seen on an X-ray after injection of contrast fluid into the shoulder joint to describe a structure such as a rotator cuff. In illness or injury, this contrast fluid can leak into areas that are not included, indicating a tear or opening, or blocked from entering the area where there is usually an opening.
- MRI (magnetic resonance imaging) - A non-invasive procedure in which the machine produces a series of cross-sectional images of the shoulder.
- Other diagnostic tests, such as injection of anesthesia into and around the shoulder joint.
Dislocation
Description
The shoulder joint is the most commonly dislocated joint of the body. In the typical case of a dislocated shoulder, a strong force pulling out the shoulder (kidnapping) or extreme rotation of the joint appears the ball of the humerus coming out of the shoulder socket. Dislocations generally occur when there is a backward pull on the arm that catches the muscles unprepared to hold or control the muscles. When the shoulder shifts frequently, this condition is referred to as shoulder instability. A partial dislocation in which the upper arm bone partially enters and exits a portion of the socket is called subluxation. In the medical community, dislocations are often referred to as fading.
Signs and diagnosis
Almost all dislocated shoulders are inferior and in between, 95 percent are in the forward direction. Clinically this is referred to as the anterior glucocarral joint dislocation. Not only does the arm appear out of position when the shoulder is dislocated, but dislocation also produces pain. Spasm muscle can increase the intensity of pain. Swelling and bruising usually develop, and in some cases there may be numbness and muscle weakness. Problems seen with dislocated shoulders are torn ligaments or tendons that strengthen joint capsules and, more rarely, nerve damage. Doctors usually diagnose dislocations by physical examination, but X-rays are taken to confirm the diagnosis and to rule out related fractures and other complications. X-rays are also taken after the relocation to make sure it's in the right place.
Treatment
Doctors treat dislocations by placing the humeral head back into the joint socket (glenoid fossa) of the scapula - a procedure called manipulation and reduction (M & amp; R). This is usually followed up with X-rays to ensure a non-fracture reduction around it. The arm is then immobilized in a sling or tool called shoulder immobilizer for several days. Usually doctors recommend to rest your shoulders and apply ice three or four times a day. Once the pain and swelling have been controlled, the patient enters a rehabilitation program that includes exercises to restore various shoulder movements and strengthen the muscles to prevent future dislocations. These exercises can progress from simple movements to weight usage.
After treatment and recovery, the previously released shoulders can remain more susceptible to reinjury, especially in young active individuals. Ligaments stretch and may tear due to dislocations. Tearing ligaments and other problems resulting from a dislocation may increase the likelihood of repeated dislocations. Shoulder sprains severe or frequent, injure the surrounding tissue or nerves, usually require surgery to repair damaged shoulder.
Sometimes doctors perform surgery through a small incision in which a small sphere (arthroscope) is inserted to observe the inside of the joint. Following this procedure, called arthroscopic surgery, the shoulders are generally held by a sling for three to six weeks, while full recovery, including physical therapy, takes several months. The arthroscopic technique involving the shoulder is relatively new and many surgeons prefer to correct the shoulders of recurrent dislocations by a time-tested open surgery under direct vision. There is usually less dislocation and increased movement after open surgery, but it may take a little longer to regain movement.
Separation
Description
Separation of the shoulder occurs where the collarbone (clavicle) meets the shoulder blades (scapula). When the ligaments that hold the AC joint (acromioclavicular) together rupture partially or completely, the outer end of the clavicle may slip out of place, preventing it from properly filling the scapula. Most often the injury is caused by a blow to the shoulder or by falling into an outstretched hand. After the injury it is difficult to rotate 180 degrees.
Signs and diagnostics
Shoulder pain or pain and, occasionally, a lump in the middle of the top of the shoulder (above the AC joint) are signs that a separation may have occurred. Sometimes the severity of a separation can be detected by taking X-rays while the patient holds a light load that pulls the muscles, making the separation more obvious.
Treatment
Shoulder separation is usually treated conservatively with rest and wearing a sling. Immediately after the injury, ice bags can be used to relieve pain and swelling. After a period of rest, a therapist helps the patient perform an exercise that puts the shoulder through his range of motion. Most shoulder separations heal within two or three months without further intervention. However, if the ligament is severely damaged, surgical repair may be necessary to hold the clavicle in place. A doctor may wait to see if conservative treatment works before deciding whether surgery is needed.
Sternoclavicular separation
Description
Although not directly a shoulder problem, this may affect the function of the shoulder due to problems with sternoclavicular rotation. The sternoclavicular separation occurs when the sternum separates from the clavicle in the sternoclavicular joint. The cleavage of sternoclavicula (dislocation and subluxation) is rare and is generally caused by accidents. If the clavicle is separated posteriorly (ie the clavicle separates and runs behind the sternum) the situation can be dangerous and the clavicle may cause damage to the inner artery, vein or organ.
Signs and diagnostics
X-rays or CT Scans may be needed to accurately diagnose sternoclavicular separations.
Treatment
Treatment consists of the use of numerous resting standards, icing, NSAIDs and slings. The joint may need to be reduced (eg put back into place), especially after posterior separation. In severe cases, surgery may be recommended.
Tendinitis, bursitis, impingement syndrome, and rotator cuff tear
Description
This condition is closely related and can occur alone or in combination. If the rotator cuff and bursa are irritated, inflamed, and swollen, they can become wedged between the humeral head and the acromion. Repetitive motion involving the arm, or aging process involving shoulder movements over the years, can also irritate and suppress the tendons, muscles, and surrounding structures.
Tendinitis is inflammation (redness, pain, and swelling) of the tendon. In shoulder tendinitis, the rotator cuff and/or biceps tendon are inflamed, usually due to being squeezed by surrounding structures. Injuries can vary from mild inflammation to the involvement of most rotator cuffs. When the rotator cuff of the tendon becomes inflamed and thickened, it may be trapped under the acromion. Crushing the rotator cuff is called an outlet syndrome.
An inflamed bursa called bursitis. Tendinitis and impingement syndrome are often accompanied by inflammation of the bursa bursa that protects the shoulder. Inflammation caused by diseases such as rheumatoid arthritis can cause rotator cuff tendinitis and bursitis. Exercise involving overuse of shoulder and work in need often overhead is another potential cause of irritation in the rotator cuff or bursa and can cause inflammation and impingement.
Alerts
Signs of this condition include the onset of slow discomfort and pain in the upper shoulder or one-third of the upper arm and/or difficulty sleeping on the shoulder, similar conditions can have sharp pain or discomfort when the upper shoulder is positioned at a certain angle. Tendinitis and bursitis also cause pain when the arms are lifted away from the body or overhead. If tendinitis involves the biceps tendon (a tendon located in front of the shoulder that helps bend the elbow and twist the forearm), the pain will occur in the front or side of the shoulder and can run downwards to the elbow and forearm. Pain can also occur when the arm is pushed up strongly.
Diagnosis
The diagnosis of tendinitis and bursitis begins with medical history and physical examination. X-rays do not show tendons or bursae but may help in the exclusion of bone or arthritis disorders. The doctor can lift and test the fluid from the inflamed area to get rid of the infection. Ultrasound scans are often used to confirm suspected tendinitis or bursitis and to remove rips in rotator cuff muscles. The impingement syndrome can be confirmed when an injection of a small amount of anesthesia (lidocaine hydrochloride) into the space under the acromion relieves the pain.
Treatment
Anti-inflammatory drugs such as aspirin, naproxen or ibuprofen can be taken to help with pain. In some cases, the physical therapist will use ultrasound and electrical stimulation, as well as manipulation. Stretching exercises and lightweight reinforcement are added gradually. If there is no improvement, the doctor may inject the corticosteroid drug into the space under the acromion. However, new one-tier evidence suggests the limited effectiveness of corticosteroid injections to relieve pain. While steroid injections are a common treatment, they should be used with caution as they may cause tendon rupture. If there is no improvement after six to 12 months, the doctor may perform an artroscopic or open surgery to repair the damage and reduce the pressure on the tendon and bursae.
In those with calcification tendinitis from extracorporeal shock wave therapy high energy shoulder can be beneficial. This is not useful in other types of tendonitis.
The rotator cuff is torn
The term "rotator cuff" refers to a group of four unified tendons when attached to the upper end of the arm bone (humerus). Usually these tendons emit muscle power that comes from the shoulder blade (scapula) to the arm that gives movement and stability. The most commonly affected tendon is the supraspinatus muscle. Defects in rotator cuff may be from injury (cuff tear) or from degeneration (cuff wear). The extent to which the tendon can be improved depends on the quantity and quality. Tendons of degeneration are often weak and retraction and may not be repairable. Individuals who are elderly, smokers, or those who have cortisone injections often have weaker tendon tissue that fail without significant injury. Conversely those whose tendons are torn by substantial reductions often have good quality tendons that can be repaired if surgery is done immediately after injury. Symptoms of rotator cuff disease include difficulty lifting arms. Repairing the rotator cuff requires that the tendon be securely bonded to the bone during surgery and repair is corrected for several months during healing. More information to consider in rotator cuff tears treatment can be found at the University of Washington School of Medicine.
SLAP tear (lesions)
Sobek (superior labrum anterior to posterior) occurs when the cartilage of the shoulder (labrum) delaminates from the glenoid. This causes shoulder instability, usually in motion overhead.
Symptoms
The symptoms include deep blunt pain in the shoulder joints, difficulty falling asleep due to instability and discomfort, and extreme weakness in overhead activities.
Diagnosis
The best diagnosis for a SLAP tear is a clinical examination followed by an MRI in combination with a contrast agent.
Treatment
Very few cases are recovered to complete mobility without surgical intervention. Some patients can strengthen their shoulders to limit day to day pain, but with limited mobility and function. Surgery connects labrum to glenoid through the use of surgical anchor.
Recovery
Recovery is often a long process. The first four weeks or more weeks of patients are required to wear a sling. After this, there is a month of physical therapy to regain the range of motion. In two months limited strength training took place. At six months patients are usually released into full active use, although many patients find that full recovery takes longer than this.
Frozen shoulder (capsulitis adhesive)
As the name implies, the shoulder movement is severely restricted to people with "frozen shoulders". This condition, which doctors call capsulitis adhesive, is often caused by injuries that cause lack of use due to pain. The development of rheumatic diseases and recent shoulder surgery can also lead to frozen shoulders. Intermittent use can cause inflammation. Adhesions (abnormal tissue bands) grow between joint surfaces, limiting motion. There is also a deficiency of synovial fluid, which usually lubricates the gap between the arm bone and socket to aid the movement of the shoulder joint. This is the confined space between the capsule and the humerus ball that distinguishes the adhesive capsulitis from the less complex and rigidly stiff shoulders. People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or who have had an accident, have a higher risk for frozen shoulder. This condition rarely appears in people under the age of 40 years.
Fracture
Description
A shoulder fracture involves a partial or total crack through one of three bones in the shoulder, clavicle, scapula, and humerus. Resting on the bone usually occurs as a result of a collision injury, such as a fall or a blow to the shoulder. Fractures usually involve the clavicle or neck (area below the ball) the humerus. Scapula fractures sometimes occur through a coracoid process.
Signs and diagnostics
Shoulder fractures that occur after a major injury are usually accompanied by severe pain. In a short time, there may be redness and bruises around the area. Sometimes the fracture is obvious because the bone looks out of position. (However this occurs in dislocations and separations that are not involved.) The diagnosis and severity of both can be confirmed with X-rays.
Treatment
When a fracture occurs, the doctor tries to bring the bone into a position that will promote healing and restore arm movement. If the clavicle is fractured, the patient must first wear a rope and swing around the chest to keep the clavicle firmly in place. After removing the rope and sling, the doctor will prescribe exercises to strengthen the shoulders and restore movement. Surgery is sometimes necessary for certain clavicle fractures, especially for disunsi.
Humerus neck fractures are usually treated with immobilizer sling or shoulder. If the bone is out of position, surgery may be needed to reset it. Exercise is also a part of restoring strength and shoulder movement.
Shoulder arthritis (glenohumeral joint)
Description
On shoulder arthritis, cartilage of the ball and socket (glenohumeral joint) is lost so that bone rubs bone. It may be caused by wear (degenerative joint disease), injury (traumatic traumatic), surgery (secondary degenerative joint disease), inflammation (rheumatoid arthritis) or infection (septic arthritis).
Signs and diagnostics
Shoulder arthritis causes pain and loss of motion and shoulder use.
The X-ray of the shoulders shows the loss of normal space between the ball and the socket. X-rays may provide radiographic staging of osteoarthritis of the shoulder.
Treatment
Early onset of shoulder can be managed with mild analgesics and mild exercise. Known gentle exercises include warm water pool treatment exercises provided by trained and licensed physical therapists; approved soil exercise to ensure free movement of the arthritic area; cortisone injections (given at least every six months according to orthopedic doctors) to reduce inflammation; the application of ice pact and moist heat is very effective. Moist heat is preferred over ice while ice is preferred if inflammation occurs during the daytime hours. Local analgesics along with ice or hot humid are adequate treatments for acute pain.
In the case of rheumatoid arthritis, certain drugs chosen by a rheumatologist may offer substantial help.
When exercise and treatment are no longer effective, shoulder replacement surgery for arthritis may be considered. In this operation, a surgeon replaces the shoulder joint with an artificial ball for the top of the humerus and a cap (glenoid) for the scapula. Passive shoulder exercises (where others move the arm to twist the shoulder joints) begin immediately after surgery. Patients start exercising on their own about three to six weeks after surgery. Ultimately, stretching and strengthening exercises are a major part of the rehabilitation program. The success of surgery often depends on the rotator cuff muscle condition before surgery and the extent to which the patient follows the exercise program.
In young patients and active partial shoulder replacement with non-prosthetic glenoid arthroplasty may also be considered.
Arthritis or osteolysis of the AC joint (acromioclavicular)
Description
Acromioclavicular articulation consists of acromioclavicular ligaments and a small disk of cartilage located between the acromion and the clavicle. This disk can be damaged by injury, extreme joint pressure (via bodybuilding) or normal wear.
Signs and diagnostics
Pain is felt on the shoulder movement, especially on certain movements. Often a crossover arm test is used in the diagnosis because it suppresses the AC joint, aggravating the symptoms. X-rays from the shoulder joint may show changes in arthritis of the ac joint or osteolysis.
Treatment
Conservative treatment for the joint is similar to treatment for other types of arthritis, including limiting activity, anti-inflammatory drugs (or supplements), physical therapy, and sometimes cortisone shots. If the pain is severe, surgery can be an option. The most common surgical treatment, known as resection arthroplasty, involves cutting a very small part of the tip of the clavicle and letting scar tissue fill its place. Some parts of the acromioclavicular ligaments may still remain attached.
Treatment
A mnemonic for the basic maintenance principles of musculoskeletal problems is PRICE : P rotection, R est, I , C compression, and E levation:
- Protection : Keep the shoulders to prevent further injury.
- Rest : Reduce or stop using the wounded area for 48 hours.
- Ice : Place an ice pack on the wound area for 20 minutes at a time, 4 to 8 times per day. Use a cool bag, ice bag, or ice pack that has been wrapped in a towel.
- Compression : Compress the area with a bandage, like an elastic wrap, to help stabilize the shoulder.
- Altitude : Keep the injured area up above the heart rate. Use pillows to help improve injuries.
If the pain and stiffness continue, see a doctor.
According to the American Academy of Orthopedic Surgeons (AAOS) visits to orthopedic specialists for shoulder pain have increased since 1998 and in 2005 over 13 million patients sought medical care for shoulder pain, of which only 34 percent were related to injury.
References
This article contains and extends the text of the public domain document "Questions and Answers on Shoulder Problems", NIH Publication No. 01-4865, available from URL http://www.niams.nih.gov/hi/topics/shoulderprobs/shoulderqa.htm
External links
Source of the article : Wikipedia
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