Tendonitis/Bursitis

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Tendonitis/Bursitis

Tendonitis refers to inflammation of a tendon. Tendons are connective tissues that attach muscle to bone. The tendons of the shoulder connect a major group of muscles known as the rotator cuff muscles. One or more of the tendons can be affected.

When these tendons become inflamed the pain is often associated with discomfort that feels like an ache deep in the shoulder.

Bursitis, inflammation of a bursa, often causes pain that is very similar to tendonitis. A bursa is a slippery, slimy, fluid-filled sac that serves an important purpose of lubricating movement of the shoulder.

Typically, the pain is noticed when the person is not using their arm much. Pain or discomfort often happens when the person is doing a simple task such as using their hand to reach up or out.

Movement of the shoulder sometimes decreases the pain and/ or discomfort.

Patients may notice they have little to no pain during the day, but at night the pain awakens them from sleep.

Diagnosis

The correct diagnosis of tendonitis or bursitis is made by a thorough exam by a doctor. The exam should include listening carefully to the patients’ description of their symptoms as well as a physical hands-on exam of the painful shoulder and the opposite shoulder.

Patients with this diagnosis typically get relief with a few straightforward steps.

Treatment may include one or more of the following:

use of over-the-counter anti-inflammatory medications, simple home exercises, activity modifications, injecting cortisone around the inflamed tendon, or platelet rich plasma.

Treatment

Rotator Cuff Tear

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Rotator Cuff Tear - Rotator cuff tendon tearWhat is a Rotator Cuff Tear?

A tear of a tendon that connects muscles on the shoulder blade to the proximal humerus (the ball of the shoulder). It is a common source of shoulder pain.

About the Rotator Cuff

The rotator cuff tendon is a connection of three shoulder blade muscles to the proximal humerus. The muscles are the supraspinatus, the infraspinatus, and the teres minor. These three muscles blend together to form one continuous tendon that attaches to the proximal humerus (the ball of the shoulder) at an area of the proximal humerus called the greater tuberosity. Many popular anatomy drawings depict the rotator cuff tendon as if it is three separate tendons. This is not the case. This tendon is not distinguishable as three distinct components by either direct inspection or microscopic inspection.

My experience with inspecting the rotator cuff tendon at surgery is that in most males it is about 2-1/2 or 3 inches wide and about 3/16 inch thick. The thickness varies with the overall stature of the patient. The thickness also varies with age.

What is the purpose of the rotator cuff tendon?

The rotator cuff tendon plays a vital role in properly centering the ball of the shoulder in the shoulder socket during arcs of movement of the shoulder. A normal shoulder is a very flexible joint. I find that the ball of the shoulder will usually move in the socket about 3/8 to a half an inch in each direction. The rotator cuff tendon helps “fine tune” the position of the ball in the socket during movements. When one uses the arm in a throwing motion, the rotator cuff is very important for its role to slow down the arm. Without the rotator cuff to decelerate the arm, a baseball pitcher’s arm might follow the ball to the plate.

The rotator cuff tendon acts in concert with many other muscles that work around the shoulder. These include, but are not limited to, the deltoid, biceps muscle, the teres major muscle, and the subscapularis muscle. Because the deltoid is able to do a lot of work around the shoulder, it can often lift the arm even in the setting of a complete tear of the rotator cuff tendon.

How can one tell if they have a rotator cuff tendon problem?

The most prominent symptom I see in my practice related to rotator cuff problems is pain. Another common symptom is weakness and trouble participating in activities that involve raising the hand higher than shoulder height. Certain arcs of movement are consistently very bothersome and other arcs of movement barely bother the shoulder at all. Nighttime pain is a prominent component of rotator cuff disorders. Patients will generally have difficulty getting a good night’s sleep if the rotator cuff tendon is generating a lot of pain. Your physical exam will be done by me. I do not utilize non-physician providers such as nurse practitioners or physician assistants.

What’s going on when the rotator cuff tendon hurts?

It appears that pain coming from the rotator cuff tendon originates from inflammation of the tendon. The tendon can become inflamed without any tearing. This may be the situation when one has overworked the shoulder on a hard day of sports activity or yard work. A tear of the tendon can also generate inflammation.

How can I tell if there is a tear?

I usually begin my evaluation with a careful history and physical exam. There are many characteristics of the pattern of pain that help me diagnose shoulder pain. Your physical exam is very helpful. An experienced examiner can often reach a diagnosis of rotator cuff pain without any imaging studies. It can be very appropriate to initiate treatment for rotator cuff pain without sophisticated imaging studies. There is almost never a rush to do an imaging study such as an MRI scan.

Rotator Cuff Tear - Rotator cuff tear as viewed from top sideA tear of the rotator cuff tendon is a very common cause of shoulder pain. When I use the terminology “tear” I’m referring to a spectrum of disease that can include a very tiny amount of tearing (think of a piece of cloth that has a little bit of fraying) to a tendon completely torn in two).

It’s important to understand that rotator cuff tendon tears are very common in people that have no shoulder pain or dysfunction. If I gathered a group of 100 people age 60 or older and performed an MRI scan on each one of them it is likely that at least one out of five would have a rotator cuff tear. Most of the patients in this group would have no shoulder pain or dysfunction. Not all rotator cuff tears require treatment. Rotator cuff tendon tears warrant treatment when they cause pain or dysfunction for a person.

How are rotator cuff tears treated?

The treatment of rotator cuff problems should be tailored to the individual. Treatment may be as simple as abstaining from certain arcs of movement of the shoulder.

Physical therapy and strengthening of certain muscle groups will sometimes resolve a rotator cuff problem.

Medication is sometimes used as an adjunct to treatment for a rotator cuff problem. It is common for anti-inflammatory medicine to be utilized in the care of rotator cuff problems. Injectables such as cortisone or platelet rich plasma can be very an effective treatment for rotator cuff pain.

There is a role for surgery in the treatment of some rotator cuff problems. If the patient has tried nonoperative treatment and has failed to gain the level of pain relief and function to meet their needs, it would be appropriate to consider surgery.

Platelet rich plasma has shown to be a very effective treatment option. Platelet rich plasma, properly placed into a discrete target zone under ultrasound guidance, initiates a response within the patient’s body that can heal the tendon without the need for surgery. To read more about this Orthobiologic treatment click the link below.

Treatment

Shoulder Impingement

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Shoulder Impingement

Impingement syndrome is a term that is used to describe a diagnosis. The diagnosis is one related to pain coming from the rotator cuff tendon. If you’ve read the general information about [rotator cuff tears], you’ll note that there are a lot of similarities between discussion about partial rotator cuff tear and “impingement syndrome”.

Impingement syndrome is a term often used by shoulder specialists interchangeably with the term “partial rotator cuff tear” or “rotator cuff tendonitis”. A common theory of shoulder pain is that “impingement” is responsible for making the rotator cuff tendon hurt more when it is inflamed. It is also believed that “impingement” can result in partial or complete tearing of the rotator cuff tendon over a long period of time.

It is often taught that impingement occurs on the rotator cuff tendon because of an unfavorable shape of the undersurface of the acromion. The acromion is a portion of the shoulder blade, the scapula. There are many references that describe the shape of the acromion as one of three types: Type I, Type II, or Type III.

I have never been able to make much of a distinction between any two adjacent types. I’m not alone. There is little reproducibility among examiners in their ability to consistently categorize an acromion as one of these three types.

The significance of the different types is that Type I is generally considered to be “normal”, and a type III is generally considered to be “abnormal”. It is thought that impingement problems are more common in patients that have a Type III acromion. The classification of acromion morphology (shape) is not of much practical value to me, because I find that patients with a Type I acromion can have impingement syndrome. Presence of a Type III acromion does not necessarily mean that person has impingement syndrome.

You may have heard the term “spur”, for example, in a shoulder patient who had surgery to “remove the spur”. That reference generally refers to a bony prominence on the undersurface of the acromion.

Treatment

Impingement syndrome is treated similar to rotator cuff pain or a partial rotator cuff tear.

Arthritis

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What is arthritis?

Shoulder arthritis is deterioration of the cartilage surrounding the joints of the shoulder. These joints include:

  • the ball and socket joint of the shoulder, also called the glenohumeral joint
  • the acromioclavicular joint, where the collarbone joins with the shoulder blade

While the scapulothoracic joint—the place where the shoulder blade interacts with the chest cavity—is also considered a joint of the shoulder, it does not develop arthritis.

The acromioclavicular joint commonly has arthritis but rarely requires treatment. The term shoulder arthritis generally refers to arthritis of the glenohumeral joint (ball and socket).

Causes

The most common form of symptomatic arthritis of the shoulder is osteoarthritis. Osteoarthritis is a condition that affects over 60 million Americans. Osteoarthritis can affect almost any joint in the body. It is a condition in which the cartilage covering of the bone ages and deteriorates. It sometimes results in stiffness and pain of the involved joint. The causes of osteoarthritis vary. It can result from injury, but most patients with osteoarthritis have it as a result of their genetic makeup. It can also be a side effect of certain drugs and environmental influences.

Shoulder Arthritis - Labrum , degenerative tearingRheumatoid arthritis is a fairly common cause of shoulder arthritis. Most people that have arthritis of their shoulder due to rheumatoid disease already carry a diagnosis of rheumatoid arthritis.

Lupus can cause shoulder arthritis. Gout can lead to shoulder arthritis. There is a form of arthritis called psoriatic arthritis that can affect the shoulder.

Lastly, infection of the shoulder joint can lead to arthritis.

Symptoms

Shoulder Arthritis _Bare bone_ humeral head. All articular cartilage is gone, leaving only boneArthritis of the shoulder is usually manifested as pain or stiffness of the shoulder. The pain is generally noted in the proximal humerus area. It is a deep pain. Patients have a hard time “putting a finger on it”. Most patients find that their pain increases if they use their shoulder for activities that involve extreme movement of the shoulder and/or where heavy loads are placed upon the shoulder. A lot of patients have difficulty sleeping when their shoulder arthritis is painful.

Diagnosis

A shoulder practitioner can usually diagnose shoulder arthritis with a combination of careful history, physical examination, and sometimes imaging studies. In most cases, a plain x-ray is sufficient imaging to establish the diagnosis.

Treatment

The following are sometimes appropriate for treatment of osteoarthritis:

Physical Therapy

It’s not clear exactly why, but physical therapy works very well for osteoarthritis of the shoulder. Physical therapy is generally oriented towards goals of increasing strength of the muscles that operate the shoulder and stretching the ligaments of the shoulder by utilizing a home exercise regimen. Most patients will notice a benefit from therapy after a month or two of trial.

Activity Modification

Sometimes simple activity modifications will lessen the pain and shoulder arthritis enough that that’s all the patient needs. For example, heavy loads on the shoulder will tend to aggravate shoulder pain due to arthritis. If the patient has the ability to lessen the loads on the shoulder, that simple step may lessen his or her pain to a satisfactory level.

Home Exercise

Home exercises have the same goal as supervised physical therapy. They are intended to strengthen the shoulder girdle muscles and stretch the ligaments of the shoulder.

Medication

Anti-inflammatory medication taken by mouth will sometimes lessen the pain and stiffness of arthritis of the shoulder.

Injection of cortisone medication into the shoulder joint is also a very effective way to control the pain and stiffness of arthritis of the shoulder.

Cortisone Injection FAQs

Surgery

There are many types of surgery that can be performed for arthritis of the shoulder. In most cases, surgery is for shoulder replacement. There are some situations of mild to moderate arthritis that can be improved with arthroscopic surgery.

Platelet Rich Plasma

Platelet rich plasma has shown to be a very effective treatment option when properly injected into a very precise location. This treatment option can improve pain and function by using the bodies natural substances to calm inflammation within the shoulder joint and surrounding tissues. Click the link below to learn more about this Orthobiologic treatment.

Treatment

Frozen Shoulder

What is Frozen Shoulder?

Frozen Shoulder is also known as Idiopathic Adhesive Capsulitis

Symptoms

The symptoms of idiopathic adhesive capsulitis include, in varying combinations, pain, stiffness, sleep disturbance and weakness.

The pain is generally a deep aching pain felt in the vicinity of the ball of the shoulder, but also commonly felt in the chest area and further down the arm to a point about midway between the shoulder and the elbow. The pain will often be present at rest and is generally more intense when one is using the arm and shoulder.

Stiffness will vary from very mild to extremely severe. An example would be stiffness so severe that one has difficulty reaching the middle belt loop on a pair of pants.

Sleep disturbance is a very common feature of idiopathic adhesive capsulitis. People find that they often awaken from sleep due to pain; they can generally return to sleep but are awakened again before their normal waking time. Sometimes changing position, using over-the-counter medication, or using ice will lessen the pain that is disturbing sleep.

Diagnosis

Diagnosing idiopathic adhesive capsulitis (frozen shoulder) requires a careful history. Certain features of the history as volunteered by the patient are very useful clues for the examiner. Does the shoulder hurt with sudden movements? Is the shoulder stiff? Have the symptoms been getting worse over the course of several weeks? These are all useful clues an examiner will seek.

Another important basic tool is a careful physical examination of both shoulders conducted by an experienced examiner. By combining the elements of a careful history, along with the findings of the physical exam, an examiner can narrow the possible causes of the patient’s shoulder pain and stiffness. It is often possible to reach a presumptive diagnosis of idiopathic adhesive capsulitis without sophisticated imaging studies.

Causes

The cause of adhesive capsulitis is unknown. There is a form of frozen shoulder that is associated with diabetes. If you are not a diabetic, please focus any research you may undertake on non-diabetic diagnosis of frozen shoulder.

It is common for patients to associate their early memories of shoulder pain with a specific task or event. This task may be an arm movement during a sporting event or a hard day of working in the yard. It is my belief that these memories are representative of symptoms present in a long evolution of frozen shoulder. The event remembered is probably not the actual cause of the frozen shoulder.

Treatment

Exercise is very effective at lessening the pain and stiffness of idiopathic adhesive capsulitis (frozen shoulder). It seems counterintuitive, but a lot of evidence shows that using a frozen shoulder helps it, and not using a frozen shoulder delays its recovery. Therefore, try to continue with your normal activities, like gardening or sports, as your tolerance allows. The intensity of your activity should be based on the level of pain you are able to tolerate.

Physical therapy is often employed in the treatment of idiopathic adhesive capsulitis. It may consist of a home exercise regimen and can also involve supervised physical therapy in combination with a home regimen.

A few patients will notice a decrease in stiffness and pain by treating frozen shoulder with cortisone injection; however, most patients do not notice substantial lasting relief. This is a treatment that I sometimes—but not generally—employ.

Over-the-counter pain medications designed to fight inflammation, such as Aleve or Advil, will sometimes lessen the pain and stiffness of frozen shoulder. I recommend that one try a seven to 10 day trial of over-the-counter anti-inflammatory medicines. If no relief is gained from this trial, I recommend that the patient stop using anti-inflammatory drugs for treatment of their frozen shoulder.

There is a role for surgery in patients with frozen shoulder who have failed to gain satisfactory relief of their pain or stiffness despite an adequate trial of nonoperative treatment. Surgery can include manipulation under anesthesia or arthroscopic frozen shoulder surgery. There are many important details to understand before making a decision about surgery for frozen shoulder.

Shoulder Instability

What is shoulder instability?

Shoulder instability is very common. Shoulders have a broad range of normal joint flexibility. Most of us have known someone who is “loose jointed”. Those patients have a natural instability in many of their joints. Many gymnasts and cheerleaders have naturally unstable joints.

A shoulder can also become unstable as a result of an injury. A forceful injury that overloads the ligaments in the shoulder may cause it to become unstable. Many unstable shoulders do not hurt at all.

WHEN TO SEE A SPECIALIST

An unstable shoulder warrants an evaluation by a shoulder specialist if the shoulder is unacceptably painful or its function is unacceptable. The evaluation of an unstable shoulder will include a history, a careful physical examination, and will sometimes involve imaging studies such as plain x-rays or MRI scanning.

Shoulder instability that is causing pain or dysfunction and is not the result of an injury can usually be successfully treated with nonoperative treatments, such as:

PHYSICAL THERAPY

Physical therapy is very effective in lessening the symptoms of a painful unstable shoulder. Physical therapy recommendations generally center around an effort to strengthen and coordinate the muscles of the shoulder that properly align the shoulder during vigorous activities.

MEDICATION

In some cases, medication taken by mouth or by injection into the shoulder joint may be appropriate.

SURGERY

Shoulder surgery is sometimes suggested for an unstable painful shoulder. If surgery is done on a naturally loose shoulder, it often affords temporary relief of symptoms. It rarely affords long-term relief. An unstable shoulder that is made more stable by surgery will usually become unstable again.

If the shoulder has become unstable because of any injury, the treatment is often different than that provided for a naturally unstable shoulder. MRI scanning is commonly utilized in the evaluation of instability that is the result of injury. MRI scanning has the ability to identify an injury to the labrum and the ligaments of the shoulder. Certain injuries to those structures will do better on a long-term basis if the patient has surgery.

Once your specialist has diagnosed the exact nature of your injury, explore the common disorders pages to find treatment FAQs.

Arthropathy

Arthropathy

Cuff tear arthropathy is a diagnostic term applied to a problem of the shoulder that consists of a torn rotator cuff tendon along with arthritis of the glenohumeral joint. The glenohumeral joint is the ball and socket joint of the shoulder. When one has cuff tear arthropathy, it is usually associated with a rotator cuff tear that cannot be surgically repaired.

The diagnosis of cuff tear arthropathy can be made by a combination of careful history, physical examination, and x-ray findings.

Patients with cuff tear arthropathy experience pain and impairment of function. Most patients present to an orthopedist with a complaint of weakness and pain in the shoulder.

Clarification of the diagnosis of cuff tear arthropathy sometimes involves obtaining an MRI scan of the shoulder. In most cases the diagnosis of cuff tear arthropathy can be made based on regular x-ray examination. An MRI scan is often not necessary.

TREATMENT

Cuff tear arthropathy is often treated with:

  • Home exercises
  • Physical therapy
  • Activity modifications
  • Medication
  • Surgery

A home exercise regimen for the treatment of cuff tear arthropathy can often be communicated to the patient with one or two visits to a physical therapist. After that, the patient exercises their shoulder at home using simple assistive devices such as an overhead pulley and elastic bands. It generally takes a couple of months of diligent exercise for the patient to notice a dramatic improvement in their weakness or pain from cuff tear arthropathy.

Supervised physical therapy may be warranted for treatment of cuff tear arthropathy if the patient is having difficulty doing exercises on their own. Some patients have such dramatic weakness from cuff tear arthropathy that they will benefit most from supervised physical therapy along with home exercises.

Some patients will find satisfactory resolution of their symptoms with simple activity modifications. These might include getting some help at home, so that they don’t spend as much time reaching high over their shoulders during a typical day. Rearranging cabinets and closets to avoid reaching high may help.

The medications used for cuff tear arthropathy are the same medications sometimes used for treatment of osteoarthritis. One may try an oral medication designed to lessen inflammation. I find the most effective medication for treatment of cuff tear arthropathy to be injection of cortisone into the shoulder joint.

Treatment