What Causes Persistent Shoulder Pain?
If you are suffering from persistent shoulder pain, it is important to know that you are not alone. In fact, in those with persistent shoulder pain, research has shown that over half of sufferers (54%) have ongoing symptoms after 3 years (Vecchio et al 1995).
In those with a new episode of shoulder pain, 70% have not recovered by 6 months. Half of individuals show persistent shoulder pain for more than 6 months & 40% fail to recover at one year (Ottenheijm et al. 2011)
If your shoulder pain is characterised by stiffness or lack of movement then you would consider the following causes:
- Frozen Shoulder
- Arthritis
- A-C (acromioclavicular) joint injury
If the shoulder has been sore for several weeks to a few months then you would consider:
- A tendon injury
- A rotator cuff tear
Weakness of the shoulder or arm can be caused by the following:
- A muscle tear
- A rotator cuff tendon rupture
- A disc herniation in the neck
- Calcific tendonitis. This is where a pocket of calcium is laid down randomly in a shoulder tendon
Why is my shoulder pain not going away? Could it be a Frozen Shoulder?
Frozen shoulder can give rise to persistent shoulder pain and is one of the more challenging presentations for a physiotherapist or chiropractor to manage. This condition is more common in women and in those who are suffering from diabetes or going through the menopause.
Frozen shoulder is characterised by thickening and the development of adhesions around the capsule that surrounds the shoulder joint.
The adhesions that develop within the capsule can cause a severe restriction of shoulder movement.
If you are suffering with a frozen shoulder you might notice some of the following:
- Difficulty putting on jumpers or coats
- Difficulty brushing your hair
- Reaching into cupboards becomes challenging.
Recent research has shown that in the early stages of a frozen shoulder, new blood vessel growth is evident on the involved side. This may occur as an attempt to initiate healing, or, can occur in response to lack of adequate blood supply to the tissue. Those suffering with diabetes, for example, have significant alterations in circulation. This may explain part of the link between conditions like diabetes, metabolic syndrome, and hypothyroidism and the presence of frozen shoulder.
Recent research has pointed to a link between chronic low grade inflammation and the presence of a frozen shoulder. Inflammatory cells have been demonstrated to be present in the early stages. One paper suggested that frozen shoulder may be an age related symptoms of metabolic syndrome and chronic low-grade inflammation (Pietrzak 2016). Indeed, the research is delving further into the link between systemic (body-wide) health state and the presence of such conditions.
If you are suffering with a frozen shoulder you are likely to report the following history:
- A slow onset over several weeks
- Difficulty lifting your arm up overhead to the front or lifting up towards your ear from the side
- Trouble sleeping on the painful side
A Frozen Shoulder has 3 Stages:
1) Stage 1 is the “freezing” stage. This stage is characterised by progressive shoulder pain
2) Stage 2 is the “Frozen” stage. This is characterised by a progressive stiffness of the shoulder. You may notice a significant limitation in lifting your arm overhead or behind your back
3) Stage 3 is the” thawing” phase. This is where the contraction of the shoulder capsule begins to ease and movement gradually increases.
Now here’s the bad news: the average duration of each of these 3 stages is 30 months. The range of time for each stage varies from between 12 to 24 months. Don’t panic just yet though: with appropriate treatment you can make significant inroads into this timescale.
What is the Best Treatment for a Frozen Shoulder?
A recent review of the literature analysed the impact of various techniques and determined which ones have been shown to be effective in treating shoulder pain.
They reported that joint mobilisation, when combined with intermittent stretching, proved more effective than either intervention when applied individually (Celik ad Kaya Mutlu).
Another option, supported by the literature, is the application of passive progressive stretching to increase shoulder range of motion. This led to improvement in movement and pain at 12 month follow-up.
Certain techniques demonstrated significant improvements in terms of pain. These included Mulligan joint mobilisation techniques, continuous passive motion, lidocaine injections and rotator cuff strengthening.
Why is my shoulder pain not going away? Could it be the Rotator Cuff Impingement?
A recent consensus paper published in the Journal of Physiotherapy Practice and Research provided guidelines on the diagnosis and rehabilitation of Shoulder Cuff Injuries.
The term ‘shoulder impingement’ is one that I commonly hear in practice. The old theory was that rotator cuff tendons could become impinged by the overlying bone (the acromion) of the shoulder, thus causing pain. You can feel this bone yourself by tapping down on the the most lateral point of the shoulder.
Should I have a Scan for my Shoulder Pain?
Scans would often demonstrate degeneration and give the impression of compressing the underlying tendon. The supposed logical conclusion was that the bone was pressing on the tendon below and, therefore, removing some of this bony pressure would alleviate symptoms. Well, as I always say to my patients:
“be careful of reading too much into MRI scan or x-ray results”
Repeated studies have refuted the theory that performing a decompression surgery has a positive impact on cuff tendon pain. A decompression surgery is where part of the bone over the tendons is shaved or removed to ease pressure on the tendon.
Indeed, the consensus guidelines of the expert group suggested that the term “impingement” should no longer be used as impingement of the structures of the shoulder has not been proven to correlate with pain.
I often see people from 50 to 70 years of age who have been diagnosed with a rotator cuff tear based on an MRI scan. The question is: how significant is this finding and is it definitely the source of their shoulder pain?
I hate to repeat myself but be very wary of the relevance of MRI findings.
The problem with having certainty that the tear found on your MRI scan is the source of your pain is that a significant proportion of people without any shoulder pain whatsoever will demonstrate cuff tears if they have an MRI of the shoulder. In fact, research demonstrates that:
- Up to 50% of people over 50 demonstrate tears in the rotator cuff
- 70% of 70 year old’s have tears of the rotator cuff muscle or tendon but not necessarily in the presence of pain
Rotator cuff tears are, however, rare in those under 35 years of age and tears in this group are usually trauma related.
How can I tell if my shoulder pain is from a rotator cuff tear?
- The pain is normally located at the outside of the shoulder at the top of the arm
- Movement of other body parts, such as the neck, should not reproduce your pain
- When the therapist assists you in moving the arm it should go to full range of motion without any blockage
What can I do for constant shoulder pain induced by a cuff injury?
- Generally, MRI or x-ray should be avoided due to poor correlation between imaging findings and a patient’s pain. Only if you are suffering with considerable shoulder stiffness or chronic pain of several month’s duration should you consider a scan.
- The expert group do not recommend steroid injections unless the pain fails to improve after an acceptable period of physiotherapy led rehabilitation (e.g. 6 to 12 weeks)
- Likewise, seeking an orthopaedic consultation should only be considered after a similar period of physiotherapy rehabilitation
- Lifestyle factors such as sleep quality, nutrition, alcohol and smoking should be assessed as such factors can impact on cellular function and can act as a driver of shoulder pain.
Oag et al. 2012. Chingford Cohort Study
The value of MRI scans are being brought into questions with greater frequency in recent years. Such scans have been shown to demonstrate structural changes which may be reflective of the natural ageing process as opposed to being the cause of pain or restricted movement
As shown in the table above, findings of cuff tears are present in high numbers in individuals who do not suffer from shoulder pain.
References:
To read more about shoulder pain visit our webpage on shoulder pain at: https://www.physioclinic.ie/conditions/shoulder-pain/
