Today’s blog will focus on chronic shoulder pain.

From the very beginning of my practice, I have always tried to identify not just THE cause of anyone’s chronic pain, but all possible causes. Here is a list of things that I look for:

  • Muscle dysfunction causing loss of range of motion, loss of strength or pain;
  • Pain causing injuries of ligaments or tendons;
  • Joint related pain;
  • Nerve related pain; and
  • Brain related pain.

Finding out which ones are contributing to your pain is not straightforward. Here’s why.

NO TEST SHOWS PAIN.

This is completely counterintuitive.

You have shoulder pain, get an ultrasound that shows a tear in one of your rotator cuff tendons and now you know why you have pain. Except maybe you don’t.

In an authoritative 1995 study, 96 people who had never had shoulder pain had an MRI scan of their shoulders. A total of 33 of them had rotator cuff tears they were unaware of. The older you were, the more likely you were to have one of these tears. 54% of the people over 60 had a tear they were unaware of.

Another study published in 2019 looked at a younger group of professional and collegiate ice hockey players who had no history of shoulder injury, pain or dysfunction. 25% of them were found to have a labral tear. Rotator cuff abnormalities were uncommon in this group.

This means that if you have shoulder pain and you are over 60, I have to be very suspicious about whether any rotator cuff tears that might have been reported during an ultrasound or MRI scan are actually the cause of your pain. In some groups of people, labral tears rather than rotator cuff tears were common findings but again, not a cause of any discernible shoulder problems.

So, how do I sort it out?

A good history and physical examination is crucial to ruling out muscle and nerve pain.

If the ultrasound suggests you have tears in the supraspinatus or the subscapularis tendons, there are specific tests for each of these tendons.  Let’s say that the exam shows you have pain and weakness when I test both of these tendons. It’s tempting just to stop there. However, sometimes I find that the problem is just that the subscapularis tendon isn’t sliding properly because the sliding surface between the tendon and the muscle above it have been damaged – and when that is addressed, the subscapularis tendon is now functioning normally.  So the problem wasn’t the tear in that muscle.

Back to the supraspinatus tendon tear. I am suspicious the tear is the cause of the pain.

To prove or disprove this I use my ultrasound to do a guided injection of a tiny amount of freezing into the tear, ensuring it is painless. If the tendon testing is now normal, then the tear is most likely the problem and we can talk about treatment options. If the pain is still there, I will need to keep looking for the source of the pain.

Conservative therapy with medications and physiotherapy is always the way to start, and treatment should never start with prolotherapy or platelet rich plasma. The entire shoulder joint movement and strength needs to be assessed to determine if there were any biomechanical problems that might have led to the shoulder problem to begin with. This is important because a small tear today can become a complete tear in a few years if you don’t change the loading pattern of the tendon.

How far we take the next steps is up to the individual, but here are some things we might talk about:

  • Ergonomic adjustments (e.g. placing monitors, keyboards, and chairs at appropriate heights)
  • Postural retraining – Education and training to improve sitting, sleeping, and standing postures
  • Mobility/flexibility interventions – Exercises for the thoracic spine, scapulothoracic joint, glenohumeral joint, and cervical spine as needed to improve shoulder mechanics
  • Strengthening and stability exercises to restore balance and coordination to the shoulder complex
  • Treatment of any underlying soft tissue conditions with manual therapy or other modalities (may include: cross friction massage, medically-assisted soft tissue mobilization, taping, ice/heat, nonsteroidal anti-inflammatory drugs [NSAIDs], injections and dry needling)

If this is a problem you might be experiencing, I look forward to helping you.

 

Reference: Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10

Brittney Hacken, Cayce Onks, Donald Flemming, Timothy Mosher, Matthew Silvis, Kevin Black, Dan Stuck, Aman Dhawan. Prevalence of MRI Shoulder Abnormalities in Asymptomatic Professional and Collegiate Ice Hockey Athletes. Orthop J Sports Med.2019 Oct 10;7 (10)