Shoulder Pain

Prevalence of Shoulder Pain

The prevalence of shoulder disorders has been reported to range from 7% to 36% of the population, accounting for 1.2% of all General Practitioner encounters in Australia, being third only to back and neck complaints as musculoskeletal reasons for primary care consultation.

The shoulder is frequently injured, particularly in competitive sports. 8% to 13% of athletic injuries involve the shoulder.

Analysis from a community-based rheumatology clinic in the UK, 65% of cases were rotator cuff lesions, 11% were caused by localised tenderness in the pericapsular musculature, 10% involved acromioclavicular joint pain, 3% involved glenohumeral joint arthritis, and 5% were referred pain from the neck.

Pain Mechanism

Rotator cuff tendinopathy is the most common cause of shoulder pain. An occupational history with repetitive movement or heavy lifting is normally related to this disease. A rotator cuff tear is usually strongly indicated by trauma in young people and atraumatic in elderly people, which is likely attributed from bone spurs or cuff degeneration. 

Frozen shoulder (adhesive capsulitis) and true glenohumeral arthritis are often preceded by history of deep joint pain and restricted activities. Adhesive capsulitis is more common in people with diabetes and may also occur after prolonged immobilisation. 

Acromioclavicular disease is usually secondary to trauma or osteoarthritis. Signs of inflammation, such as pain, tenderness, swelling are localised to the joint, with restriction in movement across another shoulder. 

Often, shoulder pain could be referred from the cervical spine, especially when the lower cervical spinal segments developed arthritis and spread across upper back and shoulders. Other commonly seen conditions, include myofascial pain where the is associated with inflammation or irritation of muscle or of the fascia surrounding the muscle. 

Hence, when we looking at the targeted pain mechanism to treat the shoulder pain, we should consider the following:

• Nociceptive: Tissue Injury e.g. rotator cuff injury, glenohumeral joint capsulitis/arthritis, bursitis,  myofascial pain, osteoarthritis 
• Neuropathic: Nerve Injury e.g. nerve impingement, referred pain from cervical spine
• Nociplastic: Sensitised Nervous System e.g. nonspecific shoulder pain, fibromyalgia

Clinical Presentation

Deep joint pain, stiffness, muscle spasm, reduced range of motion, crepitus (crackling sounds), muscle weakness, shooting pain down the arms, numbness, tingling, fatigue, and pain-related psychological distress are also seen frequently in patients with shoulder pain.

Scientific research has helped us to understand pain is a multidimensional dynamic experience with multiple brain sites activation. From localised muscle or nerve inflammation to neuroplasticity (ie. structural and chemistry changes of the nervous system) leading to emotional distress and behavioural changes. 

Factors associated with Shoulder Pain Development 

Common risk factors are: excessive overloading, instability of the glenohumeral and acromioclavicular joints, muscle imbalance, poor anatomical features, rotator cuff degeneration with ageing, ischaemia, and musculoskeletal diseases that result in wasting of the cuff muscles. 

Specific risk factors for frozen shoulder (adhesive capsulitis) include female sex, older age, shoulder trauma, surgery, diabetes, cardiorespiratory disorders, cerebrovascular events, thyroid disease, and hemiplegia. 

See Osteoarthritis page for specific factors contributing to the development of arthritis. 

Effects of Persistent Pain

• Biological: Heightened Pain, Cognitive Impairment, Sleep Disturbance, Physical De-Conditioning, Medication Over-Use, Suppression of immunity
• Psychological: Depression, Anxiety, Post-Traumatic Stress, Learned Helplessness, Suicide Risk
• Sociocultural: Social Withdrawal, Dysfunctional Relationships, Isolation, Carer Stress, Vocational Role Interference, Financial Ramifications

Pain treatment Options

It is no longer acceptable to apply single model fo care to everyone living with osteoarthritis related pain. It is best practice that treatment should be mechanism-based, symptom-based and disease-based. No two patients are alike, why should the treatment follow a strict algorithm? Treatment plans should be patient-centred with biopsychosocial strategy, with personalised approach in a stepped-care model.

The goal of the treatment is to promote resilience, healing, prevent and reduce pain chronification.

Common Treatment Options include (but not limited to):

• Patient Education 
• Pharmacotherapy
• Physical Activities
• Cognitive Modification
• Sociological Support
• Procedural Interventions 

Pain Education

“Educational Interventions that aim to change one’s understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself” – Explaining Pain

Education is a powerful tool to help you to understand information about the different treatment approaches, information about the disease, about the pathophysiology, and about the diagnostic imaging. 

Consistent recommendations for early management are that individuals should be provided with advice and education about the nature of shoulder pain; reassurance that they do not have a serious disease and that symptoms will improve over time; and encouragement to avoid immobilisation, stay active, and continue with usual activities, including work. 

Physical Activities

Exercise therapy is particularly helpful in decreasing pain and improving joint motion. Research shows that a comprehensive programme tailored to individual needs is recommended. No one exercise programme is more superior or beneficial. 

Recommended physical treatments, particularly for persistent shoulder pain, include a graded activity or exercise programme that targets improvements in function and prevention of worsening disability. 

Specifically for rotator cuff pathology and glenohumeral joint disorder (adhesive capsulitis and osteoarthritis), gradual overhead activity and weight loading is the mainstay of treatment for rotator cuff pathology. In other words, a directed and guided therapy is likely beneficial to progress and not overusing the structures. 

The benefits of exercises include Improve Sleep, Weight Loss, Endorphine Secretion, Reverse Deconditioning, Functional Gain.

Cognitive Modification

Cognitive Behavioural Therapy (CBT) is the most common psychological intervention. It consists of cognitive appraisal, restructuring beliefs, behavioural activation, problem solving and motivation. It helps people living with chronic shoulder pain to conquer fears of moving and emphasise on exacerbation management. 

If it is trauma related, specialised psychological therapy (such as Eye Movement Desensitisation and Reprocessing “EMDR” Therapy) can be adopted to mitigate the anxiety, intrusive thoughts, avoidant behaviour resulted from the injury. 

CBT is not the only psychological treatment available. More advanced therapy also available to explore the dynamic cognitive process to facilitate sustained benefits for people with complex psychological construct. 

Pain Medications  

The most often recommended in the guidelines include paracetamol and anti-inflammatories. Recent research from UNSW demonstrated paracetamol has no benefit in pain reduction. Topical or oral anti-inflammatories were shown to be effective for pain relief and for function. 

There is no scientific evidence and role for Muscle Relaxants and Benzodiazepines use.

Nerve medications have established efficacy for shoulder pain, which result in pain reduction and improve function. The mechanism is thought to be enhancing the descending modulatory systems (ie. the calming system from our brain).

Regarding opioids use, the small gain weighted against the side-effects, and the risk of addiction and overdosage, has led to an overall discouragement of prescribing these products to patients with osteoarthritis. If pain is severe and not responding to the conventional management, cautious selection of safer opioids with clear goals are essential.

Minimally invasive procedure

Depending on the symptoms, mechanism and underlying pathology, procedural interventions could be very beneficial to facilitate functional gain. These include:

• Rotator cuff and/or bursa injection with cortisone: delivering anti-inflammatory medications directly into the area of pathology. 
• Botox intramuscular injection: if Myofascial pain with trigger points are suspected
• Suprascapular nerve block with steroid injection: the most common nerve block to target posterior shoulder pain. Ask your doctor for targeted nerve block for anterior shoulder or biceps pain.
• Nerve-block with Radiofrequency Treatment: providing longer effect, especially for those who are resistant to nerve block with steroid injection only
• Neuromodulation: when there is refractory pain management from above procedures

Look at Back Pain article for referred cervical spinal pain.

Surgical options

For acromioclavicular osteoarthritis, failure to improve or maintain function with conservative measures warrants surgical referral, and resection of the distal clavicle is often effective in relieving pain symptoms

For adhesive capsulitis, referral is indicated when the patient has failed six months of conservative treatment and glenohumeral joint injection with manipulation under anaesthesia. Surgery generally involves arthroscopic capsular releases.

For glenohumeral osteoarthritis, aggressive range of movement can be counterproductive. Maintenance a function, pain-free range of movement can be beneficial. Surgical options include capsular release and arthroscopic debridement, hemiarthroplasty, and total shoulder arthroplasty.

For rotator cuff disorders, trial of conservative and minimally invasive procedures for 6-12 weeks is reasonable. For large, retracted tears, prompt referral is indicated with surgical options include open or arthroscopic decompression and rotation cuff repair. 

 Action Points

Shoulder pain is a common and important musculoskeletal problem. Management should be multidisciplinary and include education on self management, pain medications, physical therapy and/or psychological therapy. Sometimes, minimally invasive procedures and/or surgery is required to provide functional rehabilitation and reduce disabilities. Your treatment plans should be fast-tracked and tailored to your symptoms. 

Dr Chow Chow provides remarkable collaborative system with Sydney top leading experts, this includes physical therapist, pain psychologist, psychiatrist, rehabilitation physicians and shoulder surgeon. 

Have any questions about how to manage your shoulder pain? Contact email info@drchowchow.com

Resources

1. Green, S., Buchbinder, R., & Hetrick, S. E. (2003). Physiotherapy interventions for shoulder pain. Cochrane database of systematic reviews, (2).
2. Mitchell, C., Adebajo, A., Hay, E., & Carr, A. (2005). Shoulder pain: diagnosis and management in primary care. Bmj, 331(7525), 1124-1128.
3. Murphy, R. J., & Carr, A. J. (2010). Shoulder pain. BMJ clinical evidence, 2010.
4. Meislin, R. J., Sperling, J. W., & Stitik, T. P. (2005). Persistent shoulder pain: epidemiology, pathophysiology, and diagnosis. American journal of orthopedics (Belle Mead, NJ), 34(12 Suppl), 5-9.
5. Luime, J. J., Koes, B. W., Hendriksen, I. J. M., Burdorf, A., Verhagen, A. P., Miedema, H. S., & Verhaar, J. A. N. (2004). Prevalence and incidence of shoulder pain in the general population; a systematic review. Scandinavian journal of rheumatology, 33(2), 73-81.
6. Burbank, K. M., Stevenson, J. H., Czarnecki, G. R., & Dorfman, J. (2008). Chronic shoulder pain: part II. Treatment. American family physician, 77(4), 493-497.
7. Macfarlane, G. J., Hunt, I. M., & Silman, A. J. (1998). Predictors of chronic shoulder pain: a population based prospective study. Journal of Rheumatology, 25, 1612-1615.