In this blog post, I am going to be discussing a common complaint for my patients: shoulder pain. I’m going to mainly focus on muscle issues (rotator cuff pathology and biceps tendonitis) and in another post I’ll talk about some other issues affecting the shoulder. To start off, I’ll explain a little bit about the anatomy of the rotator cuff (which is actually 4 different muscles). Then, I’ll talk about how we diagnose rotator cuff issues and biceps tendonitis, and move onto various treatment options.
The rotator cuff is a group of muscles that help to keep the arm bone in the shoulder socket and allow for movement of the joint, especially overhead movement. It is comprised of four muscles- I memorized it as the SITS muscles in medical school- called the supraspinatus, infraspinatus, teres minor and subscapularis muscles. The biceps actually isn’t part of the rotator cuff, but it attaches just below the shoulder in the front of the arm, so pain there can be confused with the rotator cuff sometimes.
With repetitive overuse, dysfunctional joint movement or sometimes trauma, the muscles of the shoulder can become inflamed and irritated, known as tendonitis. Tendonitis, if untreated, can progress to microscopic tears in the muscle, which over time can worsen, sometimes into a partial or complete tear.
Patients who are having issues with the muscles in their shoulders often tell me that they have trouble doing overhead motions, like getting something down from a cabinet or washing their hair. Putting on a jacket can be another very difficult task, and many times people have trouble sleeping at night because it hurts to put pressure on that side.
In the office, after interviewing the patient, I will do a series of tests to try to determine if the pain is coming from the shoulder. I check for the range of motion in the joint, feel the muscles for areas of tenderness, check the strength of the arm, and do provocative testing, which are tests that will cause pain or weakness if certain muscles are affected. I also check to make sure that there are no signs of infection in the joint, like warmth, redness or swelling, and I assess the patient for signs of neck issues, which can often be confused with shoulder pain. .
Because typically the treatment for rotator cuff and biceps tendon issues is conservative, meaning non-surgical, I many times will start treating before doing imaging. A helpful imaging study to assess the shoulder muscles is an MRI because it shows all of the soft tissue; an X-ray will only give me information about the bones. But many times, unless I am suspicious for a complete tear, I will start with basic treatment options, such as anti-inflammatory medications (pills and ointments), and numbing ointments (Lidocaine typically), as well as physical therapy.
Physical therapy is the mainstay of treatment for these issues because it can focus on strengthening the muscles and correcting postural imbalances/other mechanical issues that may have led to the dysfunction. If a specific activity is causing the muscle issues, such as repetitive throwing or swimming, sometimes I will recommend a break from the activity to allow the body to heal.
As far as interventions, we used to commonly inject the shoulder joint with steroids to help with this type of pain. Unfortunately, we now know that the steroids may actually be harmful to the tendons, and so we’ve moved away from this treatment as a mainstay (although it can play a helpful role in frozen shoulder and other issues, which I’ll discuss in another post).
Platelet rich plasma therapy is an area of interest as a treatment for these types of disorders, with the idea that injecting the patient’s own pro-inflammatory healing factors may allow the tendons to heal. The evidence is mixed, with larger, high quality studies needed. Another area of interest is stem cell therapy, which has theoretically promising implications- again more research is needed to determine safety and efficacy.
Suprascapular nerve blocks, which are nerve blocks targeting the area of the shoulder, can also be helpful in alleviating shoulder pain. We will occasionally place steroid in the nerve block to try to prolong the effects, or do radiofrequency treatment (discussed in another post here).
Unfortunately, some patients, especially those with full thickness tears, do need surgical repair. I will send these patients to an orthopedic surgeon for evaluation and management if that is the case.
I hope this was helpful in explaining more about muscle related shoulder pain! Of course, the best way to determine if this is your issue is to see a pain management doctor in person. And don’t forget to subscribe to my blog here so you never miss a post!