I have shoulder pain – how do I know what caused it?

Dr Christelle van der Watt, orthopaedic surgeon with a special interest in shoulder surgery provides insight into caring for one of the most mobile joints in the body. 

Your shoulder provides a wide range of motion and there can be very different reasons why you experience shoulder pain. In most cases by listening to the patient’s history, the doctor can make a differential diagnosis of possible causes for the shoulder pain.

“The shoulder joint is a ball and socket joint and it has a group of 4 muscles which fit like a glove around the ball and socket. Each of them help to keep the ball in the middle of the socket but they also help to lift and rotate the arm,” she explains.

She explains that in different age groups, different conditions occur commonly.

Shoulder instability

In the young active rugby players instability is a common condition. “If you dislocate your shoulder under the age of 20 you have a very high chance of dislocating it again. There is also an 80% probability with each dislocation that there can be damage to the cartilage, which can lead to arthritis when you are older.”

Rotator cuff tears

“In the age group 40-60 we often see a rotator cuff tendon tear due to trauma. This leads to pain and loss of function. A patient would often say they can’t lift the arm above shoulder height or rotate the arm backwards. Sleeping on the affected side can be painful. When this happens we have to determine how big the tear is. Full thickness tears in this age group needs surgery. This is done with an arthroscope (keyhole surgery) and recovery takes a couple of months,” she explains.

Frozen shoulders

In females in the 40-60 year old age group who develop shoulder pain spontaneously and have a decreased range of motion, a frozen shoulder should be excluded. This is a very painful and stiff shoulder with sudden movements leading to severe pain. It can take up to 2 years to recover. She explains that a cortisone injection under ultrasound guidance helps for pain relief. Once the inflammatory phase has ended, physiotherapy helps to recover range of motion. In a small percentage of patients a Capsulotomy can be performed which helps to regain the range of motion.

Calcification tendonitis

30-60 year olds can develop calcification tendonitis, one of the most painful conditions in a shoulder. The pain can come and go and the pain can be so severe that patients seek care in the Emergency Centre. Calcium crystals form a collection in the tendons of the 4 muscles around the shoulder. From time to time these crystals leak into the subacromial space and cause severe inflammation- which leads to pain. Patients struggle to rotate their arms due to the pain. A cortisone injection under ultrasound guidance helps for the pain and often is all the patient needs. If conservative treatment fails an arthroscopic calcium deposit removal is indicated.

Biceps tendonitis

This is often due to repetitive overuse of the shoulder. We see this in active people or people who perform a lot of manual work. There will be pain in front of the shoulder and stretching forward can be painful. Again conservative treatment is indicated- anti-inflammatories, physiotherapy and a cortisone injection under ultrasound guidance can be administered. If this fails the patient will benefit from surgery.

Arthritis

Osteoarthritis of the shoulder joint is a common occurrence in the above 60 year old group. We can see it in younger patients- usually post traumatic. Treating arthritis always starts off with conservative treatment. We try to do joint replacements in the older age group. Replacements will wear out if a person is very active and this is the reason why we try to avoid putting them into younger patients.

Referred pain

An examination of the shoulder always starts with an examination of the neck to make sure there is not referred pain from nerve compression in the neck. The C5 nerve root supplies sensation to the shoulder. The lungs can also refer pain to the shoulder. This is usually pain at rest and no pain when moving the shoulder.

Other causes of pain could be bony spurs, bursitis and bad posture.

When should you seek help?

If you’ve had trauma and you have severe pain and loss of function you should see an orthopaedic specialist. If the pain that started spontaneously has not settled with rest, analgesia and physio please seek medical help.

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