Problems with the shoulder, the second most unruly joint in the body after the knee, send 4 million Americans to their doctors each year.
With young people – and active older folks as well – it’s usually a sports injury. But aging, along with plain old wear-and-tear, also wreak havoc on this flexible yet delicate joint.
“The shoulder is the most mobile joint in the body, but it’s the most unstable, too. What we gain in motion, we lose in stability,” says Dr. Jeffrey L. Zilberfarb, a shoulder surgeon at Beth Israel Deaconess Medical Center in Boston.
Indeed, the shoulder is the only place where tendons pass through a tight space between bones, making it a “set-up” for trouble, says Dr. Michael Wirth, an orthopedic surgeon at the University of Texas Southwest Medical Center in San Antonio.
And trouble comes in various forms. Tendons and muscles can shred as a result of wear and tear, making arm movement agonizing or impossible. Ligaments can be so loose congenitally or become that way from trauma or over-stretching that the arm slips out of the socket, a problem called instability or dislocation, depending on the severity. The opposite can happen, too – a shoulder joint can become so stiff from scar tissue that it becomes “frozen.”
Two summers ago, Carol Furneaux, a 55-year-old musical conductor from Carlisle, tripped over her 100-pound black lab as she got out of bed one night. The dog barely noticed.
But as she landed on her outstretched right arm, she felt a searing pain through her shoulder. By morning, the acute pain had subsided, but she couldn’t lift her arm.
Dr. Alan Curtis , an orthopedic surgeon at New England Baptist Hospital, gave her the diagnosis: a torn rotator cuff, the group of muscles and tendons that stabilizes the shoulder. He stitched it up surgically through a tiny incision and Furneaux was fine.
Until last summer, that is. She’d just had knee surgery (it has not been a good couple of years, she says) and was dutifully soaking her leg in a Jacuzzi. But as she hoisted herself out with her arms, she ripped her other rotator cuff. The verdict: another surgery.
Shoulders are particularly vulnerable to problems because a lot can go wrong in a relatively compact area. For one, spurs, or small protrusions, can develop on the acromion, a bone that sits on top of muscles and tendons, which connect the muscles to bone. The spurs rub against soft tissue, resulting in irritation and pain.
“Every time you reach forward, if the acromion has spurs on it, it rubs on top of the cuff, causing impingement, ” notes Curtis of the Baptist.
Sometimes, impingement of soft tissue is simply the result of poor anatomy – the acromion angles too far down. In other cases, the space is cramped because the bursa, a sac of fluid that lubricates the shoulder, becomes inflamed. Impingement can also occur if the rotator cuff muscles are weaker than the deltoid muscles in the arm – when the arm is raised, the cuff gets pinched.
Impingement often leads to tendonitis, an inflammation of the tendons. For reasons that are unclear, tendonitis may also cause calcium deposits in the cuff, which further irritates tissues, causing acute pain.
In 95 percent of cases, tendonitis gets better with simple remedies like rest, ice, and anti-inflammatory drugs. In severe cases, an injection of cortisone into the space beneath the acromion may be needed.
But with enough wear and tear – or with a sudden, acute injury like Furneaux’s – shoulder muscles and tendons can literally tear away from the bone. Tears that only go partway through the thickness of the rotator cuff often heal without surgery, says Curtis. But tears that go all the way through or that cause persistent pain or weakness demand surgery.
Historically, this meant a four- or five-inch incision to peel the deltoid off the acromion to gain access to the rotator cuff and stitch up the tear. The deltoid is then reattached and must heal, which takes six weeks or more. If the deltoid fails to re-attach properly after surgery, it can be irreparable.
“The worst case scenario,” says Curtis, “is a failed cuff repair and a failed deltoid repair. Then you have no cuff, no deltoid. You lose the ability to raise your arm, and there’s no good answer for that.”
In recent years, doctors have increasingly turned to less invasive, arthroscopic surgery. This involves making three quarter-inch incisions through which tiny cameras and instruments are inserted to enable doctors to sew up small tears as they monitor the procedure on a screen. For medium-size tears, doctors use a “mini-open” surgical technique, in which the deltoid is split, but not detached from the bone.
Although athrosocopy makes for speedier healing – it’s day surgery versus a night or two in the hospital for the larger incision – it’s still technically difficult enough that many surgeons haven’t yet learned to do it.
Meanwhile, surgeons are turning to a growing number of high-tech approaches for other shoulder problems.
Robert Colman is a 32-year-old Brookline man who works as a “grip,” or TV and film lighting specialist. That means he’s constantly lifting and holding lights over his head. Gradually, he says, pain from his shoulder instability became intolerable.
But instead of repairing Colman’s overstretched ligaments the old way – removing pieces of the ligaments and sewing the ends together through an open incision – his surgeon, Zilberfarb, repaired it with a new technique called thermal capsular shift.
This involves inserting lasers or radiofrequency probes through tiny incisions and heating ligaments to 152.6 degrees Fahrenheit, under anesthesia. The heat shrinks the collagen in ligaments, which causes scar tissue, which in turn tightens up the ligaments.
Potentially, ligaments could stiffen up too much or stretch out again over time. So far, though, Colman’s had no problems – he’s lifting weights and says he’s “glad I had the surgery.”
Many surgeons also now shave bone spurs off the acromion (a procedure called acromioplasty or subacromial decompression) during an arthoscopic procedure. This widens the space between the acromion and the soft tissues.
Wirth and others are also testing new ways to strengthen shoulder tendons with grafts of a material called SIS (made from the lining of the small intestine in pigs).
“It’s remarkable stuff,” he says. The material, which triggers the re-growth of tendons that have become too thin, is only done experimentally at this point.
As for “frozen” shoulders, the solution is more low-tech: stretching and physical therapy. It can take a year or more to “thaw” a frozen shoulder, with exercises to increase range of motion and break up scar tissue. In really stubborn cases, it may take surgery to remove excess scar tissue.
Many people simply live with their shoulder problems, hoping they’ll go away. And often they do. But others – especially men and older people – tend to wait too long to seek help, giving up one activity after another and putting up with considerable pain.
“What brings many men into the office is wives who can’t sleep because their husbands toss and turn because of shoulder pain,” Zilberfarb says. “Guys are in denial. We’d wait until an arm falls off to come in.”
Older people, too, often wait until the torn cuff atrophies and retracts into the socket.So the moral, as Furneaux puts it, is simple: “Don’t put it off.” With her first shoulder injury, she waited almost six months to see a doctor. “I was almost at the point where they couldn’t repair it,” she says.
Now, thanks to two athroscopic surgeries, she says, “I can lift both my arms over my head. It’s like it never happened.”
Divining and treating shoulder problems
The rotator cuff is a group of four muscles and tendons that hold the shoulder together and give it strength and flexibility. Together, these tissues hold the upper arm bone (humerus) in the shoulder socket (glenoid).
Problems can be diagnosed by X-rays (including an arthrogram, in which dye is injected into the shoulder to highlight the rotator cuff) and tests like CT scans, EMGs (electromyelograms, which assess the ability of nerves to stimulate muscle contractions), MRIs, and ultrasound, says Dr. Jeffrey L. Zilberfarb, an orthopedic surgeon at Beth Israel Deaconess Medical Center in Boston.
But you may be able to figure things out more simply. Sit on a chair with your arm held horizontally in front of you, elbow bent. Have a doctor or a friend push down lightly on the top of your hand as you pretend to pour water out of a glass. If it hurts as you “pour,” your rotator cuff may be irritated and you should see a doctor, says Zilberfarb.
Most shoulder problems can be treated without surgery. Try the following:
- Rest. In bed, lie on your good side and put a pillow between your injured arm and your side to take the pressure off the shoulder. When you’re not in bed, if your shoulder is very painful, keep your arm in a sling for a few days. (But if you have a fever, get to an emergency room – you may have a “septic shoulder,” a serious infection.) Never rest so much that your shoulder gets stiff – alternate rest with gentle exercise. – Cold. If you have tendonitis, put ice on your shoulder for 20 minutes 3 times a day. Cold helps by reducing inflammation.
- Heat. If your shoulder is stiff, try heating pads and gentle exercises like standing in a hot shower with your shoulder against a wall and “walking” your fingers up the wall. Heat helps by increasing blood flow to injuried tissues.
- Medications. Over the counter anti-inflammatory drugs like ibuprofen often help. For severe cases, you may need cortisone injections or cortisone cream applied to the skin.
- Ultrasound. Like heat, ultrasound waves can warm tissues in the shoulder, improving blood flow and speeding the healing process.
- Electrical stimulation. TENS, or transcutaneous electrical nerve stimulation, can ease pain by sending electrical signals through the skin to your shoulder to block pain signals.
- Exercises – done gently – can also help heal injured shoulders and prevent further injury. Here are some:
- Take a towel and drape it over your good shoulder. Hold the front end with your good hand. Put your bad arm behind your back and grab the dangling end of the towel. Pull gently with your good arm to raise your injured arm. Hold for a few seconds then repeat five to 10 times.
- Rest the hand of your bad arm on the shoulder of your good arm. Take your free hand and pull the elbow of your bad arm toward your good side to stretch your bad shoulder. Hold the stretch for 10 seconds, then repeat. You can also do this lying down.
- Take an inner tube from a bicycle tire or color-coded rubber tubing from a physical therapist. Tie it to a doorknob. Stand with your injured shoulder toward the doorknob. With your bad elbow pressed against your side, hold the end of the band and pull it toward your good side. Repeat 10 times. Then turn so that your good shoulder is toward the doorknob. Grab the tubing with your bad arm, and move it away from your body, again keeping your elbow tucked in.