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Bursitis

Bursae are small, fluid-filled sacs that are located in joints throughout the body, including the shoulder. They act as cushions between bones and the overlying soft tissues, helping to reduce friction between the gliding muscles and the bone.

Sometimes, excessive use of the shoulder leads to inflammation and swelling of the bursa between the rotator cuff and part of the shoulder blade known as the acromion. The result is a condition known as subacromial bursitis.

Bursitis often occurs in association with rotator cuff tendinitis. The pain and inflammation can make many daily activities, such as combing your hair or getting dressed, difficult.

Tendinitis

A tendon is a cord that connects muscle to bone. Tendinitis is a result of inflammation in the tendon.

Generally, tendinitis is one of two types:

• Acute. Excessive ball throwing or other overhead activities during work or sport can lead to acute tendinitis.
• Chronic. Degenerative diseases like arthritis or repetitive wear and tear due to age, can lead to chronic tendinitis.

The most commonly affected tendons in the shoulder are the four rotator cuff tendons and one of the two biceps tendons. The rotator cuff is made up of four small muscles and their tendons that cover the head of your upper arm bone and keep it in the shoulder socket. Your rotator cuff helps provide shoulder motion and stability.

Learn more: Biceps Tendinitis, Shoulder Impingement/Rotator Cuff Tendinitis

Tendon Tears

Splitting and tearing of tendons may result from:

• Acute injury
• Degenerative changes in the tendons due to advancing age, long-term overuse, or wear and tear

These tears may:

• Be partial (only go through part of the tendon thickness)
• Completely separate the tendon (pull it away) from where it attaches to bone

Rotator cuff and biceps tendon injuries are among the most common of these injuries.

Learn more: Rotator Cuff Tears, Biceps Tendon Tear at the Shoulder

Impingement

Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the underlying soft tissues when the arm is lifted away from the body. As the arm is lifted, the acromion rubs, or "impinges" on, the rotator cuff tendons and bursa. This can lead to bursitis and tendinitis, causing pain and limiting movement. 

Learn more: Shoulder Impingement/Rotator Cuff Tendinitis

Instability

Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This usually happens initially as a result of a sudden injury, but it can become chronic.

• Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation.
• A complete dislocation means the ball comes all the way out of the socket.

Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Recurring (repeated) dislocations, which may be partial or complete:

• Cause pain and unsteadiness when you raise your arm or move it away from your body
• Lead to an increased risk of developing arthritis in the joint

Learn more: Chronic Shoulder Instability, Shoulder Dislocation

Arthritis

Shoulder pain can also result from arthritis. There are many types of arthritis. The most common type of arthritis in the shoulder is osteoarthritis, also known as wear-and-tear arthritis. Symptoms such as pain and stiffness typically begin during middle age. Osteoarthritis develops slowly and the pain it causes worsens over time.

Osteoarthritis may be related to sports or work injuries or chronic wear and tear. Other types of arthritis can be related to rotator cuff tears, infection, or an inflammation of the joint lining.

Often people will avoid shoulder movements to try to lessen arthritis pain. This sometimes leads to a tightening or stiffening of the soft tissue parts of the joint, resulting in a painful restriction of motion.

Learn more: Arthritis of the Shoulder

Fracture

Fractures are broken bones. Shoulder fractures commonly involve the clavicle (collarbone), humerus (upper arm bone), and scapula (shoulder blade).

Shoulder fractures in older patients are often the result of a fall from standing height. In younger patients, shoulder fractures are often caused by a high-energy injury, such as from a motor vehicle collision or contact sports impact (like a football tackle or crashing into the boards in hockey).

Fractures often cause severe pain, swelling, and bruising about the shoulder.

Learn more: Shoulder Trauma (Fractures and Dislocations)

Medical History

The first step in the evaluation is a thorough medical history. Your doctor may ask:

• How and when the pain started
• Whether the pain has occurred before and, if so, how it was treated
• Other questions to help determine both your general health and the possible causes of your shoulder problem

Because most shoulder conditions are aggravated by specific activities, and relieved by specific activities, a medical history can be a valuable tool in finding the source of your pain.

Physical Examination

A comprehensive examination will be required to find the causes of your shoulder pain. Your doctor will:

• Look for physical abnormalities, swelling, deformity, and/or muscle weakness
• Check for tender areas
• Observe your shoulder range of motion and strength

Tests

Your doctor may order specific tests to help identify the cause of your pain and any other problems.

• X-rays. X-rays will show any injuries to the bones that make up your shoulder joint.
• Magnetic resonance imaging (MRI) scans and ultrasound. These imaging tests create better pictures than X-rays of soft tissues. MRI may help your doctor identify injuries to the ligaments and tendons surrounding your shoulder joint.
• Computed tomography (CT) scan. A CT scan combines X-rays with computer technology to produce a very detailed view of the bones in the shoulder area.
• Electrodiagnostic testing. Your doctor may order a test, such as an electromyography (EMG), to evaluate nerve function.
• Arthrogram. During this X-ray study, dye is injected into the shoulder to better show the joint and its surrounding muscles and tendons. It may be combined with an MRI or CT scan.
• Arthroscopy. In this surgical procedure, your doctor looks inside the joint with a fiber-optic camera. Arthroscopy may show soft tissue injuries that are not apparent from the physical examination, X-rays, and other tests. In addition to helping find the cause of pain, arthroscopy may be used to treat the problem.

Activity Changes

Treatment generally involves:

• Rest
• Altering your activities
• Physical therapy to help you improve shoulder strength and flexibility

Common sense solutions, such as not overdoing activities in which you normally do not participate, can help to prevent shoulder pain.

Medications

• Your doctor may prescribe medication to reduce inflammation and pain. If medication is prescribed to relieve pain, it should be taken only as directed.
• Your doctor may also recommend injections of numbing medicines or steroids to relieve pain.

Surgery

Surgery may be required to resolve some shoulder problems. However, most patients with shoulder pain will respond to simple treatment methods such as altering activities, rest, physical therapy, and medication.

Certain types of shoulder problems, such as recurring dislocations and some rotator cuff tears, may not benefit from exercise. In these cases, surgery may be recommended fairly early.

Surgery can involve arthroscopy to remove scar tissue or repair torn tissues, or traditional open procedures for larger reconstructions or shoulder replacement.