SHOULDER PAIN
What is the cause of shoulder pain? Most of the time, pain in the shoulder comes from overuse. If you look at the picture of the shoulder with the deltoid (that's the big muscle that covers your whole shoulder joint) removed, you will see that your arm bone, your humerus sits underneath the top of your shoulder blade and that the muscles that move the shoulder all start out attached to the shoulder blade and have to travel under that bony bridge to move your humerus. If your shoulders slump forward, or if the bridge is crooked, these muscle tendons will be squeezed between the humerus and your shoulder blade every time you move your shoulder. The tendon at the very top of the humerus is the supraspinatus tendon and is the one most likely to be damaged. When you raise your arms, the squeezing gets worse. This will eventually wear out the tendons and cause a great deal of pain. The muscles that get squeezed are called the rotator cuff, because they help your shoulder rotate and keep it in its socket. The wearing out of the rotator cuff tendons is called rotator cuff syndrome.
Ligaments and tendons are made up of collagen, the same substance that holds up your skin, and, just as your skin loses its tone as you get older, so do your ligaments and tendons. Because of this, as you get older, the ligaments and tendons that surround your shoulder joint get looser and weaker. This means the head of your humerus will move too much inside the shoulder joint and wear out the cartilage which lines the joint. In order to try and stabilize your shoulder, the bones around the joints will start to grow. This thinning of the cartilage and the growth of the surrounding bone is called osteoarthritis. It can also be a source of pain. Another joint in your shoulder area that can develop arthritis is the joint between the acromion and your clavicle called the acromioclavicular joint.
What can relieve shoulder pain?
Acetaminophen, Tylenol, which has a mild anti-inflammatory effect, and anti-inflammatory medications such as aspirin, ibuprofen, Advil, Motrin have, until now, been the mainstay of treatment to relieve shoulder pain. They all relieve the symptoms that occur with overstretched and worn ligaments and tendons. They work by relieving inflammation which is a cause of pain. Unfortunately, inflammation is the mechanism the body uses to repair itself, and using these medications interferes with the process which would help regrow the affected ligaments and tendons. Anti-Inflammatory References
People who have suffered from intractable shoulder pain are often given cortisone shots. These, being even more powerful anti-inflammatory substances, unfortunately also interfere with healing of the shoulder and can at times cause rupture of shoulder tendons. Steroid references.
Physiotherapy helps shoulder pain by improving your posture so that your rotator cuff muscles don't get squeezed as much between your humerus and your acromion, and strengthening the muscles which stabilize your shoulder. Unfortunately, it is impossible to strengthen ligaments and tendons with exercise. Since your muscles are pulling on these weakened ligaments and tendons, your symptoms are likely to recur.
Surgery may be needed in refractory cases, particularly if one of the shoulder tendons has been completely ruptured, or if the acromion is crooked. More and more, orthopedic surgeons are performing keyhole surgery to help repair these structures. In Canada, the wait to see a shoulder specialist can be more than one year. In all countries, surgery can be very costly.
Narcotics can be used to deaden the pain and do not interfere with inflammation, but they can be addictive and should be used very sparingly.
How effective are these treatments? Statistics show that 54% of those who have a rotator cuff problem will still be in pain and have limited use of their shoulder after three years.
Can prolotherapy help with shoulder pain? Prolotherapy, a series of injections of growth promoting substances has been shown to be effective in stimulating the growth and repair of ligaments and tendons. Injections to the shoulder ligament and tendon insertions strengthen and thicken them. These stronger ligaments and tendons will help restore the strength of your shoulder and help correct the cause of shoulder pain. Prolotherapy has been shown to reduce the overgrowth of bone which occurs in osteoarthritis of the fingers and of the knee. It probably does so because it stabilizes the joints by strengthening the ligaments that surround them. This reduces the wear and tear on the joints which is the main reason bones around the joints proliferate. If this occurs in your shoulder it may help prevent the onset of osteoarthritis of your shoulder joint.
If you have tried other treatments and still experience pain, you may want to try prolotherapy. There is a good chance that prolotherapy can bring you relief from your shoulder pain. There have unfortunately not been any “gold standard” studies done to prove the value of prolotherapy in rotator cuff problems. This is why Dr. Bertrand will carry out such a “gold standard” study. In a preliminary observational study, 75% of those treated with prolotherapy were better after three months (as opposed to 46% after three years).
If you want to participate in this research program click on the consent form for the rotator cuff tendinopathy study.
references on the shoulder
Lewis JS Rotator cuff tendinopathy / subacromial impingement syndrome: Is it time for a new method of assessment? Br J Sports Med Oct 2008 Shows how long the disability from rotator cuff injuries and tears will last, mostly because people don't understand the underlying pathology
Rathbun JB, Macnab I: The microvascular pattern of the rotator cuff. J Bone Joint Surg Br 1970;52:540-553. Shows how poor the circulation is to the supraspinatus tendon
Google: American Academy of orthopedic surgeons: Rotator Cuff Tears: Frequently Asked Questions A good overview of how effective the currently available treatments are, and what are their possible risks and side effects
J.Carpenter, S.Thomopoulos, C.Flanagan, C.DeBano, L.Soslowsky Rotator cuff defect healing: A biomechanical and histologic analysis in an animal model
Journal of Shoulder and Elbow Surgery, Volume 7, Issue 6, Pages 599-605
Shows that left on their own tendons healed very poorly
Click here for more information on what prolotherapy is, how prolotherapy works , what conditions respond to it when should you avoid it what are the risks what are the benefits how long does it last how much does it cost the prolotherapy consent form who is Dr. Bertrand as well as testimonials and how to get to Dr. Bertrand's office.