Treating Shoulder Pain Part 1

There are several types of treatment for shoulder pain. The main treatment options include:

• Avoiding activities that make your symptoms worse
• Painkillers
• Anti-inflammatories
• Physiotherapy – where physical methods, such as massage and manipulation, are used to promote healing
• Surgery (in some cases)

The treatment that you have may depend on the cause of your shoulder pain (see Shoulder pain - causes) and your symptoms. For example, as well as pain, you may also have reduced strength or movement in your shoulder. In this case, a combination of different treatments may be used.


Avoiding Activities

Depending on what is causing your shoulder pain, your GP may recommend that you avoid certain activities or movements that may make your symptoms worse.
For example, in the early, painful stage of frozen shoulder, your GP may suggest that you avoid activities that involve lifting your arms above your head. However, you should continue using your shoulder for other activities because keeping it still could make your symptoms worse.
If you have shoulder instability, your GP may recommend that you avoid any movements that are likely to make the instability worse, such as overarm throwing.
If you have sprained your acromioclavicular joint (the joint at the top of your shoulder), your GP may suggest that you avoid moving your arm across your body. You may also be given a sling (a supportive bandage) to wear to support your arm for up to a week after your injury.

Painkillers

If your pain is mild, taking painkillers such as paracetamol or codeine may be enough to control it. Always follow the dosage instructions on the packet to ensure that the medicine is suitable and that you do not take too much.
If your shoulder pain is more severe, your GP may recommend or prescribe a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen, diclofenac or naproxen.


As well as easing the pain, NSAIDs can also help to reduce swelling in your shoulder capsule. They are most effective when taken regularly rather than when your symptoms are most painful.
Cautions

Side effects can sometimes occur when using NSAIDs. They may include:

• Nausea (feeling sick)
• Diarrhoea
• Headaches
• Dizziness

Before taking NSAIDs, you should speak to your GP if you have any of the following:

• asthma – a long-term condition that can cause coughing, wheezing and breathlessness
• high blood pressure (hypertension)
• kidney problems 
• heart problems

Oral Corticosteroids

Corticosteroids are medicines that contain steroids, which are a type of hormone. Hormones are powerful chemicals that have a wide range of effects on the body, including reducing swelling and pain.
You may be prescribed corticosteroid tablets for frozen shoulder. Some evidence suggests that these may provide short-term pain relief for a few weeks. However, it is not clear whether corticosteroid tablets are any better than the other treatment options, such as corticosteroid injections.

Read Part 2 Here

Treating Shoulder Pain Part 2

 Treating Shoulder Pain:Part 2

Corticosteroid Injections

If your shoulder pain is very severe, such as in certain cases of frozen shoulder, painkillers may not be enough to control the pain. In this case, you may have corticosteroids injected into and around your shoulder joint.
Corticosteroid injections can help to relieve the pain that is caused by frozen shoulder and increase your range of movement for several weeks at a time, particularly during the first stage of symptoms. However, the injections cannot cure your condition completely, and your symptoms will gradually return.
Research also suggests that corticosteroid injections can provide pain relief for up to eight weeks for tendonitis (inflammation of a tendon). They may also improve your ability to use your shoulder, although they may not be as effective as some other treatments, such as NSAIDs.
One study found that corticosteroid injections may be most effective if they are used within 12 weeks of tendonitis symptoms starting. However, some experts believe that the use of corticosteroid injections should be delayed for as long as possible.

Cautions

After having a corticosteroid injection, you may experience a number of side effects at the site of the injection.
Possible side effects can include:

• Temporary pain
• Depigmentation – when your skin becomes lighter 
• Skin atrophy – when your skin becomes thinner as some of the skin cells waste away

Having too many corticosteroid injections can damage your shoulder. Therefore, you may only be able to have this treatment up to three times in the same shoulder in one year.


Hyaluronate Injections

Hyaluronate is another medicine that can be injected into your shoulder to treat shoulder pain. One review of a number of studies found that hyaluronate was effective at reducing pain.
However, the National Institute for Health and Clinical Excellence (NICE) does not recommend hyaluronate to treat osteoarthritis (a condition that affects the joints). It found that hyaluronate only had small benefit and that corticosteroid injections were a better treatment choice. Therefore, hyaluronate may not be used.

Physiotherapy

Physiotherapy, often referred to as physio, uses a number of different physical methods to promote healing. If you are referred to a physiotherapist, they should explain to you what treatment they will use and how it will work. Possible treatments include:

• Massage – where the physiotherapist uses their hands to manipulate your shoulder
• Laser therapy – where the energy from lasers (narrow beams of light) are used to stimulate your nervous system and reduce pain  
• Transcutaneous electrical nerve stimulation (TENS)

TENS is a type of physiotherapy where small electrical pads (electrodes) are applied to the skin over your shoulder. The TENS machines delivers small pulses of electricity through the electrodes, which numb the nerve endings and control your pain.
As well as these treatment methods, your physiotherapist may also recommend shoulder exercises. These will be specific for your needs. For example, if you have shoulder instability, you may be given exercises that will strengthen your shoulder.

Shoulder Exercises

If you have shoulder pain, it is important to keep your shoulder joint mobile by doing gentle, regular exercise. Not using your shoulder can cause your muscles to waste away and may make any stiffness worse. Therefore, if possible, you should continue using your shoulder as normal.
If your shoulder is very stiff, exercise may be painful. Your GP or physiotherapist can give you some exercises that you can do without further damaging your shoulder.
You may be given exercises to carry out on your own or you may complete the exercises with supervision from your GP or physiotherapist. You may also have manual therapy, which is when the healthcare professional moves your arm for you. Manual therapy uses special techniques to move the joints and soft tissues in your shoulder.
One review of a number of studies found that long-term physiotherapy was equally as effective as surgery for impingement syndrome (any type of damage to the tendons in the rotator cuff).

Surgery For Frozen Shoulder

If other treatments for frozen shoulder have not worked, you may be referred for surgery. There are two possible surgical procedures, which are explained in more detail below.

Manipulation

Manipulation involves having your shoulder moved while you are under general anaesthetic. General anaesthetic is a painkilling medication that makes you unconscious. During the procedure, your shoulder will be gently moved and stretched while you are asleep.
Afterwards, you will usually need to have physiotherapy to help maintain mobility in your shoulder. Manipulation may be used if you are finding the pain and disability from your shoulder difficult to cope with.

Arthroscopic Capsular Release

An alternative procedure to manipulation is arthroscopic capsular release. This is a type of keyhole, or non-invasive, surgery. The surgeon will carry out the procedure after making an incision (cut) that is less than 1cm (0.4in) long.
During arthroscopic capsular release surgery, your surgeon will use a special probe to open up your contracted shoulder capsule. They will then remove any bands of scar tissue that have formed in your shoulder capsule, which should greatly improve your symptoms.
As with manipulation, you will need to have physiotherapy after arthroscopic capsular release surgery. This will help you regain a full range of movement in your shoulder joint.

Surgery For A Rotator Cuff Tear

Surgery may be used to treat rotator cuff tears if the tear is very large or if other treatment options have not worked after three to six months. It is possible that having surgery earlier will lead to a quicker recovery, although at the moment there is not enough research into whether early surgery is beneficial or not.
During the procedure, a small amount of bone may be shaved off the bones in your shoulder. Damaged tendons and bursae (fluid-filled sacs that are found over joints and between tendons and bones) may also be removed. This creates more space within the joint to allow your rotator cuff to move freely.

The Operation Can Be Performed As:

• Open surgery – a large incision is made in your shoulder
• Mini-open surgery – a small incision is made in your shoulder 
• Arthroscopic surgery – a type of keyhole surgery that uses a camera to look inside your shoulder joint

Evidence suggests that people return to work about a month earlier if they have mini-open surgery rather than open surgery.
As with frozen shoulder surgery, you will need to have physiotherapy after your operation to help you regain a full range of movement in your shoulder joint.

Surgery For Shoulder Instability

If your shoulder dislocates (the ball comes out of the socket) regularly or severely, you may need to have surgery to prevent it happening again and to prevent the surrounding tissues and nerves from becoming damaged. Depending on the type of instability that you have, surgery may involve:

• Tightening stretched ligaments or reattaching them if they have torn – ligaments are tough bands of connective tissue that link two bones together at a joint
• Tightening the shoulder capsule by using heat to shrink it or tightening it with sutures (stitches)

Surgery for shoulder instability can either be done using keyhole or open surgery. After the operation, your shoulder will need to be immobilised (prevented from moving) using a special sling for several weeks. You will also need to have physiotherapy to improve your strength. Full recovery may take a number of months.

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Frozen Shoulder:Symptoms

A frozen shoulder is a painful, persistent stiffness of the shoulder joint, which makes it very difficult to carry out the full range of normal shoulder movements.





You May Find It Difficult To Carry Out Everyday Tasks, Such As:

• Dressing
• Driving
• Sleeping comfortably

Some people find they are unable to move their shoulder at all, which is why the condition is known as a frozen shoulder.

Stages Of Frozen Shoulder

The symptoms of a frozen shoulder advance slowly and are usually experienced in three separate stages that are spread over a number of months or years. However, the symptoms of frozen shoulder can vary greatly from person to person.
The three stages of frozen shoulder are described below.

Stage One

During stage one, your shoulder will start to ache and will feel stiff before becoming very painful. The pain is often worse at night and when you lie on the affected side. This stage lasts two to nine months.

Stage Two

Stage two is known as the adhesive stage. Your shoulder may become increasingly stiff, but the pain will not usually get worse. Your shoulder muscles may start to waste slightly because they are not being used. This stage lasts four to twelve months.

Stage Three

Stage three is the recovery stage. During this stage, you will gradually regain movement in your shoulder. The pain will begin to fade, although it may recur from time to time as the stiffness eases.
Although you may not regain full movement of your shoulder, you will be able to do many more tasks. Stage three can last five months to three or four years.

Shoulder Pain:Over View

Shoulder pain is a symptom rather than a condition in itself

Shoulder pain is a symptom rather than a condition in itself. Shoulder disorders are the most common causes of shoulder pain.


Examples Of Shoulder Disorders Include:

• Frozen shoulder – a painful condition that reduces normal movement in the joint and can sometimes prevent movement in the shoulder altogether 
• Rotator cuff disorders – the rotator cuff is a group of muscles and tendons that surround the shoulder joint and help to keep it stable 
• Shoulder instability – where the shoulder is unstable and has an unusually large range of movement (hypermobility) 
• Acromioclavicular joint disorders – conditions that affect the acromioclavicular joint, which is the joint at the top of the shoulder

How Common Are Shoulder Disorders?

• Shoulder disorders are fairly common. About 3 in 10 adults are affected by these types of conditions at any one time.
• Frozen shoulder and rotator cuff disorders are most common in middle-aged and older people. 
• Shoulder instability and acromioclavicular joint disorders tend to affect younger people, particularly men who play certain sports.

For Example:

Sports that involve repetitive shoulder movements, such as overarm bowling or throwing
contact sports, such as rugby, where you may injure or fall on your shoulder

Outlook

Shoulder pain can be a long-term problem. Up to half of people still have symptoms after 18 months. It is therefore important to obtain the correct diagnosis so that you can receive effective treatment for your symptoms.
Several treatment options are available for shoulder pain. They include:
painkillers – such a paracetamol
physiotherapy – where physical methods, such as massage and manipulation, are used to promote healing
injections of corticosteroids – corticosteroids are a type of medication that contain hormones
surgery (in some cases)

Lumbar Decompressive Surgery - Who Needs It?

1. Healthy disc
2. Nerve root
3. Extruded disc protrusion
4. Disc bulge
5. Spinal nerves (cauda equina)

Conditions that may require lumbar decompressive surgery include:

Spinal Stenosis:

Spinal stenosis is the narrowing of the central spinal canal or side root canals of the spine. This narrowing causes pressure on the nerves in the canal, leading to pain, usually in the lower back and legs.

Causes Of Spinal Stenosis Include:

Age-related degeneration of the spine. The main cause of spinal stenosis is natural age-related degeneration. This is often linked to osteoarthritis. As the vertebrae (bones) of the spine begin to weaken and deteriorate, they rub against each other. This causes bony growths called bone spurs, which can cause the spinal canal to narrow.

Changes in the ligaments of the spine. Like the bones of your spine, the ligaments in your back degenerate over time and can become stiff and thick. This loss of elasticity can have the effect of narrowing your spinal canal.
Diseases of the bone. Diseases that affect bone growth, such as Paget’s disease and achondroplasia, can cause malformation of the bones of the spine and a narrowing of the spinal canal.

Slipped (herniated) Disc

A slipped or herniated disc is when the tough coating of a disc in your spine tears, causing the jelly-like filling to seep out. The torn disc can press on the surrounding nerves causing pain in your back and legs.
A slipped disc can happen at any age, but is more common in people between 20 and 40 years of age. It is usually caused by a combination of minor degeneration in the disc combined with trauma. The trauma can be minor, such as a cough or sneeze.
A slipped disc can press on the nerve sac in the spinal canal causing back pain, or on the surrounding nerves causing pain in the back and legs.

Spinal Tumours

Abnormal growths and tumours can form along your spine. These are usually benign (not cancerous), but growing tumours may compress your spinal cord and nerve roots causing pain.
Injury

Injury to your spine, such as dislocation and fractures, or the swelling of tissue after spinal surgery, can put pressure on your spinal cord or nerves.

When To Consider Surgery

Lumbar decompressive surgery is considered as a treatment for spinal stenosis when:
pain relief medication and other treatments have failed to help your symptoms,
the pain is so severe it is interfering with your quality of life, including work and sleep,
you have had an MRI scan that shows you have a disc, bony spur or thickened ligament pressing on a nerve, or
you have cauda equina syndrome, a rare and severe form of spinal stenosis. Pressure on the nerves in the lower back causes numbness in the buttocks and prevents you from urinating. In this case, emergency surgery is needed.

Lumbar Decompression Surgery

Lumbar decompressive surgery is an operation to relieve pressure on the spinal nerves in the lower back. It is often used to treat a condition called spinal stenosis.
Spinal stenosis is the narrowing of areas of the spine. It occurs when the bones, ligaments or discs of the spine squash the nerves of the spine causing pain, usually in the lower back and legs.

Causes Of Spinal Stenosis Include:

• Age-related degeneration of the spine,
• Changes in the ligaments of the spine, and
• Diseases of the bone, such as Paget’s disease.
• Other conditions that may require lumbar decompressive surgery include:
• A slipped (herniated) disc,
• Spinal tumours, and
• Spinal injury.

Lumbar decompressive surgery is recommended when the pain in your back and legs is affecting your quality of life and alternative treatments, such as pain relief and physiotherapy, have not worked.
Types of surgery

There Are Two Types Of Lumbar Decompressive Surgery:

A laminectomy or partial laminectomy removes or trims the bony arch of a vertebra (bone) or ligaments of the spine to relieve the pressure on the spinal cord.
A discectomy removes the damaged or bulging part of a slipped disc to relieve pressure on the spinal cord.

Outlook

70% and 75% of patients experience a significant improvement in leg pain after lumbar decompressive surgery. 20-25% of patients experience an improvement, but still have some pain.
The success rate for microdiscectomy (keyhole surgery) is slightly better, with 80-85% of patients experiencing an improvement in their leg pain.