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	Publication Date May 2001				
Questions and Answers about Shoulder Problems
- How Common Are Shoulder Problems?  What Are the Structures of the Shoulder and How Does             the Shoulder Function?What Are the Origin and Causes of Shoulder Problems?
- How Are Shoulder Problems Diagnosed?  DislocationSeparation
- Tendinitis, Bursitis, and Impingement Syndrome  Torn Rotator CuffFrozen Shoulder (Adhesive Capsulitis)
- Fracture  Arthritis of the ShoulderWhere Can People Get Additional Information About             Shoulder Problems?

This booklet first answers general questions about the           shoulder and shoulder problems. It then answers questions about specific           shoulder problems (dislocation, separation, tendinitis, bursitis, impingement           syndrome, torn rotator cuff, frozen shoulder, and fracture) as well           as shoulder pain caused by arthritis of the shoulder.

How Common Are Shoulder Problems?

According to the American Academy of Orthopaedic Surgeons,           about 4 million people in the United States seek medical care each year           for shoulder sprain, strain, dislocation, or other problems. Each year,           shoulder problems account for about 1.5 million visits to orthopaedic           surgeons--doctors who treat disorders of the bones, muscles, and related           structures.

What Are the Structures of the Shoulder and How Does the           Shoulder Function?

The shoulder joint is composed of three bones: the clavicle           (collarbone), the scapula (shoulder blade), and the humerus (upper arm           bone) (see diagram). Two joints facilitate shoulder movement. The acromioclavicular           (AC) joint is located between the acromion (part of the scapula that           forms the highest point of the shoulder) and the clavicle. The glenohumeral           joint, commonly called the shoulder joint, is a ball-and-socket type           joint that helps move the shoulder forward and backward and allows the           arm to rotate in a circular fashion or hinge out and up away from the           body. (The "ball" is the top, rounded portion of the upper arm bone           or humerus; the "socket," or glenoid, is a dish-shaped part of the outer           edge of the scapula into which the ball fits.) The capsule is a soft           tissue envelope that encircles the glenohumeral joint. It is lined by           a thin, smooth synovial membrane.

The bones of the shoulder are held in place           by muscles, tendons, and ligaments. Tendons are tough cords of tissue           that attach the shoulder muscles to bone and assist the muscles in moving           the shoulder. Ligaments attach shoulder bones to each other, providing           stability. For example, the front of the joint capsule is anchored by           three glenohumeral ligaments.

The rotator cuff is a structure composed of tendons that,           with associated muscles, holds the ball at the top of the humerus in           the glenoid socket and provides mobility and strength to the shoulder           joint.

Two filmy sac-like structures called bursae permit smooth           gliding between bone, muscle, and tendon. They cushion and protect the           rotator cuff from the bony arch of the acromion.

What Are the Origin and Causes of Shoulder           Problems?

The shoulder is the most movable joint in the body. However,           it is an unstable joint because of the range of motion allowed. It is           easily subject to injury because the ball of the upper arm is larger           than the shoulder socket that holds it. To remain stable, the shoulder           must be anchored by its muscles, tendons, and ligaments. Some shoulder           problems arise from the disruption of these soft tissues as a result           of injury or from overuse or underuse of the shoulder. Other problems           arise from a degenerative process in which tissues break down and no           longer function well.

Shoulder pain may be localized or may be referred to areas           around the shoulder or down the arm. Disease within the body (such as           gallbladder, liver, or heart disease, or disease of the cervical spine           of the neck) also may generate pain that travels along nerves to the           shoulder.

How Are Shoulder Problems Diagnosed?

Following are some of the ways doctors diagnose shoulder           problems:
- Medical history (the patient tells the doctor about an injury or             other condition that might be causing the pain).     Physical examination to feel for injury and discover the limits             of movement, location of pain, and extent of joint instability.Tests to confirm the diagnosis of certain conditions. Some of these             tests include:
x ray
- arthrogram--Diagnostic record that can be seen on an x ray after                 injection of a contrast fluid into the shoulder joint to outline                 structures such as the rotator cuff. In disease or injury, this                 contrast fluid may either leak into an area where it does not                 belong, indicating a tear or opening, or be blocked from entering                 an area where there normally is an opening.     MRI (magnetic resonance imaging)--A non-invasive procedure in                 which a machine produces a series of cross-sectional images of                 the shoulder.Other diagnostic tests, such as injection of an anesthetic into                 and around the shoulder joint, are discussed in specific sections                 of this booklet.
   Dislocation  What Is a Shoulder Dislocation?  The shoulder joint is the most frequently dislocated major           joint of the body. In a typical case of a dislocated shoulder, a strong           force that pulls the shoulder outward (abduction) or extreme rotation           of the joint pops the ball of the humerus out of the shoulder socket.           Dislocation commonly occurs when there is a backward pull on the arm           that either catches the muscles unprepared to resist or overwhelms the           muscles. When a shoulder dislocates frequently, the condition is referred           to as shoulder instability. A partial dislocation where the upper arm           bone is partially in and partially out of the socket is called a subluxation.  What Are the Signs of a Dislocation and How Is It Diagnosed?  The shoulder can dislocate either forward, backward, or           downward. Not only does the arm appear out of position when the shoulder           dislocates, but the dislocation also produces pain. Muscle spasms may           increase the intensity of pain. Swelling, numbness, weakness, and bruising           are likely to develop. Problems seen with a dislocated shoulder are           tearing of the ligaments or tendons reinforcing the joint capsule and,           less commonly, nerve damage. Doctors usually diagnose a dislocation           by a physical examination, and x rays may be taken to confirm the diagnosis           and to rule out a related fracture.  How Is a Dislocated Shoulder Treated?  Doctors treat a dislocation by putting the ball of the           humerus back into the joint socket--a procedure called a reduction.           The arm is then immobilized in a sling or a device called a shoulder           immobilizer for several weeks. Usually the doctor recommends resting           the shoulder and applying ice three or four times a day. After pain           and swelling have been controlled, the patient enters a rehabilitation           program that includes exercises to restore the range of motion of the           shoulder and strengthen the muscles to prevent future dislocations.           These exercises may progress from simple motion to the use of weights.  After treatment and recovery, a previously dislocated           shoulder may remain more susceptible to reinjury, especially in young,           active individuals. Ligaments may have been stretched or torn, and the           shoulder may tend to dislocate again. A shoulder that dislocates severely           or often, injuring surrounding tissues or nerves, usually requires surgical           repair to tighten stretched ligaments or reattach torn ones.  Sometimes the doctor performs surgery through a tiny incision           into which a small scope (arthroscope) is inserted to observe the inside           of the joint. After this procedure, called arthroscopic surgery, the           shoulder is generally immobilized for about 6 weeks and full recovery           takes several months. Arthroscopic techniques involving the shoulder           are relatively new and many surgeons prefer to repair a recurrent dislocating           shoulder by the time-tested open surgery under direct vision. There           are usually fewer repeat dislocations and improved movement following           open surgery, but it may take a little longer to regain motion.  Separation  What Is a Shoulder Separation?  A shoulder separation occurs where the collarbone (clavicle)           meets the shoulder blade (scapula). When ligaments that hold the joint           together are partially or completely torn, the outer end of the clavicle           may slip out of place, preventing it from properly meeting the scapula.           Most often the injury is caused by a blow to the shoulder or by falling           on an outstretched hand.  What Are the Signs of a Shoulder Separation and How Is           It Diagnosed?  Shoulder pain or tenderness and, occasionally, a bump           in the middle of the top of the shoulder (over the AC joint) are signs           that a separation may have occurred. Sometimes the severity of a separation           can be detected by taking x rays while the patient holds a light weight           that pulls on the muscles, making a separation more pronounced.  How Is a Shoulder Separation Treated?  A shoulder separation is usually treated conservatively           by rest and wearing a sling. Soon after injury, an ice bag may be applied           to relieve pain and swelling. After a period of rest, a therapist helps           the patient perform exercises that put the shoulder through its range           of motion. Most shoulder separations heal within 2 or 3 months without           further intervention. However, if ligaments are severely torn, surgical           repair may be required to hold the clavicle in place. A doctor may wait           to see if conservative treatment works before deciding whether surgery           is required.  Tendinitis, Bursitis, and Impingement Syndrome  What Are Tendinitis, Bursitis, and Impingement Syndrome           of the Shoulder?  These conditions are closely related and may occur alone           or in combination. If the rotator cuff and bursa are irritated, inflamed,           and swollen, they may become squeezed between the head of the humerus           and the acromion. Repeated motion involving the arms, or the aging process           involving shoulder motion over many years, may also irritate and wear           down the tendons, muscles, and surrounding structures.  Tendinitis is inflammation (redness, soreness, and swelling)           of a tendon. In tendinitis of the shoulder, the rotator cuff and/or           biceps tendon become inflamed, usually as a result of being pinched           by surrounding structures. The injury may vary from mild inflammation           to involvement of most of the rotator cuff. When the rotator cuff tendon           becomes inflamed and thickened, it may get trapped under the acromion.           Squeezing of the rotator cuff is called impingement syndrome.  Tendinitis and impingement syndrome are often accompanied           by inflammation of the bursa sacs that protect the shoulder. An inflamed           bursa is called bursitis. Inflammation caused by a disease such as rheumatoid           arthritis may cause rotator cuff tendinitis and bursitis. Sports involving           overuse of the shoulder and occupations requiring frequent overhead           reaching are other potential causes of irritation to the rotator cuff           or bursa and may lead to inflammation and impingement.  What Are the Signs of Tendinitis and Bursitis?  Signs of these conditions include the slow onset of discomfort           and pain in the upper shoulder or upper third of the arm and/or difficulty           sleeping on the shoulder. Tendinitis and bursitis also cause pain when           the arm is lifted away from the body or overhead. If tendinitis involves           the biceps tendon (the tendon located in front of the shoulder that           helps bend the elbow and turn the forearm), pain will occur in the front           or side of the shoulder and may travel down to the elbow and forearm.           Pain may also occur when the arm is forcefully pushed upward overhead.  How Are These Conditions Diagnosed?  Diagnosis of tendinitis and bursitis begins with a medical           history and physical examination. X rays do not show tendons or the           bursae but may be helpful in ruling out bony abnormalities or arthritis.           The doctor may remove and test fluid from the inflamed area to rule           out infection. Impingement syndrome may be confirmed when injection           of a small amount of anesthetic (lidocaine hydrochloride) into the space           under the acromion relieves pain.  How Are Tendinitis, Bursitis, and Impingement Syndrome           Treated?  The first step in treating these conditions is to reduce           pain and inflammation with rest, ice, and anti-inflammatory medicines           such as aspirin, naproxen (Naprosyn*), ibuprofen (Advil, Motrin, or           Nuprin), or cox-2 inhibitors (Celebrex or Nobic). In some cases           the doctor or therapist will use ultrasound (gentle sound-wave vibrations)           to warm deep tissues and improve blood flow. Gentle stretching and strengthening           exercises are added gradually. These may be preceded or followed by           use of an ice pack. If there is no improvement, the doctor may inject           a corticosteroid medicine into the space under the acromion. While steroid           injections are a common treatment, they must be used with caution because           they may lead to tendon rupture. If there is still no improvement after           6 to 12 months, the doctor may perform either arthroscopic or open surgery           to repair damage and relieve pressure on the tendons and bursae.  * Brand names included in this booklet are provided as           examples only, and their inclusion does not mean that these products           are endorsed by the National Institutes of Health or any other Government           agency. Also, if a particular brand name is not mentioned, this does           not mean or imply that the product is unsatisfactory.  Torn Rotator Cuff  What Is a Torn Rotator Cuff?  One or more rotator cuff tendons may become inflamed from           overuse, aging, a fall on an outstretched hand, or a collision. Sports           requiring repeated overhead arm motion or occupations requiring heavy           lifting also place a strain on rotator cuff tendons and muscles. Normally,           tendons are strong, but a longstanding wearing down process may lead           to a tear.  What Are the Signs of a Torn Rotator Cuff?  Typically, a person with a rotator cuff injury feels pain           over the deltoid muscle at the top and outer side of the shoulder, especially           when the arm is raised or extended out from the side of the body. Motions           like those involved in getting dressed can be painful. The shoulder           may feel weak, especially when trying to lift the arm into a horizontal           position. A person may also feel or hear a click or pop when the shoulder           is moved.  How Is a Torn Rotator Cuff Diagnosed?  Pain or weakness on outward or inward rotation of the           arm may indicate a tear in a rotator cuff tendon. The patient also feels           pain when lowering the arm to the side after the shoulder is moved backward           and the arm is raised. A doctor may detect weakness but may not be able           to determine from a physical examination where the tear is located.           X rays, if taken, may appear normal. An MRI can help detect a full tendon           tear, but does not detect partial tears. If the pain disappears after           the doctor injects a small amount of anesthetic into the area, impingement           is likely to be present. If there is no response to treatment, the doctor           may use an arthrogram, rather than an MRI, to inspect the injured area           and confirm the diagnosis.  How Is a Torn Rotator Cuff Treated?  Doctors usually recommend that patients with a rotator           cuff injury rest the shoulder, apply heat or cold to the sore area,           and take medicine to relieve pain and inflammation. Other treatments           might be added, such as electrical stimulation of muscles and nerves,           ultrasound, or a cortisone injection near the inflamed area of the rotator           cuff. The patient may need to wear a sling for a few days. If surgery           is not an immediate consideration, exercises are added to the treatment           program to build flexibility and strength and restore the shoulder's           function. If there is no improvement with these conservative treatments           and functional impairment persists, the doctor may perform arthroscopic           or open surgical repair of the torn rotator cuff.  Frozen Shoulder (Adhesive Capsulitis)  What Is a Frozen Shoulder?  As the name implies, movement of the shoulder is severely           restricted in people with a "frozen shoulder." This condition, which           doctors call adhesive capsulitis, is frequently caused by injury that           leads to lack of use due to pain. Rheumatic disease progression and           recent shoulder surgery can also cause frozen shoulder. Intermittent           periods of use may cause inflammation. Adhesions (abnormal bands of           tissue) grow between the joint surfaces, restricting motion. There is           also a lack of synovial fluid, which normally lubricates the gap between           the arm bone and socket to help the shoulder joint move. It is this           restricted space between the capsule and ball of the humerus that distinguishes           adhesive capsulitis from a less complicated painful, stiff shoulder.           People with diabetes, stroke, lung disease, rheumatoid arthritis, and           heart disease, or who have been in an accident, are at a higher risk           for frozen shoulder. The condition rarely appears in people under 40           years old.  What Are the Signs of a Frozen Shoulder and How Is It           Diagnosed?  With a frozen shoulder, the joint becomes so tight and           stiff that it is nearly impossible to carry out simple movements, such           as raising the arm. People complain that the stiffness and discomfort           worsen at night. A doctor may suspect the patient has a frozen shoulder           if a physical examination reveals limited shoulder movement. An arthrogram           may confirm the diagnosis.  How Is a Frozen Shoulder Treated?  Treatment of this disorder focuses on restoring joint           movement and reducing shoulder pain. Usually, treatment begins with           nonsteroidal anti-inflammatory drugs and the application of heat, followed           by gentle stretching exercises. These stretching exercises, which may           be performed in the home with the help of a therapist, are the treatment           of choice. In some cases, transcutaneous electrical nerve stimulation           (TENS) with a small battery-operated unit may be used to reduce pain           by blocking nerve impulses. If these measures are unsuccessful, the           doctor may recommend manipulation of the shoulder under general anesthesia.           Surgery to cut the adhesions is only necessary in some cases.  Fracture  What Happens When the Shoulder Is Fractured?  A fracture involves a partial or total crack through a           bone. The break in a bone usually occurs as a result of an impact injury,           such as a fall or blow to the shoulder. A fracture usually involves           the clavicle or the neck (area below the ball) of the humerus.  What Are the Signs of a Shoulder Fracture and How Is           It Diagnosed?  A shoulder fracture that occurs after a major injury is           usually accompanied by severe pain. Within a short time, there may be           redness and bruising around the area. Sometimes a fracture is obvious           because the bones appear out of position. Both diagnosis and severity           can be confirmed by x rays.  How Is a Shoulder Fracture Treated?  When a fracture occurs, the doctor tries to bring the           bones into a position that will promote healing and restore arm movement.           If the clavicle is fractured, the patient must at first wear a strap           and sling around the chest to keep the clavicle in place. After removing           the strap and sling, the doctor will prescribe exercises to strengthen           the shoulder and restore movement. Surgery is occasionally needed for           certain clavicle fractures.  Fracture of the neck of the humerus is usually treated           with a sling or shoulder immobilizer. If the bones are out of position,           surgery may be necessary to reset them. Exercises are also part of restoring           shoulder strength and motion.  Arthritis of the Shoulder  What Is Arthritis of the Shoulder?  Arthritis is a degenerative disease caused by either wear           and tear of the cartilage (osteoarthritis) or an inflammation (rheumatoid           arthritis) of one or more joints. Arthritis not only affects joints;           it may also affect supporting structures such as muscles, tendons, and           ligaments.  What Are the Signs of Shoulder Arthritis and How Is It           Diagnosed?  The usual signs of arthritis of the shoulder are pain,           particularly over the AC joint, and a decrease in shoulder motion. A           doctor may suspect the patient has arthritis when there is both pain           and swelling in the joint. The diagnosis may be confirmed by a physical           examination and x rays. Blood tests may be helpful for diagnosing rheumatoid           arthritis, but other tests may be needed as well. Analysis of synovial           fluid from the shoulder joint may be helpful in diagnosing some kinds           of arthritis. Although arthroscopy permits direct visualization of damage           to cartilage, tendons, and ligaments, and may confirm a diagnosis, it           is usually done only if a repair procedure is to be performed.  How Is Arthritis of the Shoulder Treated?  Most often osteoarthritis of the shoulder is treated with           nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, or           cox-2 inhibitors. (Rheumatoid arthritis of the shoulder may require           physical therapy and additional medicine, such as corticosteroids.)           When non-operative treatment of arthritis of the shoulder fails to relieve           pain or improve function, or when there is severe wear and tear of the           joint causing parts to loosen and move out of place, shoulder joint           replacement (arthroplasty) may provide better results. In this operation,           a surgeon replaces the shoulder joint with an artificial ball for the           top of the humerus and a cap (glenoid) for the scapula. Passive shoulder           exercises (where someone else moves the arm to rotate the shoulder joint)           are started soon after surgery. Patients begin exercising on their own           about 3 to 6 weeks after surgery. Eventually, stretching and strengthening           exercises become a major part of the rehabilitation program. The success           of the operation often depends on the condition of rotator cuff muscles           prior to surgery and the degree to which the patient follows the exercise           program.  
If you receive a shoulder injury, here's what you can do:

RICE = Rest, Ice, Compression, and Elevation

**Rest**--Reduce or stop using the injured area for 48 hours.

**Ice**--Put an ice pack on the injured area for 20 minutes                 at a time, 4 to 8 times per day. Use a cold pack, ice bag, or                 a plastic bag filled with crushed ice that has been wrapped in                 a towel.
**Compression**--Compression may help reduce the swelling.                 Compress the area with bandages, such as an elastic wrap, to help                 stabilize the shoulder.

**Elevation**--Keep the injured area elevated above the level                 of the heart. Use a pillow to help elevate the injury.

If pain and stiffness persist, see a doctor.

Where Can People Get Additional Information           About Shoulder Problems?

**National Institute of Arthritis and Musculoskeletal           andSkin Diseases Information Clearinghouse**National Institutes of Health1 AMS CircleBethesda, MD 20892-3675Phone: 301-495-4484 or877-22-NIAMS (226-4267) (free of charge)TTY: 301-565-2966Fax: 301-718-6366http://www.niams.nih.gov/

The clearinghouse provides information about various forms           of arthritis and rheumatic disease and bone, muscle, and skin diseases.           It distributes patient and professional education materials and refers           people to other sources of information. Additional information and updates           can also be found on the NIAMS Web site.

**American Academy of Orthopaedic Surgeons**P.O. Box 2058Des Plaines, IL 60017Phone: 800-824-BONE (2663) (free of charge)www.aaos.org

The academy provides education and practice management services for orthopaedic surgeons and allied health professionals. It also serves as an advocate for improved patient care and informs the public about the science of orthopaedics. The orthopaedist's scope of practice includes disorders of the body's bones, joints, ligaments, muscles, and tendons. For a single copy of an AAOS brochure, send a self-addressed stamped envelope to the address above or visit the AAOS Web site.

**American College of Rheumatology**1800 Century Place, Suite 250Atlanta, GA 30345Phone: 404-633-3777Fax: 404-633-1870www.rheumatology.org

This national professional organization can provide referrals           to rheumatologists and allied health specialists, such as physical therapists.           One-page fact sheets are also available on various forms of arthritis.           Lists of specialists by geographic area and fact sheets are also available           on their Web site.

**American Physical Therapy Association**1111 North Fairfax StreetAlexandria, VA 22314-1488Phone: 703-684-2782 or800-999-2782, ext. 3395 (free of charge)www.apta.org

This national professional organization represents physical           therapists, allied personnel, and students. Its objectives are to improve           research, public understanding, and education in the physical therapies.           A free brochure titled "Taking Care of Your Shoulder: A Physical Therapist's           Perspective" is available on the association's Web site or by sending           a business-size, stamped, self-addressed envelope to the address above.

**Arthritis Foundation**1330 West Peachtree StreetAtlanta, GA 30309Phone: 404-872-7100 or 800-283-7800 (free of charge)or call your local chapter (listed in the telephone directory)www.arthritis.org

This is the major voluntary organization devoted to arthritis.           The foundation publishes pamphlets on arthritis, such as "Arthritis           Answers," that may be obtained by calling the toll-free telephone number.           The foundation also can provide physician and clinic referrals. Local           chapters also provide information and organize exercise programs for           people who have arthritis.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of James           Panagis, M.D., M.P.H., of the NIAMS; Frank A. Pettrone, M.D., of Arlington,           Virginia; and Thomas J. Neviaser, M.D., of Fairfax, Virginia, in the           preparation and review of this booklet.

The mission of the National Institute of Arthritis                 and Musculoskeletal and Skin Diseases (NIAMS), a part of the National                 Institutes of Health (NIH), is to support research into the causes,                 treatment, and prevention of arthritis and musculoskeletal and                 skin diseases, the training of basic and clinical scientists to                 carry out this research, and the dissemination of information                 on research progress in these diseases. The National Institute                 of Arthritis and Musculoskeletal and Skin Diseases Information                 Clearinghouse is a public service sponsored by the NIAMS that                 provides health information and information sources. Additional                 information can be found on the NIAMS Web site at http://www.niams.nih.gov/.

NIH Publication No. 01-4865
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