The ‘Nagging’ Shoulder
What is worse than a nagging spouse? A nagging shoulder off course. Most of us would have definitely experienced some form of shoulder pain throughout our lives. More often then not, this would be a consequence of some form of injury or activity. Nevertheless, as we age, this tends to happen more frequently and most of the time without any obvious trigger.
From my experience, most patients who come to see me tell me that they have been suffering from a ‘frozen shoulder’ and have tried all sorts of medications, but to no avail.
No doubt frozen shoulder is a clinical condition, but this diagnosis has been more often than not, misused. There are actually many other considerations when someone is suffering from shoulder pain. Identifying the actual cause is pertinent to treat the condition optimally.
Typically in the younger age group (generally, less than 50 years old), this condition is precipitated by some form of trauma, be it from the gym, work related activities, carrying heavy loads, accidents, sports or even performing certain strenuous household chores. Hence, the duration of symptoms (usually more acute) and the individual’s pain threshold or functional limitation will actually determine the time of which they first seek medical attention. More often than not, most will do well with conservative treatment. However, certain conditions will warrant surgery.
On the other hand, the older age groups tend to have no obvious precipitating incident and develop their symptoms gradually. These tend to progress with time or present occasionally (waxing and waning pattern) when provoked. Underlying medical conditions such as diabetes mellitus, autoimmune diseases and inflammatory arthritis (e.g. gout, rheumatoid arthritis) are known risk factors.
There are several conditions that are commonly seen in my clinical practice. Amongst them are instability related conditions (affecting the labrum), rotator cuff tendinopathies, acromio-clavicular joint (ACJ) arthritis, biceps tendinopathies, impingements syndromes, glenohumeral (shoulder) arthritis and not to forget radiating pain from conditions affecting the neck (cervical spine).
Lastly, I would mention adhesive capsulitis (frozen shoulder), which can develop after any of the above conditions or in those who have diabetes mellitus, thyroid disorders, autoimmune diseases, following breast cancer treatment or after a period of immobilizing the affected limb.
So as you can see, there are many conditions that can cause this nagging shoulder pain and to top it off they may even occur concomitantly. A consultation with the right doctor may improve your chances of getting diagnosed and treated correctly. A thorough history taking, physical examination and appropriate investigations (e.g. x-ray, MRI) will collectively help your doctor to make the right diagnosis. In certain conditions a Magnetic Resonance Arthrogram (medical grade dye injected into the joint before the MRI) may be required.
Painkillers and physiotherapy alone are unlikely to resolve the issue, especially if the condition has been persisting or progressing for several months. Many of these conditions will require some form of injection or percutaneous procedures. Those being used currently range from corticosteroids, hyaluronic acid, platelet rich plasma, stem cells and radiofrequency procedures. All of which have mixed results and many confounding factors.
This leaves us with surgical options. Traditionally, surgery (especially those with big incisions) for shoulder conditions has been a taboo in Malaysia. Unlike receiving surgery for a fractured limb, many Malaysians irrespective of their background, are very reluctant for surgery to the shoulder especially when they can still cope with the pain and carry out their basic functions.
This is where the role of shoulder arthroscopy comes to play. With a minimally invasive approach, several small stab incisions (number of portals will vary on the type of surgery) are made to introduce a camera and specialized equipment into the joint. The live video is projected to a screen in high definition and the surgeon performs the procedures without the need of opening up the joint. This technique is also frequently known as keyhole surgery and is used for other parts of the body. It offers quicker healing time, shorter hospital stay and faster return to function. This has revolutionized management of shoulder conditions.
In a nutshell, while the ‘nagging’ shoulder is a relatively common disorder in our population, most people have chosen to just tolerate and live with it. With the information that I have shared above, I trust more people will now choose to seek an opinion from their preferred orthopaedic surgeon. Optimal treatment will most definitely improve your quality of life and may even allow you to return to activities you once thought you had to avoid entirely.
Dr. Taran Singh a/l Pall Singh
Consultant Orthopaedic Surgeon: Arthroscopy, Sports & Traumatology.
MD (USM), MMed Ortho (USM), Arthroscopy & Sports Orthopaedics Fellowship (Munich), AO Trauma Fellowship (Oxford).
KPJ Perlis Specialist Hospital.