BY DR JONAS FERNANDEZ
The other day while we were seated at the dining table, my wife suddenly turned to me and said, “Eh, you got so many aunts with shoulder pain, why don’t you write something about it?”. I looked at her, nodded and continued to gobble up my dinner.
She was right, though, you know. Looking back, I recall doing many such “consultations” for family members.
So why not? Let’s discuss why shoulder pain is such a problem, especially amongst ladies in the “golden age group”.
Many structures around the shoulder could be a potential pain generator. Chief among the culprits that cause patients’ ailing is the rotator cuff tendons. They are a group of four tendons, namely the supraspinatus, infraspinatus, subscapularis and the teres minor.
These muscles/tendons are responsible for various types of movements of the shoulder joint. Thus, when they become injured, shoulder movement is also limited.
Patients often complain about specific limitations in activities, such as difficulty in combing their hair and reaching out for objects in high places. And for ladies, hooking on or off their undergarments.
Each muscle/tendon is responsible for a particular type of shoulder motion. So, to elicit which tendon is causing the pain, your doctor will have to perform a physical examination.
The doctor may ask you to move your shoulder in various ways. It might seem like you are doing the Macarena dance during one of these examinations.
These “injuries” to the tendons are usually not caused by a single event or trauma. Instead, they have been described as a spectrum of diseases.
One thing leads to another, and so forth. Often, there is degeneration and inflammation of the tendon, which leads to them being worn down to the point that they eventually tear.
This tear can be a partial tear or a complete tear. Another way these tendons get injured is when they come into contact with the bone overlying them. The friction between the tendon and the bone causes pain and wears down the tendon. This condition is known explicitly as impingement syndrome, where the tendons are impinged by the acromion bone.
If this condition is left untreated and unchecked, it can lead to further destruction within the shoulder joint. Because the rotator cuff tendons/muscles are not functioning like they are supposed to, the stability of the shoulder joint is also affected.
This is because this joint is an inherently unstable one. Being a “ball and socket” joint, stabilising the head of the humerus (the ball) on the glenoid (the socket) is like a seal balancing a ball on its nose or a golf ball balancing itself on a tee.
Because of how unstable it is, the muscles and tendons play a critical role in maintaining a balance. Medically, this balancing act of the shoulder is called muscle patterning.
So what happens when there is a loss of said muscle balance? Because the humerus head is now not articulating or gliding how it’s supposed to against the glenoid, it predisposes the shoulder joint to develop arthritis.
Options for treatment
This is why this condition is called a spectrum of diseases. Initially, what may have seemed like a benign inflammation of the tendon has led to it being torn. This, in turn, leads to a loss of balance within the joint and has finally resulted in shoulder osteoarthritis.
As in any other medical condition, history and examination play the most prominent role in diagnosis. However, your doctor might order an ultrasound or MRI scan to confirm it.
These scans will show the presence of tears, the size of the tears and if any muscle atrophy might have occurred as a result of prolonged misuse. All of this information plays an integral part in decision-making in terms of treatment plans.
So how do we treat this? For small tears, treatment will usually be focused more on physiotherapy for pain control, muscle strengthening and a range of motion exercises. A steroid injection into the shoulder joint also plays a significant role in relieving pain symptoms of those with impingement of the tendon.
However, in cases where the tear is large, one might need to go under the knife. The repair is usually done via a “keyhole surgery”, whereby specialised sutures called anchor sutures are used to secure these torn tendons. In the final step of the disease, when arthritis has set in, joint replacement surgery might be indicated.
The shoulder joint plays a significant role in all our daily activities, owning much to its ability to provide a considerable range in motion. These movements are well illustrated in the Macarena dance.
So, to continue dancing at the next big wedding event or dance festival, you would be well advised to
look after that shoulder of yours. – The Health
Dr Jonas Fernandez is an Orthopaedic Surgeon at Putrajaya Hospital. He is also a member of the Malaysian Arthroscopy Society (MAS).