I know you’ve seen me write about the numbers of patients I see each day with the various disorders about which I have written. If you add them up, they might come out to more than the number of patients I see each day. But remember that some patients come with several complaints! I just had to qualify that so I can now tell you that EVERY day in my clinic I see at least five patients with shoulder bursitis and its related disorders; rotator cuff impingement, tendonitis, rotator cuff tears and problems with the biceps tendon.
First a little anatomy and physiology. We just got done talking about hip bursitis. Many people think that all forms of bursitis are related to each other and that if they have more than one of these disorders, then they have some kind of bursitis disease. Not true. These conditions are only related in that they pertain to the little sacks of fluid which we have all over our bodies. They’re there to protect various structures in our musculoskeletal system from rubbing against each other. Sometimes they get inflamed and certain bursas, because of where they are, are more likely than others to get that way; shoulder, hip, the bursa in front of your knee cap and behind your elbow. And you could have every one of them inflamed at the same time and still not consider yourself to have a disease of the bursas. These are just very common areas to be repeatedly irritated, mostly because of the way our bodies are put together and the things we do on a regular basis to wear them out. And I’ll refer you back to my Caveman Blog , to understand all that a little better.
About 95% of the people I see with rotator cuff problems have a shape of the bone called the acromion which essentially rubs the rotator cuff the wrong way. You might just be born with a predisposition to developing problems with the rotator cuff. In those people, the front of the bone is pointed down in a way that makes it look like a spur. It’s not the kind of spur you have with arthritis. It’s just the way the bone is shaped. Sometimes that spur is made larger by a lifetime of traction on it by the ligament or muscle attached to it. This can give it a large deformity which can almost act like a blade against the rotator cuff sitting directly under it. The only thing between the rotator cuff and the blade is…your sub-acromial bursa!
95% of the people I see with rotator cuff problems are over 40. So what does that tell you? That this is just another one of those adult repetitive strain disorders we get as we age and serves as a reminder that we are still alive and kickin’!
There are a few of you who injure your rotator cuffs by getting flung from bicycles, falling from great heights or during a friendly game of flag football. But as I said above, most of you have a physical predisposition to having this spectrum of disorders and it’s bound to rear its ugly head eventually; usually when you’re around 50-60 years old. But don’t feel left out if you’re only 40 or if you’re 70 cuz it can get you too. If you’re between 20 and 40 there are other things I would worry more about, like drinking and driving or starting to save for your kid’s education. Then when they actually enroll in college, you can start thinking more about your shoulders. But read on anyway.
So you woke up one morning with this little aching pain around your deltoid muscle. Or you reached over to pick up your purse from the floor behind the front passenger seat (where you think it is hidden from would-be thieves). Or you do some kind of repetitive lifting on a daily basis; like throwing mail or lifting hay bales. You feel a little tugging in that shoulder while you’re working or even after you finish working. These are all activities that can be related to the onset of rotator cuff impingement or bursitis.
There is a group of folks who just develop severe pain spontaneously and cannot figure out what caused it. Usually after a lot of questioning, I’m able to come up with some related factors. Sports…hobby…work related. It doesn’t really matter. Most patients have the little downward turn to their acromion and they’re just predisposed to getting it.
About a third of you come in having already become stiff. It’s usually women who get contractures and I can’t really tell you why that is. It might be some physiological or hormonal or anatomical factor. But I also think it can be related to many women’s attitude toward pain. I think many are fearful of pain and their first instinct is to protect the arm. Don’t move it. Pain might mean something bad is happening. If I could fix one thing, it would be to tell you to move that arm. Unless a bone is broken and sticking out of the skin…then move that arm. If you just wake up one day with a stiff, sore shoulder…or a stiff sore anything for that matter…move it. Move it gently, BUT MOVE IT!
I had shoulder impingement in both of my shoulders about 6 years ago. I was lifting weights at the time and doing a lot of horseback riding; saddling, washing horses, fixing gear, etc. I don’t recall any injury. Of course on Day One of the pain, I knew exactly what I had. One of the fringe benefits of having gone to medical school! I went ahead and took an X-ray (fringe benefit of having my own machine) and found that indeed I had that inferior projection of my acromion. It hurt to raise my arm to the side, especially with my hand pointed down. Rather than stop moving it there, I just raised my arm with the hand turned upward because that didn’t hurt. I never lost range of motion or developed a contracture. As I discovered new ways in which my shoulder hurt, I soon figured out ways to move it and accomplish the same movement in another way which didn’t hurt.
Try everything possible to keep that shoulder moving and if you can’t, then don’t wait around for 6 weeks before seeing your primary care doc or your orthopod. Once you develop a contracture, it is very hard to rehabilitate your shoulder, no matter what the problem is. Don’t wait to see if this is going to get better on its own.
Here’s an easy exercise to do on your own in order to regain range of motion.
Flexion: Face a wall and put your finger tips on the wall. Then use your fingers to help you elevate the arm as high as you can to the point of resistance or discomfort. Then bring your hand back down and repeat as you’re able.
Abduction: Turn your side to the wall and use your finger tips to assist you in raising your arm to the side. Raise the arm to the point of resistance or discomfort. Then back down and repeat as you’re able.
The next step is to pay attention to the activities which are causing you pain. The earlier you catch this, the more quickly you can get better if you just have bursitis or tendonitis. Rotator cuff tears are not going to get well. But I think if you deal with this condition early, maintain your range of motion and quit doing the things that hurt the rotator cuff, you might just be able to get well. Later I’ll talk about staying well. This has pretty much been my mantra over the past 10-15 years. Recognize the problem early, maintain mobility and condition and limit or modify the things that result in pain.
Fortunately for my business but unfortunately for mankind, most of you don’t do this. You wait. You think it will get better on its own because that’s what it did when you were 20 years old. You try to “work through it,” or you just stop using it altogether. This doesn’t work. And then you end up in my office somewhere between 6 weeks and 2 years later. If you don’t read this in time or you can’t figure it out, I’d much rather you get in to see your primary care doc or your orthopedic surgeon early on in the course of your problem. You’re much more likely to have success with conservative treatment if we catch this early on.
So with rotator cuff disease (bursitis, tendonitis and partial tears) you will probably start experiencing pain in the front of your shoulder or down into the deltoid muscle (upper arm) when you;
- raise your arm to do things like lift items (light and heavy) from upper shelves. Milk cartons from the top shelf of your fridge, plates from your cabinets, books and supplies from across your desk.
- sleep with your arm over or under your head. This pain might actually wake you up from sleep. Of all the conditions I see, rotator cuff problems are most likely to keep my patients from sleeping. Many are pretty wigged out because of long sleepless nights!
- throw overhead. 40+ dads who are just starting to throw to their kids in t-ball. Tennis league gals. Weekend warriors playing quarterback with 20 year-olds.
- put your purse over on or behind the passenger seat.
These are just some of the common presenting complaints I see in about 5 patients every day. When you recognize you have this pain, I want you to start thinking about how you can modify each of these activities to keep them from hurting your shoulder.
Here are some examples of how you can modify those simple, everyday activities I mentioned in the last blog. Make these modifications to keep from hurting, and therefore damaging, your rotator cuff;
- Lower the items you lift from higher to lower shelves. Use step stools to reach the things you can’t lower. Move things around in your house! Keep the things you use most in mid-level cabinets. Remember…don’t put them in the bottom cabinet either. Don’t forget your poor knees. Keep top and bottom cabinets for stuff you use once a month.
- The sleeping issue is a tough one. But for sure you must stop going to sleep with your arm over or under your head. You can’t much effect what you do after you’ve gone to sleep, but if it wakes you up in pain, then put your arm back down. In time you might get out of the habit of doing that. Adjust your pillows to encourage your shoulder to stay in a painless position.
Also work on your sleep hygiene. Better sleepers are less likely to wake up with pain. See my blogs on sleep deprivation.
- If you’re not an experienced throwing athlete, you should be careful when you start throwing as an adult. This is no different than trying to run a marathon. You’re not going to start out with the 26 miles. Start out with one. Same for throwing. Don’t go throw 40 balls to your 6 year old on day one. Work up to it. Make sure a few throws aren’t causing frank pain. Throw underhand. Don’t be a hero. Really. You’ll end up like bunches of my dads; not being able to do it AT ALL! Same with tennis and weekend warriors. Follow the old rules you learned a long time ago which still hold true. Work up to it. And if you have pain above and beyond the mild soreness you get with a new exercise routine, then back off. Try something different. And if you’re dead set on doing this activity and it’s causing pain every which way you try it, then you need to get it checked out.
- Get a smaller purse or open your passenger seat, put your purse in and walk around to the other side.
Modify any activity which is not necessary to do for the quality of your life. If you can modify…then modify!
These are good rules of thumb for just about any adult repetitive strain disorder. I have followed them myself and have cured myself of shoulder impingement syndrome, greater trochanteric bursitis, ankle tendonitis, tennis elbow, among other things. Yep, like you, I’m falling apart. Getting old. I’m entering my “golden years.” And I continue to try to beat myself up. But I stick to these principles and most of these conditions are dead in the water in about 6 weeks or less. I try to get well without medications, so I can test my theory of activity modification out. And it works.
The definition of quality of life for you is different than for me. It’s different for a child than for an adult and it’s different for a skilled athlete than for a weekend warrior. For me, right now, in order to be able to have what I define as a good quality of life, I’ve got to be able to do surgery and ride horses. Both of those activities require physical and mental abilities. If I lost a hand, I couldn’t do either to the extent that I do now. Oh sure, I could see patients and I could ride horses if someone else could saddle my horses and operate on my patients, but I couldn’t do those things like I do now.
But my quality of life also depends on my ability to read, write and spend quality time with my family and friends. I could still do all those things if I lost my hand. But would I want to? Would I feel the same about those things if I lost my hand? If I couldn’t work or couldn’t ride horses, would I feel the same about everything else? That’s a question I can’t answer for myself, never mind answering it for my patients.
Sometimes a patient loses all perspective on the other parts of their life, just because they can’t run a marathon. They might still be able to run a 10K, but if they can’t run a marathon, then nothing else matters. You and I might sit back and say that’s not that important, but to them it is, and it’s the kind of problem I have to deal with every day in my practice.
And it’s what makes dealing with REST so difficult. To each individual person, dealing with rest is the hardest thing to define and to accomplish. Rest…to one person, might mean not being able to work. That’s different than not being able to participate in a weekend sporting activity. Yet these restrictions might seem equal in their individual minds. The ability to read, write and spend quality time with your family gives absolutely no solace to a high school football player who has injured his knee and can’t play in the last 3 games of his senior year. To you and me, with all of our perspective on life, this is just a minor setback. To that senior, it is everything.
But in 90% of the cases I see, rest is a key part, if not THE ONLY PART of getting well. Rest can come in the form of a cast at one extreme, or simply in the form of limiting some routine, mundane activity you do every day. Really, this is a basic tenet of treating the repetitive strain conditions from which we suffer as adults. If you’ve been reading some of my previous blogs, you will begin to see the patterns of activity modifications. Ideally you might be able to figure this out for yourself next time you feel some pain you haven’t previously experienced. I’m not talking about the kind of pain you suddenly experience when you get hit by a car. And I’m not talking about the pain you experience in the left side of your chest when you over exert yourself. Although frankly, just about any pain you experience should be accompanied by some form of rest. But let’s just say for the purposes of these discussions, we’re talking about musculoskeletal pain.
Now back to finishing up on shoulders. Most of these repetitive strain disorders are associated with some degree of inflammation. And inflammation will respond in some way, to anything which helps decrease inflammation; namely ice and anti-inflammatories. A little massage never hurts too. Just rub it. Use a little Tiger Balm or Ben-Gay or whatever kind of lotion is available. Don’t be afraid to touch.
Put a little ice on it. Frankly, if heat makes it feel better…use heat. Feel free to use anything that makes it feel better…with the exception of narcotics and alcohol.
Non-steroidal anti-inflammatory drugs (NSAIDs) are usually helpful. Now this is where I have to do that little thing they do on the end of commercials. Say it out loud, very quickly, and with a deep voice. You should not take these medications if your doctor has told you not to. And if you haven’t had that discussion with your doctor then you should not take them if you are taking blood thinners, if you have peptic ulcer disease, if you have liver or kidney disease or if you have had allergic reactions to these medications in the past. There, that’s out of the way.
Now these medications are readily available over-the-counter (OTC). They include medications such as Aleve, Advil (and their generic forms; naproxen sodium and ibuprofen), and aspirin. There are many forms available by prescription, but for now we’re limiting this discussion to just those you can buy in the store without a prescription.
So if you have no contra-indications to using these medications, they might be a useful adjunct to your activity modifications. Just use them as they are recommended on the bottle. Don’t plan to use them for long periods of time and make sure you’re not already taking a prescription NSAID. I often see patients who have been on prescription NSAIDs for a long time and are also take OTC NSAIDs.
I can often nip a potential repetitive strain disorder in the bud with just a little activity modification and a couple of days of Aleve.
When all else fails…go see your primary care doc or your local orthopod. You’ve tried resting your shoulder. You made sure you didn’t lose range of motion. You’ve changed things around in your refrigerator and stopped drying your hair. You gave your t-ball aged kids up for adoption, quit your job and dropped your membership at the gym. You’ve rubbed your shoulder raw and now have to have an upper GI because you’ve developed a stomach ulcer. Okay…maybe a little before that. But you’ve still got that gnawing little pain around the front and side of your shoulder that radiates down the deltoid muscle. It continues to wake you up at night. It’s even bothering you to drive. It’s time to come see me.
As I mentioned in the first blog on shoulder bursitis; this is part of a spectrum of disorders related to the rotator cuff. If not addressed, it is likely to progress. We’re going to try physical therapy, cortisone injections and prescription strength medications first. And if you haven’t done any of the things I’ve talked about in this blog…we’re going to do some of that too. Sometimes a relatively minor surgical procedure can be used to treat this condition, if you fail to improve with conservative treatment.
But bursitis often progresses to rotator cuff tendonitis and ultimately to rotator cuff tears. Tears often require surgery, and sometimes if the tears are chronic and massively large, they are not repairable. You might think that you would know if you had a large, chronic tear, but it’s amazing how often we see this devastating condition. And I would have to say that this condition is completely preventable. It just requires a little awareness, some preemptive action on your part, and possible a visit to your doctor. And don’t have that common attitude that it’s just something you’re going to have to live with. Because it’s not.