Shoulder Injuries: Q&A

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By Mary Carpenter

In MyLittleBird’s Well-Being series, Answers to Readers’ Questions.

QUESTION:  What is it with shoulders? Why do there seem to be so many injured shoulders; and when and how should these injuries be treated?

MY LITTLE BIRD: Most shoulder discomfort can ratchet up slowly (except for serious injuries), beginning with the barely noticeable and moving almost imperceptibly to the unpleasant and worrisome—therein lies the challenge in figuring out when and how to seek help. In general, though, inflammation is at the root of most shoulder issues—and most respond to the same treatments regardless of the specific diagnosis.

(Shoulder symptoms indicating serious damage that requires immediate medical attention include: the shoulder joint looks deformed; the shoulder doesn’t work at all; the pain is intense; the shoulder swells suddenly; or the arm or hand is weak or numb. Also, some injuries, such as dislocation—when the top of the arm pops out of the socket— need a doctor to get the shoulder back in place; separation—when a torn ligament causes movement of the collarbone; and fracture—usually of the collarbone or humerus, upper arm bone. )

Common shoulder impairments arise either from an incident, like falling; or over time from arthritis—and motion-related issues—anything from immobility to excess or repetitive movements, especially when done incorrectly. Diagnosis can depend on details of the discomfort —such as what time of day or night it most often occurs and which activities make it worse, such as raising the affected arm—and is often confirmed using a scan— an X-ray or MRI. Noises the shoulder makes can provide important clues: crackling sounds when lifting the arm overhead can signal a rotator cuff tear, as can pain at night; while catching, locking or grinding sounds and sensations more likely indicate injury to the cartilage.

So many muscles, tendons and bones converge at the shoulder joint—with each susceptible to its own damage leading to pain or impeding normal movement. The rotator cuff alone has four tendons, each attaching a different muscle to the scapula (shoulder blade) and the humerus.  According to Harvard Health Publications, “The most common cause of shoulder pain is rotator cuff tendonitis—inflammation of key tendons in the shoulder.”

When accompanied by normal muscle strength, shoulder pain suggests rotator cuff tendinitis, while pain with weakness can indicate a tear. Rotator cuff impingement, by contrast, occurs when a rotator cuff muscle swells and cramps the space between the shoulder and arm bones to cause pinching. Muscle strain and bone spurs can also cause swelling around the joint. The risk of rotator cuff tears increases with age and long-term wear and tear on the body.

Pain slightly lower on the upper arm may signal biceps tendinitis, often found in concert with rotator cuff damage—which occurs, for example, in swimmer’s shoulder, linked to the high number of swim stroke repetitions. Also for swimmers, impingement syndrome arises when a “tendon in the shoulder rubs and catches on surrounding tissues,” creating a dull ache that hurts during use or when sleeping on the affected side of the body.

Frozen shoulder is another specific shoulder issue, which often seems to arise out of the blue, more commonly in women, and after age 40. Also called adhesive capsulitis, the capsule of connective tissue surrounding the shoulder thickens and tightens, and raising the affected arm can create a sudden, sharp pain.

Treatments include steroid injections; physical therapy; and strong “medical doses” of NSAIDs, such as for naproxen (Alleve), two pills twice a day. Frozen shoulder has a reputation of resolving in six months no matter what steps are taken – but according to the Mayo Clinic, the average is more like one to three years.

When shoulder pain arises suddenly—most often after a fall —the initial treatment is several days of rest, along with ice applied every four to six hours. Afterwards, and for most slowly worsening shoulder ailments, recovery includes a combination of physical therapy and NSAIDs like Advil—taking as little as two weeks though more “stubborn cases” take months or longer to heal. Corticosteroid injections can offer quick relief but appear to offer no long-term advantage over the PT/NSAID combination, according to Harvard Health.

Professional physical therapy sessions can help kickstart treatment, although most shoulder exercises are easy to master. The challenge is maintaining a regular practice. Most shoulder exercises require holding positions for 5 to 20 seconds, with many repeats. The doorway stretch involves standing in a doorway, holding the side of the frame with the affected arm slightly below shoulder height, and turning away from the arm to feel a slight stretch. For the cross-body or crossover arm stretch, lift the affected arm in front of the body, using the opposite arm for support if needed and to pull the affected arm across the body.

The pendulum exercises may be the most versatile: standing pendulum uses the weight and momentum of the arm to “encourage movement at the shoulder joint while maintaining inactivity of the injured muscle,” according to Healthline. Lying Pendulum is best for those who have trouble standing due to balance or back pain; and the more advanced “weighted pendulum” —done while leaning on a table with the unaffected arm—adds a dumbbell or wrist weight.

When I had a “frozen shoulder,” I did everything —the doctor’s visit with scan, the steroid shot and the physical therapy. When I recovered in about six months, I had no idea what did or did not help. Now I have something like “swimmer’s shoulder,” even after months of no swimming due to Covid, and suspect the time has come to begin exercises.

—Mary Carpenter regularly reports on topical issues in health and medicine.