Shoulder Pain & Anatomy

Anatomy of the Shoulder

The shoulder is a complex ball-and-socket joint that gives full movement of the arms, allowing patients to reach up high, down low and side to side. 

It offers a wide range of motion, but also makes it vulnerable to injury.

At the shoulder, three major bones meet and create a 90-degree angle. These bones are —collarbone (clavicle), shoulder blade (scapula) and the largest arm bone (the humerus)

Three joints are formed from the junctions of these three bones and the sternum. These joints are the glenohumeral joint, the acromioclavicular (AC) joint and the sternoclavicular joint.

Each joint in the shoulder is surrounded by cartilage for padding, ligaments to connect the bones, muscles and tendons to attach the muscles to the bones. 

How the Shoulder Works

To understand the functions, conditions and surgical procedures of the shoulder, Dr Ryan du Sart has included an interactive animated presentation. 

The ball-shaped upper arm bone, (humerus), fits into the cup-like hollow of the top part of the shoulder bone (scapula).

The shoulder joint is surrounded by the capsule, a tough fibrous sleeve, which helps to hold the joint together. The synovium, the inner layer of the capsule, allows the joint to move smoothly by producing a fluid to nourish the cartilage and lubricate the joint. 

The rotator cuff in the shoulder is made up of four muscles and their tendons, they control movement and help hold the joint together.

Shoulder Tendon Pain

What is a Shoulder Tendon?

A tendon is a fibrous tissue that connects muscle to bone and is capable of withstanding significant tension.Tendons are made of collagen and together with the muscles they work to move bones.

The role of the tendon is:
  • connecting muscles to bones
  • to withstand tension
Common tendon problems include:
  • Tendinopathy

What is Tendinopathy?

The term tendinitis includes both tendon inflammations and tiny tears in the tissue and around the tendon caused by overuse. 

Tendon injuries are often caused by gradual wear and tear to the tendon from overuse and aging. Sufferers generally make the same motions over and over in their jobs, sport or daily activities. 

The inability for your tendon to adapt to the load quickly enough causes tendon to progress through four phases of tendon injury.
  • Reactive Tendinopathy
  • Tendon Dysrepair
  • Degenerative Tendinopathy
  • Tendon Tear or Rupture

Tendinopathy Symptoms

Tendinopathy usually causes pain and sufferers have the following symptoms:
  • stiffness
  • loss of strength in the affected area.
  • worsening pain with tendon use
  • shoulder tenderness 
  • a feeling of warmth
  • redness and swelling
  • audible crunchy sound or feeling
You may have more pain and stiffness during the night or when you get up in the morning.

Tendinopathy can affect the following areas:
  • Quadriceps
  • Rotator cuff
  • Biceps

Diagnosis of Tendinopathy 

Dr Ryan du Sart will need to diagnose the specific nature of the tendinopathy.

Often, Tendinopathy can be identified during a physical exam by a medical professional. By examining the joint the cause of symptoms can be pinpointed. 

Diagnostic methods include: 
Consultation - During this consultation Dr du Sart will: 
  • take a medical history 
  • perform a physical examination 
  • assess the joint’s range of motion 
Arthroscopy - link to Arthroscopy page 
Imaging tests - In order to clearly understand the nature of any loss in the joint space or bone spur formation imaging scans are required: 
  • X-rays - do not show tendons but are often normal as they can help rule out other problems with the affected area that may have similar symptoms like fractures (broken bone) or bone deformation. 
  • MRI - can create detailed images of both hard and soft tissues. An MRI can produce cross-sectional images of internal structures required if the diagnosis is unclear. 
  • Ultrasound - can allow the doctor to examine the inside of your affected area in motion. 
While not all of these approaches or tests are required to confirm the diagnosis, this diagnostic process will also allow Dr Ryan du Sart to review any possible risks or existing conditions that could interfere with the surgery or its outcome.

Treatment for Tendinopathy

Non surgical treatments can include:

  • Resting the painful area
  • Avoiding activities that makes the pain worse
  • Cold packs
  • Do a gentle-of-motion exercises and stretching to prevent stiffness

Surgery considered for prolonged Tendinopathy

A common procedure is open surgical removal of dead tendons.

This involves the removal of damaged or infected tendon tissue to improve the healing potential of the remaining healthy tissue (debridement) as well as surgically repairing or augmenting the tendon as needed.

Rotator cuff - Acromioplasty, removal of the coracoacromial ligament and repair of the rotator cuff tendon, usually results in near full rotator cuff strength.

Biceps - In young people unwilling to accept the loss of function and mild deformity involved with this injury, surgery is performed to repair the tendon. Surgery is also considered for the middle-aged person who requires full supination strength in their line of work.

Untreated Tendinopathy

Tendinopathy is not life threatening but can severely impact a patient’s quality of life and function.

It can affect anyone: elite athletes and the active individual, manual labourers and office workers. 

Damage to tendons can lead to 
  • Short Term Impact - ongoing pain and disability. 
  • Long Term Impact - osteoarthritis of the joint or permanent damage

Surgery Risks with Tendinopathy

Prior to making any decision to have surgery, it is important that the patient discusses any concerns with Dr du Sart and understands the potential risks.

While complications due to surgery are uncommon they can occur, the following are some: 
  • numbness or tingling in the area
  • some discomfort to the area 
  • joint stiffness 
  • local nerve or blood vessel damage 
  • reflex sympathetic dystrophy 
Rarely do these complications prevail over the long term. It is important to avoid high impact activities during the early phase of recovery to minimise the risk of fracture. 

Other general medical and surgical risks can include: 
  • risk of infection 
  • bleeding and clots in the leg (DVT) or lung post-operatively 
  • allergies and anaesthetic complications can occur 
If there are any postoperative concerns or pain please do not hesitate in contacting Dr du Sart or the rooms. 

Preparing for Tendinopathy Surgery

Once [doctor] decides that surgery is required, preparation is necessary to achieve the best results and a quick, problem free recovery.

 Preparing mentally and physically for surgery is an important step toward a successful result. 
  • Dr du Sart will create a treatment plan and 
  • patients will also need to understand the process and their role in it
Participating and completing a tailored exercise program before (ie. pre-hab) with a trained physiotherapist will achieve the best result after surgery. 

Dr du Sart will also need to: 
  • discuss any medications being taken with your doctor or physician to see which ones should be stopped before surgery 
  • do not eat or drink anything, including water, for 6 hours before surgery 
  • stop taking aspirin, warfarin, anti-inflammatory medications or drugs that increase the risk of bleeding one week before surgery to minimise bleeding 
  • review blood replacement options (including banking blood) with your doctor 
  • stop or cut down smoking to reduce your surgery risks and improve your recovery 
Report any infections to Dr du Sart prior to surgery as the procedure cannot be performed until all infections have cleared up. 

After Your Operation:

Recovery 
Some patients need one night in hospital, although it is possible to leave hospital the day of surgery. The incision wounds take 7-10 days to heal.

Most patients improve dramatically in the first 6 weeks. Occasionally, there are periods where the shoulder may become sore and then settle again. This is part of the normal healing process. 

It takes three months for the patient's Shoulder to recover from surgery. 

Continued improvements may be gained up to 1 year post-surgery. 

Complications 
If any postoperative problems arise with the Patient’s Shoulder, such as redness, increasing pain or fevers, [doctor] should be contacted . If unavailable, seek advice from the hospital or your general practitioner. 

Pain Management after Surgery 
A patient’s experience of pain will vary depending on the procedure performed and the amount of pre-existing damage. 

After your operation you will have pain medication and antibiotics. 

Most patients are pleasantly surprised at how little pain they have after the procedure. Local anaesthetic is injected before and after the procedure to minimise any pain you may feel. 

Mobility 
  • Lifting- After surgery, the patient’s arm may be placed in a sling for a short period of time. This allows for early healing. As soon as your comfort allows, doctor] will remove the sling to begin exercise and use of the arm.
  • Walking - full weight-bearing and walking is allowed immediately. 
  • Driving - do not drive for 48 hours after an anaesthetic. After 48 hours, ability to drive will depend on the area you had your operation, left or right, and the type of vehicle driven, manual or automatic. Otherwise, it is reasonable to drive when the patient is confident. 

Return to Work After Surgery 

Return to work will vary depending on the procedure performed and type of work the patient is engaged in. Most people can return to office work within 2 weeks. Labour intensive work however, may require the patient to take 4-6 weeks before returning to full duties.

 During this period patients are not fit to perform work duties that involve: 
  • heavy lifting, 
  • excessive swing movement
  • repetitive upper arm activity
Return to Sport
Activities or sports can be restarted after the wound is healed, this means postoperative swelling has subsided and range of movement is restored. However, it is best to delay leisure activities or sports for 6 weeks to allow the shoulder time to heal and repair.

Low impact activities, such as cycling and swimming, can be commenced from week 4. If your procedure involves bone removal, high impact activities, such as throwing or lifting are best avoided for 6 weeks post-surgery. 

Sport specific re-training can commence from week 6, with the aim to return to elite level sports 2-3 months post-surgery. 

Post Operative Rehab 
Participating and completing a tailored exercise program after surgery. (ie. rehab) with a trained physiotherapist will achieve the best result for you after surgery.
Share by: