The commonest cause of shoulder pain is rotator cuff disease. The pain is typically at the top of the shoulder and can go to the elbow. It can be particularly painful in bed and will prevent sleep. When reaching for something in the back of the car you may feel a sudden dart of pain. It usually comes on gradually but it can be brought on by a sudden bout of activity such as gardening or lifting luggage bags on holiday.
If you fall on your arm or your side you can tear the rotator cuff. Your x-ray will be normal. If you cannot lift your arm away from your side you probably have torn your tendon. Only surgery will repair the tendon.
In the under 30 age group there is no degeneration of the tendons and it can be treated well by a programme of scapular exercises. The shoulder is brought in to proper alignment and the impinging type pain is relieved.
In older patients the rotator cuff tendons are degenerating or if you like slowly wearing. The body is not able to continue to heal the tendons and they gradually get worse. There is no inflammation. The tendon may be impinging against the bone at the top of the shoulder called the acromion. This may add to the wear. The wear can go on and result in an actual hole in the tendon. This can deteriorate and lead to exposure of the head of the humerus which will then rub bone on bone on the acromion.
The condition can be diagnosed by a good clinical examination. An ultrasound or an MRI will help to outline the extent of the wear. The MRI can show what extent the tendon has retracted and what atrophy there is in the muscle. This will help decide if the tendon can be actually be repaired.
Initially physiotherapy will help. The physio will instruct the patient in rotator stabilisation exercises which will correct or at least reduce the impingement. However the wear of the rotator cuff tendons will not actually change.
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Steroid injections can help in the short term but again do not actually heal the tendon. However healing of the tendon is not actually necessary to decrease the pain.
Surgery can be the answer when the above does not solve the problem. A sub-acromial space decompression will increase the space at the top of the shoulder so that the shoulder has more space when lifting it up. It can take 3 to 6 months for a full improvement. The operation is done with the arthroscope (key hole surgery) so there are no large wounds.
During the operation the integrity of the cuff is assessed. Even though scanning is done before the operation tears of the cuff can be better seen with the arthroscope. Repairing these tears with sutures can result in actual healing of the tendon. Healing of the tendon will take away the pain and prevent joint wear and tear.