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Shoulder & Elbows
The Shoulder: A Vulnerable Joint
Far from a simple hinge, the human shoulder
is a series of four joints, including a wobbly ball-and-socket
held together by ligaments, muscles and tendons.
Mobility is its miracle. Stability is its weak
point.
The shoulder is the most agile joint in the
body. Its loose construction gives the arm nearly complete range
of motion, allowing it to lug a suitcase, swing a golf club,
chop wood or fetch a book from the top shelf.
That range of motion even allows the most intimidating
pitcher in baseball, Randy Johnson, to throw a baseball at up
to 100 mph. It then allows the unlucky batter to swing at (and
probably miss) the pitch, the unlucky opposing manager to scratch
his head and shrug, and jubilant fans to slap high-fives.
But the shoulder's versatility and wide range
of motion come at a price. It's an inherently unstable joint.
There are countless things that can go wrong.
One of the most serious is a dislocation —
the ball pops out of its socket. Unlike the hip, which is a
true ball-and-socket joint with a secure, snug fit, the shoulder
is a ball-and-socket in name only. Much more than in any other
joint, we depend heavily on muscles to do the work of holding
the shoulder together. The ball is much larger than the socket.
It's like putting a beach ball on a saucer. Others have compared
it to a baseball on a golf tee.
Once the shoulder is dislocated, it becomes
more vulnerable, because even with the ball back in its socket,
the ligaments usually are stretched or torn. That further loosens
the already precarious joint.
Far more common than dislocation is inflammation
of the muscles and tendons that hold the shoulder together.
It comes in many forms and goes by many names: tendinitis, bursitis,
rotator cuff syndrome, impingement. It can afflict anyone who
tries to serve a tennis ball, paint the kitchen ceiling or pull
an ungainly carry-on down from the overhead bin. But the number
one shoulder problem we see is rotator cuff tendinitis.
What's In A Name?
Shoulder terminology can be confusing. For example, a shoulder
dislocation and a shoulder "separation" involve completely
different bones. Bursitis and tendinitis usually refer to the
same pain in the shoulder.
And then there's the so-called rotator cuff,
a name that sounds like a fan belt but actually refers to a
series of four muscles anchoring the shoulder. They extend
from
the shoulder blade down to the top of the arm bone — the
ball of the ball-and-socket joint. Their fibrous, sinewy tendons
come together in a kind of "cuff" that helps to hold
the ball in its socket.
Rotator cuff strains tend to set off a vicious
cycle. Already cramped for room beneath the shoulder blade,
the tendons have even less room if they become swollen, which
only increases the inflammation, pinching them further.
It also hurts. Typically, the pain radiates
from the top and outside the shoulder, especially when the arm
is raised or extended with the elbow not in close to the side.
Once the shoulder tendons are inflamed, even everyday motions
like putting the arm into a shirtsleeve or reaching into a back
pocket can be painful.
In addition, there is a bursa — a fluid-filled
sac — between the tendons and the bone to cushion the joint
and keep the tendons from wearing through. That's why inflammation
in that area is sometimes called bursitis.
The Problem of Instability
The second most common type of shoulder problem after tendinitis
is instability — when the beach ball slips out of the saucer.
A dislocation is complete when the ball pops out of the socket
— usually when the arm is yanked backward and upward at
the same time. A subluxation is when it comes part way out.
A "separation" involves a different
part of the shoulder, the joint where the end of the collarbone
meets the shoulder blade. It too is held together by ligaments,
which can be sprained or torn, throwing the collarbone out of
alignment. That is the injury that nearly kept Dallas Cowboys'
All-Pro running back Emmitt Smith out of the 1995 NFL playoffs.
Usually it heals without surgery.
Other shoulder problems include arthritis,
a painful degenerative disease in which the joint itself becomes
inflamed from aging and wear-and-tear, and fractures, usually
caused by a collision or fall. Justice Sandra Day O'Connor fractured
her shoulder this past winter when she fell while skiing at
Sun Valley, Idaho. In very rare cases, shoulder pain is caused
by a cancerous tumor.
First, Reduce the Swelling
Fortunately, most shoulder soreness goes away within a few days
or weeks without surgery. The basic first-line treatment is
to reduce the swelling and inflammation by rest, ice (applied
before and after exercise or at least once a day) or nonsteroidal
anti-inflammatory medications such as aspirin, ibuprofen (Advil®,
Motrin®, Nuprin®) or naproxen (Naprosyn®, Aleve®).
If the pain and inflammation persist, rotator
cuff tendinitis is sometimes treated with steroids — either
pills or an injection directly into the bursa. Because of their
many possible side effects with extended use, steroids are used
sparingly.
Surgery is a last resort for otherwise untreatable
rotator cuff tendinitis. Guided by an arthroscope — a lighted
tube carrying a tiny television camera through an incision the
size of a buttonhole — the surgeon removes or repairs damaged
tissue and shaves the underside of the shoulder blade to make
more room for the irritated tendons.
In the most severe cases, surgeons use open
surgery to repair tears in the rotator cuff. The injured tendon
is trimmed and reattached to the ball of the arm bone with stitches.
The incision is larger than in arthroscopy, and the recovery
time longer. After either kind of surgery, physical therapy
helps to stretch and strengthen the recuperating muscles.
Preventing shoulder strains is largely common
sense. It means starting gradually when taking up an exercise
program. It means lifting weights carefully and under the guidance
of an expert.
And it means paying attention to all muscles,
not just the big visible ones. When it comes to shoulder health,
the relatively small rotator cuff muscles, hidden within the
joint, are as important as the biceps in the upper arm and the
pectorals in the chest. Rotator cuff muscles can be strengthened
by a series of isometric exercises in which the arm pulls against
the resistance of an elastic band or small weights.
When To Seek Help
Which kind of shoulder pain is worrisome, and which merely a
nuisance?
Besides the obvious throbbing of a dislocation
or fracture, the pain to worry about is soreness that is not
relieved by ice and nonprescription medications. Pain that doesn't
improve in a few days. Pain that wakes you up in the night.
All are good reasons to see a doctor.
Discoloration of the skin is another
serious warning. Things don't turn black and blue for no reason.
Either you tore something or you broke something.
Resting a sore shoulder is a good idea.
Not using it at all isn't. That can result in a "frozen
shoulder," where the lining of the joint becomes so stiff
and rough from lack of use that it won't budge — like a
stuck drawer.
Avoid the things that make it worse —
in moderation. While the shoulder mends, don't do what hurts
a lot, but you should still move.
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