Understanding Shoulder Pain
Understanding Shoulder Pain
By Daniel Rocha LMT CPT CNS
Pain is interpreted as an unpleasant sensation of physical discomfort, usually in a specific body part. Pain is a complex experience with an emotional and psychological extent. Pain is differentiated from suffering in that suffering involves a psychological threat or damage to the person's sense of self. It is probable for someone to experience pain without suffering and suffering without physical pain.
Pain is classified by duration, acute or chronic, or by type. Acute pain is defined as sudden onset pain lasting for a few days, hours, or minutes and is usually the result of tissue damage. Acute pain ceases when the injury to the body heals. Chronic pain is persistent, lasts six months, is not life-threatening, and has several causes.
There are four basic types of pain:
Nociceptive: results from activating nociceptors, nerve organs in tissue that sense pain from harmful stimuli and relay pain messages to the brain. Nociceptive pain includes burns, inflammation, visceral pain, trauma, and muscular cramps.
Neuropathic: results from a dysfunctional nerve that causes a burning, electrical shock, or pins-and-needles quality. Common causes include diabetes, herpes zoster infections, alcoholism, and autoimmune disorders.
Psychological pain: caused by psychological factors rather than physical ones. Somatization disorder is a mental disorder where the patient converts emotional distress into physical complaints such as headaches, sexual problems, and gastrointestinal complaints. Most patients with somatization disorder begin to have symptoms in their 30s; a senior with somatization symptoms for the first time are checked for depression.
Mixed pain: arises from a combination of sources or sources not fully understood. Migraine headaches are an example of mixed pain.
CAUSES AND SYMPTOMS
The most common causes of pain are musculoskeletal disorders, and the most common pain locations in those over 65 are the joints. For seniors, pain is complicated by other concurrent physical and mental disorders. Seniors with osteoarthritis may stop exercising due to pain, become depressed because they are housebound, and then feel more pain in their joints because they are depressed. The physician must take a complete physical, mental, and social history when asking a senior about pain.
Repetitive shoulder strain
Common repetitive strain injuries (RSIs) occur primarily in the workplace. Repetitive strain injuries occur from repeated stress on soft tissue structures, including muscles, tendons, and nerves. They occur in patients who perform repetitive movements in their jobs or extracurricular activities. Common RSIs include tendon-related disorders, like rotator cuff tendonitis, and peripheral nerve entrapment disorders, like carpal tunnel syndrome. A history and physical examination lead to the diagnosis, but imaging techniques, like magnetic resonance imaging and ultrasound, aid in refractory cases. Treatment includes medication, physiotherapy, or bracing. Surgery is a last resort for patients that do not respond to treatment. A repetitive strain injury is common, but to be diagnosed, primary care physicians must establish a diagnosis and, more importantly, its relationship to occupation. Treatment can be offered by family physicians who refer to specialists for cases refractory to conservative management.
The four most common causes of shoulder pain and disability are rotator cuff disorders, glenohumeral disorders, acromioclavicular joint disease, and neck pain. A primary care study showed that standardized clinical tests for shoulder disorders reported rotator cuff tendinopathy in 85% of patients. Still, patients also were clinically diagnosed with tendinosis, impingement, acromioclavicular disease, and adhesive capsulitis. Blood tests and radiography indicated symptoms and signs of systemic disease such as weight loss, generalized joint pains, fever, lymphadenopathy, new respiratory symptoms, history of cancer, or local features such as a mass lesion or bony tenderness or swelling.
Treatment will depend on the cause of the pain, and a naprapath will account for the patient's medications and where the person is living. Seniors do best with a combination of drugs and non-drug treatments rather than either approach alone. Available holistic therapy for shoulder pain includes analgesia, along with motivation and encouragement for rehabilitation. However, the typical primary care interventions include steroid injections. So the general practitioner must decide whether the pain is arising from the shoulder; or if it is originating elsewhere.
Pain arising from the shoulder is due to a rotator cuff disorder or a glenohumeral joint problem. For both these shoulder disorders, the analgesics paracetamol, a non-steroidal anti-inflammatory drug, is used intermittently as a second-line if no contraindications exist. Activity is encouraged, along with physical therapy.
Naprapathic non-drug treatments include therapeutic exercise, which is beneficial for seniors with pain in the joints and muscles. Other complementary and alternative (CAM) treatments that a naprapath could provide include massage therapy, relaxation techniques, meditation, and dietary guidelines.
Surgery is recommended in emergencies such as unreduced dislocation, infection, and traumatic acute rotator cuff tear. For frozen shoulder, surgeons advocate manipulation under anesthesia and arthroscopic release. A study found comparable results between physiotherapy programs and arthroscopic decompression for patients with rotator cuff disease. For significant persistent disability associated with impingement and rotator cuff tear, surgery relieves pain and restores function in patients who have failed conservative treatment. Controversy exists considering mildly symptomatic small rotator cuff tears, where these small tears should be repaired to relieve symptoms and prevent progression to more giant tears, which are associated with high levels of disability. For resistant acromioclavicular joint pain, an arthroscopic excision of the distal clavicle is a practical procedure with low risk. Surgery remains the mainstay for recurrent shoulder instability. The management of osteoarthritis and rheumatoid arthritis has considerably improved, and joint replacement surgery provides pain relief for end-stage disease.
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