This booklet first answers general questions about the
shoulder and shoulder problems. It then answers questions about specific
shoulder problems (dislocation, separation, tendinitis, bursitis,
impingement syndrome, torn rotator cuff, frozen shoulder, and fracture)
as well as shoulder pain caused by arthritis of the shoulder.
How Common Are Shoulder Problems?
According to the American Academy of Orthopaedic Surgeons,
about 4 million people in the United States seek medical care each year
for shoulder sprain, strain, dislocation, or other problems. Each year,
shoulder problems account for about 1.5 million visits to orthopaedic
surgeons--doctors who treat disorders of the bones, muscles, and related
What Are the Structures of the Shoulder
and How Does the Shoulder Function?
The shoulder joint is composed of three bones: the
clavicle (collarbone), the scapula (shoulder blade), and the humerus
(upper arm bone) (see diagram). Two joints facilitate shoulder movement.
The acromioclavicular (AC) joint is located between the acromion (part
of the scapula that forms the highest point of the shoulder) and the
clavicle. The glenohumeral joint, commonly called the shoulder joint, is
a ball-and-socket type joint that helps move the shoulder forward and
backward and allows the arm to rotate in a circular fashion or hinge out
and up away from the body. (The "ball" is the top, rounded portion of
the upper arm bone or humerus; the "socket," or glenoid, is a
dish-shaped part of the outer edge of the scapula into which the ball
fits.) The capsule is a soft tissue envelope that encircles the
glenohumeral joint. It is lined by a thin, smooth synovial membrane.
The bones of the shoulder are held in place by
muscles, tendons, and ligaments. Tendons are tough cords of tissue that
attach the shoulder muscles to bone and assist the muscles in moving the
shoulder. Ligaments attach shoulder bones to each other, providing
stability. For example, the front of the joint capsule is anchored by
three glenohumeral ligaments.
The rotator cuff is a structure composed of tendons that,
with associated muscles, holds the ball at the top of the humerus in the
glenoid socket and provides mobility and strength to the shoulder joint.
Two filmy sac-like structures called bursae permit smooth
gliding between bone, muscle, and tendon. They cushion and protect the
rotator cuff from the bony arch of the acromion.
What Are the Origin and Causes of Shoulder
The shoulder is the most movable joint in the body.
However, it is an unstable joint because of the range of motion allowed.
It is easily subject to injury because the ball of the upper arm is
larger than the shoulder socket that holds it. To remain stable, the
shoulder must be anchored by its muscles, tendons, and ligaments. Some
shoulder problems arise from the disruption of these soft tissues as a
result of injury or from overuse or underuse of the shoulder. Other
problems arise from a degenerative process in which tissues break down
and no longer function well.
Shoulder pain may be localized or may be referred to areas
around the shoulder or down the arm. Disease within the body (such as
gallbladder, liver, or heart disease, or disease of the cervical spine
of the neck) also may generate pain that travels along nerves to the
How Are Shoulder Problems
Following are some of the ways doctors diagnose shoulder
- Medical history (the patient tells the doctor about an injury or
other condition that might be causing the pain).
- Physical examination to feel for injury and discover the limits of
movement, location of pain, and extent of joint instability.
- Tests to confirm the diagnosis of certain conditions. Some of
these tests include:
- x ray
- arthrogram--Diagnostic record that can be seen on an x ray after
injection of a contrast fluid into the shoulder joint to outline
structures such as the rotator cuff. In disease or injury, this
contrast fluid may either leak into an area where it does not
belong, indicating a tear or opening, or be blocked from entering an
area where there normally is an opening.
- MRI (magnetic resonance imaging)--A non-invasive procedure in
which a machine produces a series of cross-sectional images of the
- Other diagnostic tests, such as injection of an anesthetic into
and around the shoulder joint, are discussed in specific sections of
What Is a Shoulder Dislocation?
The shoulder joint is the most frequently dislocated major
joint of the body. In a typical case of a dislocated shoulder, a strong
force that pulls the shoulder outward (abduction) or extreme rotation of
the joint pops the ball of the humerus out of the shoulder socket.
Dislocation commonly occurs when there is a backward pull on the arm
that either catches the muscles unprepared to resist or overwhelms the
muscles. When a shoulder dislocates frequently, the condition is
referred to as shoulder instability. A partial dislocation where the
upper arm bone is partially in and partially out of the socket is called
What Are the Signs of a Dislocation and How Is It
The shoulder can dislocate either forward, backward, or
downward. Not only does the arm appear out of position when the shoulder
dislocates, but the dislocation also produces pain. Muscle spasms may
increase the intensity of pain. Swelling, numbness, weakness, and
bruising are likely to develop. Problems seen with a dislocated shoulder
are tearing of the ligaments or tendons reinforcing the joint capsule
and, less commonly, nerve damage. Doctors usually diagnose a dislocation
by a physical examination, and x rays may be taken to confirm the
diagnosis and to rule out a related fracture.
How Is a Dislocated Shoulder Treated?
Doctors treat a dislocation by putting the ball of the
humerus back into the joint socket--a procedure called a reduction. The
arm is then immobilized in a sling or a device called a shoulder
immobilizer for several weeks. Usually the doctor recommends resting the
shoulder and applying ice three or four times a day. After pain and
swelling have been controlled, the patient enters a rehabilitation
program that includes exercises to restore the range of motion of the
shoulder and strengthen the muscles to prevent future dislocations.
These exercises may progress from simple motion to the use of
After treatment and recovery, a previously dislocated
shoulder may remain more susceptible to reinjury, especially in young,
active individuals. Ligaments may have been stretched or torn, and the
shoulder may tend to dislocate again. A shoulder that dislocates
severely or often, injuring surrounding tissues or nerves, usually
requires surgical repair to tighten stretched ligaments or reattach torn
Sometimes the doctor performs surgery through a tiny
incision into which a small scope (arthroscope) is inserted to observe
the inside of the joint. After this procedure, called arthroscopic
surgery, the shoulder is generally immobilized for about 6 weeks and
full recovery takes several months. Arthroscopic techniques involving
the shoulder are relatively new and many surgeons prefer to repair a
recurrent dislocating shoulder by the time-tested open surgery under
direct vision. There are usually fewer repeat dislocations and improved
movement following open surgery, but it may take a little longer to
What Is a Shoulder Separation?
A shoulder separation occurs where the collarbone
(clavicle) meets the shoulder blade (scapula). When ligaments that hold
the joint together are partially or completely torn, the outer end of
the clavicle may slip out of place, preventing it from properly meeting
the scapula. Most often the injury is caused by a blow to the shoulder
or by falling on an outstretched hand.
What Are the Signs of a Shoulder Separation and How Is It
Shoulder pain or tenderness and, occasionally, a bump in
the middle of the top of the shoulder (over the AC joint) are signs that
a separation may have occurred. Sometimes the severity of a separation
can be detected by taking x rays while the patient holds a light weight
that pulls on the muscles, making a separation more pronounced.
How Is a Shoulder Separation Treated?
A shoulder separation is usually treated conservatively by
rest and wearing a sling. Soon after injury, an ice bag may be applied
to relieve pain and swelling. After a period of rest, a therapist helps
the patient perform exercises that put the shoulder through its range of
motion. Most shoulder separations heal within 2 or 3 months without
further intervention. However, if ligaments are severely torn, surgical
repair may be required to hold the clavicle in place. A doctor may wait
to see if conservative treatment works before deciding whether surgery
Tendinitis, Bursitis, and Impingement
What Are Tendinitis, Bursitis, and Impingement Syndrome of
These conditions are closely related and may occur alone
or in combination. If the rotator cuff and bursa are irritated,
inflamed, and swollen, they may become squeezed between the head of the
humerus and the acromion. Repeated motion involving the arms, or the
aging process involving shoulder motion over many years, may also
irritate and wear down the tendons, muscles, and surrounding structures.
Tendinitis is inflammation (redness, soreness, and
swelling) of a tendon. In tendinitis of the shoulder, the rotator cuff
and/or biceps tendon become inflamed, usually as a result of being
pinched by surrounding structures. The injury may vary from mild
inflammation to involvement of most of the rotator cuff. When the
rotator cuff tendon becomes inflamed and thickened, it may get trapped
under the acromion. Squeezing of the rotator cuff is called impingement
Tendinitis and impingement syndrome are often accompanied
by inflammation of the bursa sacs that protect the shoulder. An inflamed
bursa is called bursitis. Inflammation caused by a disease such as
rheumatoid arthritis may cause rotator cuff tendinitis and bursitis.
Sports involving overuse of the shoulder and occupations requiring
frequent overhead reaching are other potential causes of irritation to
the rotator cuff or bursa and may lead to inflammation and
What Are the Signs of Tendinitis and Bursitis?
Signs of these conditions include the slow onset of
discomfort and pain in the upper shoulder or upper third of the arm
and/or difficulty sleeping on the shoulder. Tendinitis and bursitis also
cause pain when the arm is lifted away from the body or overhead. If
tendinitis involves the biceps tendon (the tendon located in front of
the shoulder that helps bend the elbow and turn the forearm), pain will
occur in the front or side of the shoulder and may travel down to the
elbow and forearm. Pain may also occur when the arm is forcefully pushed
How Are These Conditions Diagnosed?
Diagnosis of tendinitis and bursitis begins with a medical
history and physical examination. X rays do not show tendons or the
bursae but may be helpful in ruling out bony abnormalities or arthritis.
The doctor may remove and test fluid from the inflamed area to rule out
infection. Impingement syndrome may be confirmed when injection of a
small amount of anesthetic (lidocaine hydrochloride) into the space
under the acromion relieves pain.
How Are Tendinitis, Bursitis, and Impingement Syndrome
The first step in treating these conditions is to reduce
pain and inflammation with rest, ice, and anti-inflammatory medicines
such as aspirin, naproxen (Naprosyn*), ibuprofen (Advil, Motrin, or
Nuprin), or cox-2 inhibitors (Celebrex, Vioxx, or Nobic). In some cases
the doctor or therapist will use ultrasound (gentle sound-wave
vibrations) to warm deep tissues and improve blood flow. Gentle
stretching and strengthening exercises are added gradually. These may be
preceded or followed by use of an ice pack. If there is no improvement,
the doctor may inject a corticosteroid medicine into the space under the
acromion. While steroid injections are a common treatment, they must be
used with caution because they may lead to tendon rupture. If there is
still no improvement after 6 to 12 months, the doctor may perform either
arthroscopic or open surgery to repair damage and relieve pressure on
the tendons and bursae.
* Brand names included in this booklet are provided as
examples only, and their inclusion does not mean that these products are
endorsed by the National Institutes of Health or any other Government
agency. Also, if a particular brand name is not mentioned, this does not
mean or imply that the product is unsatisfactory.
Torn Rotator Cuff
What Is a Torn Rotator Cuff?
One or more rotator cuff tendons may become inflamed from
overuse, aging, a fall on an outstretched hand, or a collision. Sports
requiring repeated overhead arm motion or occupations requiring heavy
lifting also place a strain on rotator cuff tendons and muscles.
Normally, tendons are strong, but a longstanding wearing down process
may lead to a tear.
What Are the Signs of a Torn Rotator Cuff?
Typically, a person with a rotator cuff injury feels pain
over the deltoid muscle at the top and outer side of the shoulder,
especially when the arm is raised or extended out from the side of the
body. Motions like those involved in getting dressed can be painful. The
shoulder may feel weak, especially when trying to lift the arm into a
horizontal position. A person may also feel or hear a click or pop when
the shoulder is moved.
How Is a Torn Rotator Cuff Diagnosed?
Pain or weakness on outward or inward rotation of the arm
may indicate a tear in a rotator cuff tendon. The patient also feels
pain when lowering the arm to the side after the shoulder is moved
backward and the arm is raised. A doctor may detect weakness but may not
be able to determine from a physical examination where the tear is
located. X rays, if taken, may appear normal. An MRI can help detect a
full tendon tear, but does not detect partial tears. If the pain
disappears after the doctor injects a small amount of anesthetic into
the area, impingement is likely to be present. If there is no response
to treatment, the doctor may use an arthrogram, rather than an MRI, to
inspect the injured area and confirm the diagnosis.
How Is a Torn Rotator Cuff Treated?
Doctors usually recommend that patients with a rotator
cuff injury rest the shoulder, apply heat or cold to the sore area, and
take medicine to relieve pain and inflammation. Other treatments might
be added, such as electrical stimulation of muscles and nerves,
ultrasound, or a cortisone injection near the inflamed area of the
rotator cuff. The patient may need to wear a sling for a few days. If
surgery is not an immediate consideration, exercises are added to the
treatment program to build flexibility and strength and restore the
shoulder's function. If there is no improvement with these conservative
treatments and functional impairment persists, the doctor may perform
arthroscopic or open surgical repair of the torn rotator cuff.
Frozen Shoulder (Adhesive
What Is a Frozen Shoulder?
As the name implies, movement of the shoulder is severely
restricted in people with a "frozen shoulder." This condition, which
doctors call adhesive capsulitis, is frequently caused by injury that
leads to lack of use due to pain. Rheumatic disease progression and
recent shoulder surgery can also cause frozen shoulder. Intermittent
periods of use may cause inflammation. Adhesions (abnormal bands of
tissue) grow between the joint surfaces, restricting motion. There is
also a lack of synovial fluid, which normally lubricates the gap between
the arm bone and socket to help the shoulder joint move. It is this
restricted space between the capsule and ball of the humerus that
distinguishes adhesive capsulitis from a less complicated painful, stiff
shoulder. People with diabetes, stroke, lung disease, rheumatoid
arthritis, and heart disease, or who have been in an accident, are at a
higher risk for frozen shoulder. The condition rarely appears in people
under 40 years old.
What Are the Signs of a Frozen Shoulder and How Is It
With a frozen shoulder, the joint becomes so tight and
stiff that it is nearly impossible to carry out simple movements, such
as raising the arm. People complain that the stiffness and discomfort
worsen at night. A doctor may suspect the patient has a frozen shoulder
if a physical examination reveals limited shoulder movement. An
arthrogram may confirm the diagnosis.
How Is a Frozen Shoulder Treated?
Treatment of this disorder focuses on restoring joint
movement and reducing shoulder pain. Usually, treatment begins with
nonsteroidal anti-inflammatory drugs and the application of heat,
followed by gentle stretching exercises. These stretching exercises,
which may be performed in the home with the help of a therapist, are the
treatment of choice. In some cases, transcutaneous electrical nerve
stimulation (TENS) with a small battery-operated unit may be used to
reduce pain by blocking nerve impulses. If these measures are
unsuccessful, the doctor may recommend manipulation of the shoulder
under general anesthesia. Surgery to cut the adhesions is only necessary
in some cases.
What Happens When the Shoulder Is Fractured?
A fracture involves a partial or total crack through a
bone. The break in a bone usually occurs as a result of an impact
injury, such as a fall or blow to the shoulder. A fracture usually
involves the clavicle or the neck (area below the ball) of the
What Are the Signs of a Shoulder Fracture and How Is It
A shoulder fracture that occurs after a major injury is
usually accompanied by severe pain. Within a short time, there may be
redness and bruising around the area. Sometimes a fracture is obvious
because the bones appear out of position. Both diagnosis and severity
can be confirmed by x rays.
How Is a Shoulder Fracture Treated?
When a fracture occurs, the doctor tries to bring the
bones into a position that will promote healing and restore arm
movement. If the clavicle is fractured, the patient must at first wear a
strap and sling around the chest to keep the clavicle in place. After
removing the strap and sling, the doctor will prescribe exercises to
strengthen the shoulder and restore movement. Surgery is occasionally
needed for certain clavicle fractures.
Fracture of the neck of the humerus is usually treated
with a sling or shoulder immobilizer. If the bones are out of position,
surgery may be necessary to reset them. Exercises are also part of
restoring shoulder strength and motion.
Arthritis of the Shoulder
What Is Arthritis of the Shoulder?
Arthritis is a degenerative disease caused by either wear
and tear of the cartilage (osteoarthritis) or an inflammation
(rheumatoid arthritis) of one or more joints. Arthritis not only affects
joints; it may also affect supporting structures such as muscles,
tendons, and ligaments.
What Are the Signs of Shoulder Arthritis and How Is It
The usual signs of arthritis of the shoulder are pain,
particularly over the AC joint, and a decrease in shoulder motion. A
doctor may suspect the patient has arthritis when there is both pain and
swelling in the joint. The diagnosis may be confirmed by a physical
examination and x rays. Blood tests may be helpful for diagnosing
rheumatoid arthritis, but other tests may be needed as well. Analysis of
synovial fluid from the shoulder joint may be helpful in diagnosing some
kinds of arthritis. Although arthroscopy permits direct visualization of
damage to cartilage, tendons, and ligaments, and may confirm a
diagnosis, it is usually done only if a repair procedure is to be
How Is Arthritis of the Shoulder Treated?
Most often osteoarthritis of the shoulder is treated with
nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, or
cox-2 inhibitors. (Rheumatoid arthritis of the shoulder may require
physical therapy and additional medicine, such as corticosteroids.) When
non-operative treatment of arthritis of the shoulder fails to relieve
pain or improve function, or when there is severe wear and tear of the
joint causing parts to loosen and move out of place, shoulder joint
replacement (arthroplasty) may provide better results. In this
operation, a surgeon replaces the shoulder joint with an artificial ball
for the top of the humerus and a cap (glenoid) for the scapula. Passive
shoulder exercises (where someone else moves the arm to rotate the
shoulder joint) are started soon after surgery. Patients begin
exercising on their own about 3 to 6 weeks after surgery. Eventually,
stretching and strengthening exercises become a major part of the
rehabilitation program. The success of the operation often depends on
the condition of rotator cuff muscles prior to surgery and the degree to
which the patient follows the exercise program.
If you receive a shoulder injury, here's what you can do:
RICE = Rest, Ice, Compression, and Elevation
Rest--Reduce or stop using the injured area for 48
Ice--Put an ice pack on the injured area for 20 minutes
at a time, 4 to 8 times per day. Use a cold pack, ice bag, or a
plastic bag filled with crushed ice that has been wrapped in a
Compression--Compression may help reduce the swelling.
Compress the area with bandages, such as an elastic wrap, to help
stabilize the shoulder.
Elevation--Keep the injured area elevated above the
level of the heart. Use a pillow to help elevate the injury.
If pain and stiffness persist, see a
Keeping on Top of Your Condition
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