Below are short extracts from three pages of the shoulder section.
Problems in Brief - Injuries - Pain
CONTENTS of PROBLEMS IN BRIEF SECTION
This is a summary of some of the more usual problems suffered by the shoulder region. For a more detailed look at the problems, see Pain in the Shoulder, or Shoulder Injuries, here on the CasualtyClinic.com site
Problems in the shoulder region can be from the shoulder joint proper, or the acromio-clavicular joint, or (in the case of pain) can come from the neck.
In The Young
Nothing specific.
In One’s Prime - (say) 17 to 38
Problems begin as the body begins to get larger and more powerful, in adolescence. This is also when the sporting injuries begin.
Dislocation: A powerful trauma can cause the shoulder to be dislocated - a very painful occurrence. The dislocation damages the muscles and ligaments that are there to prevent dislocation. It can also injure the joint itself. Shoulder dislocations are a serious injuries. They should be reduced in the A/E Dept, X-rayed to exlude bony damage, and followed up by the Orthopaedic team. These injuries can give chronic problems which stem from instability - from the tears of musces and ligaments. Awareness and care in the post-trauma and rehabilitation phase is important: to allow healing tissues to repair neither too short or too long; and to refer early for orthopaedic assessment and possible operative repair when needed.
Sprain: A lesser trauma will cause a sprain or strain, where the muscles and ligaments have been stretched but not so much as to allow dislocation. This is also an injury that ought to have the same care in the rehab phase.
The acromio-clavicular joint is above the shoulder joint proper, about two or three fingersbreadths in from the shoulder tip. The story is the same here, dislocation being from a powerful force, and lesser forces producing a strain or sprain. Some surgeons are repairing a dislocated and damaged A.C joint, but it is considered to be less serious than a shoulder dislocation. But it should still be seen in A/E and followed up by the Orthopaedic team.
END OF PREVIEW for PROBLEMS IN BRIEF SECTION
CONTENTS of INJURIES SECTION
Dislocated Shoulder - Acute traumatic
Acute: Usually from trauma or sport (same thing really ) - a sudden blow or a twist to an otherwise normal shoulder, followed by great pain. The arm cannot be used, and is usually held to the body if it is not in a sling. The sufferer is usually taken to an Accident Department.
The clinician will examine; she will see that your shoulder is misshapen:
- A dip replaces the usual smooth roundness at the shoulder tip;
- The elbow is held out from the waist, and cannot be brought in to the waist;
- The line of the upper arm points below the shoulder.
She may feel in your armpit, because if the joint is dislocated, she might feel the rounded head of the humerus there.
Surprisingly, you may still be able to move the shoulder a little. The elbow can still be moved, as it is not injured.
Dislocated shoulders are best treated in A & E, first because the injury may be a fracture and not a dislocation, and secondly because nerves can be injured while the shoulder is being reduced.
[However if very far from help, there is a method that is used in some U.K hospitals whilst the patient is waiting: The patient is asked to lie on his front, on a trolley, and given analgesia or alcohol. The injured arm is then hung over the edge of the trolley with a 5 Kgm weight attached to the wrist or elbow (mind you don’t obliterate the pulses !). If the pain can be controlled, and if the sufferer can be made sleepy, this method will work. It should be checked every 10 minutes. It should be discontinued after 30 mins.].
However if you are not in the antarctic or the southern ocean but in an Accident Unit, a quick x-ray is requested. When it has been checked, preparations are made for reduction. Relatives may feel that the reduction takes a long time, but most of the time is taken by ensuring that the patient has his pain reduced and is quite sleepy.
An incident that causes a dislocated shoulder is a major force - significant damage is done to the joint and the structures around it. For instance there can be a fracture as well as a dislocation, or a part of the fibrous joint margin can be torn off. It is essential that it is followed up by the orthopaedic team. Even with a straightforward dislocated shoulder, there may be damage to big arteries or large nerves in the armpit. The commonest finding is a patch of numbness on the outer shoulder, from damage to the axillary nerve. In this case there could also be weakness of the muscle over the shoulder (deltoid) so that taking the arm out to the side (jargon = abduction) is weak. This can take two or three months to show any recovery.
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Dislocated Shoulder - Recurrent
This can follow a single dislocation, especially if the stabilising structures have been badly damaged. The sufferer find that shoulder has begun to ‘slip out’ - with very little force and not much pain - but only occasionally. This is a critical state, because each time the shoulder dislocates the stabilising structure are being stretched. In that way it may progress to the state of Habitual Dislocation. See below
Dislocated Shoulder - Habitual
The shoulder repeatedly slips out, often without force or warning, and may be put back by the patient. The dislocation may even be deliberate - as a party trick. Such fun and games are bad for joint structures and will lead to joint wear and degeneration, pain and arthritis. The best advice is to get a referral to a specialist as soon as possible. No party games.
Operations to prevent the shoulder from dislocating are excellent. However in order to stabilise the joint, some mobility is sacrificed. So you will find that the range of the joint is less, and you may notice it especially when taking the hand out to the side (jargon = reduced external rotation).
Lax Shoulder Joint; Unstable or Subluxing Joint
This is when the shoulder is ‘loose’ - the jargon words describing a joint like this are ‘unstable’ or ‘lax’. Because the parts of the joint that keep it in place are slightly damaged, the joint surfaces will skid around too freely on each other. The parallel that comes to mind is the wobbly ankles of a novice skater, although it is not an exact parallel. The joint is slightly dislocating all the time, going over the edge of where it ought to be, banging against things that should be out of range, and needing excessive muscle work to try and keep it in place. One word used for this state is 'subluxing' joint. The continental word for 'dislocated' is 'luxed'; 'subluxed' is when the joint is less than fully dislocated.
If your shoulder is like this, you will not know. You will just find that the shoulder is giving trouble.
It becomes apparent weeks or months after the injury that caused the problem, though patients may present with symptoms of lax shoulder without a history of of trauma. The sort of problems that might suggest that the joint is lax are an easily fatigued shoulder, a 'weak shoulder', pain in the joint after exercise or work, and a 'dead arm’. A patient will say "I’m not sure of my shoulder, especially in this position " - and he will show how he puts box-files away on high shelves, or throws a ball for the dog. The joint may gradually become even looser, and move into the 'recurrent subluxation' bracket.- see above.
Even with a history as that above, which is highly suspicious of a lax shoulder, a clinician may find that a standard examination will not show up the problem. A lax shoulder will only show up with special tests, clinical hand-on-joint tests. These should give the answer to the question "Are his problems because this joint is partly or slightly unstable?" If the joint is found to unstable or loose clinically, there is usually a history supporting this. But in any case, if the joint is suspect, it will be referred to the specialist.
Treatment: Skilled manipulative therapy and refer to the orthopaedic team.
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END OF PREVIEW for INJURIES SECTION
CONTENTS of PAIN SECTION
Anyone suffering from pain in the shoulder could well be warned that shoulder pain is usually much harder to diagnose and treat than (say) pain in the knee or wrist.
The reasons are, first, that the knee is more anatomical, a purely mechanical joint, with the controlling structures all visible; whereas the shoulder is more physiological - the structures are there for all to see, but how they work is dependent on the way the shoulder muscles interact. SeeSarrafin (1983)
And the second reason is that shoulder pain can be caused by problems in many distant structures, including the neck, chest and abdomen.
Sorting out shoulder pain may need the help of a patient, deeply experienced therapist. And if the sufferer is middle-aged or more, she probably will do best with a therapist who is likewise - middle-aged or more ! See Jenkins D (1979)
One useful generalisation is ‘Shoulder pain in the young comes from the shoulder, but in those in the latter half of life, from the neck’. See o'Reilly & Bernstein 1990, in the references. In fact, in the older patient, pain often comes from both shoulder and neck. However shoulder pain can be a symptom of other problems, some of which can turn out to have serious implications. Do not ignore it !
If you want seriously to read up shoulder pain referred from distant structures, it is a fascinating story. If you do not, ignore the next two paragraphs.
Problems in the neck may produce pain in the shoulder. Different levels in the neck produce pain in different regions of the shoulder or arm. This is in keeping with the segmental arrangement of our nerve layout. Trouble in some spinal joint, or an intervertebral disc in the neck, can be felt as pain in some distant place in the body - say the shoulder or elbow - which is also supplied with nerves from the same spinal level. Early work was done by spinal surgeons who used the patients undergoing operations to perform harmless research (Cloward 1959).
These early papers, by Cloward, Chann Gunn and Kellgren (in the references) show what scientific clinicians could do when not hedged in by litiginous patients and over-zealous ethical committees. The more modern efforts by Wells or Butler or Gifford are a fine read in front of a fire with a generous glass of something (Gifford 1997, Gifford and Butler 1997).
Here we shall approach the pain that is felt in the shoulder region under two main headings - pain that comes from problems in structures actually in the shoulder region, here called intrinsic shoulder pain; and pain that is derived from problems in structures at a distance, here called extrinsic shoulder pain.
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END OF PREVIEW for PAIN SECTION