Question
I fell on an outstretched hand while carrying my bike up three steps in Sept. 2006. I was in some intense pain for a month or so. Got an Xray at the time. It was normal.  I was still in pain and had to stop biking and could no longer lift groceries or carry bag with my rt arm.  In 2007 I started getting massages for the shoulder and was able to bike again for most of the summer. Then in Nov. 2007 my shoulder flared up again and I had to stop biking (too jarring on the shoulder). In Dec. 2007 had an MRI which showed supraspinatus tendinopathy.  I went to PT in January 2008 to learn exercises to strengthen shoulder. Was able to perform the exrcises and stretches for Feb- April 08. Still couldn't lift things with my right arm (carry a bag of groceries) but I had full range of motion the entire time since injury and pain was low.  At end of May 2008 went back for check up. The Dr. suggested I needed more one on one PT to increase my strength.  He also offered a cortisone shot (Kenalog 40). I was in some pain at the time, probably didn't think it through and accepted the shot. He said to not perform my exercises for a few days.  I took a few bike rides  and tried some stretching a week later after the shot and I woke up one day in intense pain thathas been getting worse the last 7 weeks. Am waiting for the doctor to call me back. Now, my pain is intense and constant, am wearing a sling because it hurts to move my shoulder. Did I make a mistake accepting the cortisone.  All this intense pain was after the shot...almost 2 months.  Could the steroid worsen, weaken or degenerate a supraspinatus tendinopathy even more. am scared now and feel like the cortisone was a HUGE mistake as I had pain-free range of motion and was able to do my home PT exercises before this...Any thoughts.Will this ever resolve? Formerly active 35 year old male

Answer
Dear Robert,

Questions I have for you:  have you had an MRI to verify your diagnosis?  Did the doctor actually perform an examination on the shoulder with active range of motion and mnual testing of the joint?  This has been going on for a long time and the MRI should have been ordered if you were not responding to care.  You may not have the correct diagnosis!!  By the way are you going to your general practitioner, or an orthopedist?

Now, the shot you received would normally reduce the pain due to the inflammation lowering effect of the Kenelog (glucocorticoid).  Cortisone shots are given specifically to reduce local inflammation.  They do not normally cause increased pain except for a day or two directly at the injection site.  However, it is possible that you had an increased inflammatory reaction to the medication, and this should be explored with your doctor.  

Below you will find a more detailed synopsis on shoulder pain, diagnosis, and treatment options.  Unfortunately, I cannot send illustrations in this format.

Shoulder problems are common. Most cases of shoulder pain only last for a short while and are not caused by arthritis or traumatic injury. Often shoulder problems settle with simple treatments, but more complex treatments, such as arthroscopy and other forms of surgery, may need to be explored. (Underlined & italicized words are defined at the end of the document.)

The shoulder is the most mobile joint in the body and consequently may also be the most unstable.  It is often affected by painful problems, which limit movement. Movement takes place at the main shoulder joint (glenohumeral joint) as well as the shoulder blade (scapula), which moves over the back of the chest (Figure 1).

A group of muscles called the rotator cuff plays a very important part in the working of the shoulder, helping to move it and hold the joint together. Problems with the rotator cuff can cause several painful conditions.

Where is the pain coming from? Not all shoulder pain is actually caused by a problem in the shoulder joint. When the problem is in the shoulder joint the pain is often felt over the front of the shoulder or in the upper part of the arm. It can appear to spread down the arm to the elbow (known as referred pain). But if the pain spreads further, or if you have tingling or pins and needles, the pain probably comes from a problem in the neck. Pain at the top of the shoulder may come from the small joint at the end of the collarbone (the acromioclavicular joint).

Pain from the shoulder joint itself is often caused by inflammation, either around a tendon or around the outer coating (capsule) of the joint. Arthritis in the shoulder joint is uncommon, although minor degrees of arthritis are often found in the acromioclavicular joint. Each shoulder problem has its own pattern. Most conditions cause pain with use and movement, and it is worth noting which movements give most pain because this will be a good indication of where the problem is. Pain is usually not at rest, other than at night. Some people cannot lie on the affected side and find it better to be propped up in bed.

What can I do? Unless the pain is extremely bad or you have had a definite injury, you do not need to see your doctor straight away. Simple painkillers or anti-inflammatory tablets and creams that can be bought at the local grocer or pharmacy may be helpful, but only use them for a few days. You should aim for a balance between rest and activity to prevent the shoulder from stiffening.

One good exercise for all shoulder problems is called a pendulum exercise (see Figure 2). Stand with your good hand resting on a table. Let your other arm hang down and try to swing it gently backwards and forwards and in a circular motion. Another good exercise is to use your good arm to help lift up your painful arm.

Try to avoid the movements that are most painful, especially those that hold your arm away from your body and above shoulder height for prolonged periods.  If your pain persists then schedule a functional examination of the affected area.

When lifting your arm up you can reduce the strain or pull on your shoulder by remembering the following:
1.   Keep your elbow bent and in front of your body.
2.   Keep your palm facing the ceiling when you reach up.
3.   To lower your arm, bend your elbow, bringing your hand nearer your body.
4.   Check your posture. It can be tempting to sit leaning forwards with the arm held tightly by your side. This position can make the problem worse, especially if some of the pain is coming from your neck. When sitting, try to keep a pillow or cushion behind your lower back and your arm supported on a cushion on your lap. Some people find that placing a cushion or rolled towel under the armpit and gently squeezing onto it can ease some of their pain.
5.   If your shoulder is painful to lie on, try the following positions to reduce the discomfort:
6.   Lie on your good side with a pillow under your neck. Use a folded pillow to support your painful arm in front of your body. Another pillow behind your back can stop you from rolling back onto your painful side.
7.   If you prefer to sleep on your back, use one or two pillows under your painful arm to support it off the bed.  

What about blood tests & x-rays? The majority of shoulder problems do not require blood tests. However, your doctor might ask for them to rule out other conditions or as part of an investigation of arthritis. For most people, an x-ray is not needed to diagnose a shoulder problem either. X-rays are often normal even if you have severe pain. This indicates pain is emanating from the soft tissues of the joint (muscles, tendons, cartilage, bursa, etc.). An x-ray may show minor changes, especially in the acromioclavicular joint (see Figure 1). These changes are quite common but rarely cause much of a problem. An x-ray may show a deposit of calcium in the tendons. Sometimes the deposit does not cause any symptoms, but occasionally calcium in the tendon can cause intense pain due to inflammation. This is often called acute calcific tendinitis.

Do I need a scan? Magnetic resonance imaging (MRI) and ultrasound scans are only needed in certain situations. Description of your symptoms and the physical examination of your shoulder will usually provide all the information needed to plan your treatment. Scans may be carried out when a complex problem in the shoulder is suspected, or when further, more specialized, treatment is planned. An MRI will allow the soft tissues around the shoulder to be seen (including muscles, tendons and cartilage). The most common reason to have a scan is to see if there is a tear in the rotator cuff tendons.

Will rehabilitation help? After detailed assessment, rehab is often very helpful卼his may include: ultrasound, transcutaneous electrical nerve stimulation (TENS) or heat/cold therapy.  Information on how to control the shoulder and shoulder blade muscles when moving the arm to prevent the pain coming back, applying adhesive tape to the skin to reduce the strain on the tissues and to help increase your awareness of the position of the shoulder and support normal stabilization (strapping), shoulder blade exercises to stop the shoulder stiffening up, exercises to strengthen weakened muscles and to get them working together efficiently, and education on improving neck and spine posture, as well as ergonomic considerations to reduce pressure on the various parts of the shoulder, should be utilized.

Will an injection help me? Injections of steroids (cortisone) help many shoulder problems. The injections work by reducing the inflammation and allowing you to move your shoulder more comfortably. Be careful not to use your shoulder for anything too strenuous in the first 2 weeks after an injection. Sometimes the pain may be worse the night following the injection. This does not mean that it has gone wrong. You only need to seek advice if the pain continues. For many people an injection is all that is needed to allow recovery, but for some people the problem can come back and in this case you may need more investigations. There are usually very few side effects from steroid injections and the injections can be repeated if necessary.

Where is the injection given? This depends on what condition you have. If your rotator cuff tendons or bursa are inflamed (called, tendinitis or bursitis) then the injection is given at the tip of your shoulder in the tendon or bursa. If the problem is in your main shoulder joint (glenohumeral joint) then the injection is given in that joint from the front, side or back of the shoulder. If you have problems in the acromioclavicular joint then the injection is given into this joint on the top of your shoulder. Injections are particularly helpful for acute calcific tendinitis. An injection into the bursa outside the tendons can allow this to settle down completely.

What is a 'frozen' shoulder and how is it treated? A 'frozen' shoulder is where the tissues tighten around the joint and stop you from moving the shoulder ?the medical name for this is adhesive capsulitis. There is no actual change in temperature ?'frozen' means that the joint cannot be moved. Frozen shoulders may just happen, but they usually follow an injury. They can also occur after a stroke and are more common in people with diabetes. Frozen shoulder usually lasts for 18 months to 2 years and treatment can be ineffective. The main aim of treatment is to reduce the pain and give you back the movement after the pain has gone. Pain can be particularly bad at night and you may need painkillers and sedatives to deal with this. Once the pain begins to lessen it is important to regain your shoulder movement, and you will probably need physiotherapy at this point. If your shoulder movement remains very restricted then manipulation under anesthesia (MUA) has been shown to be the most beneficial.  Specially trained chiropractic physicians and orthopedists are who perform the manipulation.  For more information on MUA, go to: http://suncoasthealthcare.net/chiropracticinformation/manipulationunderanesthesi...

What surgical option exists? Most shoulder problems improve without the need for surgery, to a point where they do not cause much pain or interfere with daily life. However, some conditions may need a surgical resolution. If surgery is needed it can be performed using either conventional or 'keyhole' techniques. Keyhole techniques allow an investigation, or the treatment itself, to be carried out through a smaller incision than with normal surgery.

Keyhole techniques (arthroscopy) can be used to find out more about your problem  (diagnostic arthroscopy). However, an increasing number of treatments can also be carried out using keyhole techniques (therapeutic arthroscopy). Examples include removing loose pieces of bone or calcium deposits. Another procedure is called subacromial decompression (see Figure 3). Bone and tissue are trimmed from the underside of the acromion at the top of the shoulder to give more space outside the rotator cuff tendons. This allows them to move more freely without causing pain.

The advantage of keyhole surgery is that the scar is smaller and it is less painful than conventional operations because there is less damage to the tissue. As a result recovery can be quicker.

What about a rotator cuff tear? If you have a torn rotator cuff tendon it may require rehabilitation or surgery. Rehab is often successful but if pain cannot be reduced while function improves, surgical resolution may be indicated. It is a complicated operation that needs a lengthy recovery period and exercise program. You will not be able to drive for at least 6 weeks after surgery and it will take 3? months to get the full benefit of the procedure. Unfortunately, some tears are so big that complete repair is not possible, although there is usually something that can be done to reduce the pain.

Can the shoulder joint be replaced? Yes. Shoulder joint replacement is well established and can be successful for several conditions. It is used mainly for osteoarthritis and rheumatoid arthritis when severe pain restricts movement and use of the shoulder. A metal head and stem replaces the upper part of the upper arm bone, or humerus (see Figure 4). Some conditions need a plastic 'cup' fitted into the shoulder blade (scapula); others are best without it.

The procedure is utilized to increase the active mobility of the affected shoulder joint complex and to remove the pain. Amount of improvement depends on what the shoulder was like before surgery. If arthritis has damaged the rotator cuff you will probably not get full movement back. However, you should have more movement than before and, because the pain is much less, you will be able to use your shoulder better.  Physiotherapy and exercise protocols after surgery are important to help you regain movement gradually. You will have to wear a sling for about 4 weeks, although you will need to take your arm out of the sling for some exercises. You will not be able to drive for 3 months after surgery. It may take 6 months to feel all the benefits of the operation.

What are the surgical risks? All surgeries have calculated risks and the potential for complications, because of both the anesthetic and the procedure itself. Since the shoulder is a complicated joint, it can be difficult to predict outcome. Generally the more extensive and more complex the surgery, the greater the risk. However, the risk will also vary depending on how fit

you are. Because of the complexity of the joint, complete recovery is not always possible. As with any operation there are other risks, such as infection, or damage to delicate tissues such as nerves, but precautions are taken to reduce the risks as much as possible. It is important that you are given a realistic idea of what you can expect to gain from any operation as well as any particular risks. If you are in any doubt you should make sure you discuss it with your surgeon before the operation.

Summary The shoulder is a very mobile joint that is prone to several painful conditions, but severe arthritis is fairly uncommon. Many conditions will settle down with a short period of rest, medication, soft tissue mobilization or rehab. Exercises are important to help prevent stiffness and decreasing range of motion. If problems persist there are many things that can be done to help, from physiotherapy, physical rehab, injections and occasionally surgery.

Glossary
Acromioclavicular joint (ACJ) ?the joint at the outer end of the collarbone (clavicle). It joins the collarbone to the shoulder blade at the acromion.
Acromion ?a part of the shoulder blade (scapula) that can be felt on the top of the shoulder. Some of the muscles that move the shoulder are attached to this.
Acute calcific tendinitis ?inflammation in a tendon in the shoulder caused by a deposit of calcium (chalky material). Sometimes the pain is very intense; sometimes the calcium does not cause any problem. It is not known why calcium builds up here in some people. This may be further classified as a chondrocalcinosis such as Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD) or Hyroxyapatite Deposition Disease (HADD).
Arthroscopy ?the medical name for 'keyhole' surgery where small (less than 1 cm) incisions are used to allow a special light and camera to look at the inside of a joint. This can be seen by the orthopedic surgeon on a monitor. More than one incision is often used to allow instruments to be introduced. Stitches are not usually needed in the incisions.
Bursa ?the soft tissue (actually a sac of tissue) that is present between bone and the tendons that have to move over it. It is rather like the lining of joints (synovium). There is a bursa under the acromion (subacromial bursa) that helps to stop the tendons of the shoulder 'rubbing' on the underside of the acromion. Another example is the tissue at the point of the elbow that stops the tip of the elbow bone rubbing on the skin over it.
Bursitis ?a condition where the tissue of the bursa becomes inflamed. It swells and causes pain.
Diagnostic arthroscopy ?where keyhole surgery is used to gain more information about a problem in a joint, in order to make a clear diagnosis. No treatment is performed.
'Frozen' shoulder ?a painful condition of the shoulder that affects people in middle age, usually without a specific cause. Very soon movement is restricted. It is usually painful at night. Without treatment, full recovery usually occurs but can take several years. Treatment doesn't usually speed up the recovery process, but it should make the condition easier to live with.
Glenohumeral joint ?the main ball-and-socket joint of the shoulder. To allow such a lot of movement the socket, or cup, at the shoulder is not as deep as that of the hip joint.
Impingement ?a painful condition of the shoulder where there is 'tightness' between the acromion and rotator cuff tendons - that is, in effect, they jam against one another. This can be caused by extra bone under the acromion or if the muscles of the shoulder are not working strongly enough. Pain is usually felt when the arm is moved away from the body in certain positions. This is known as the 'painful arc' and the condition itself is known as 'painful arc syndrome'.
Osteoarthritis ?a common condition where the cartilage becomes thinner and damaged and extra bone forms at the edges of the joint. It can result from abnormal stress on the joints, or from many different forms of injury or joint disease. However, many cases develop without any obvious reason. The hips, knees and hands are most likely to be affected, but osteoarthritis can occur in any joint.
Painful arc syndrome ?a condition which causes pain when the shoulder is moved in certain positions, usually in part of the range or 'arc' of movement of the arm away from the body. It can be caused by impingement and other causes of tendinitis.
Rheumatoid arthritis ?a common inflammatory disease considered to be autoimmune in origin.  It affects the joints, mainly starting in the smaller joints in a symmetrical pattern (e.g. both hands or both wrists at once).
Rotator cuff ?The group of muscles close to the shoulder that surrounds the glenohumeral joint. They are responsible for the proper working of the shoulder and hold the joint together. The tendons of these muscles are prone to inflammation (tendinitis) and damage.
Scapula ?the medical name for the shoulder blade. The rotator cuff muscles are attached to this and the socket of the glenohumeral joint is part of it.
Tendinitis ?inflammation in the tendon of a muscle. The tendons of the rotator cuff are prone to this. One of the rotator cuff muscles is called the supraspinatus muscle. When this is the cause of pain it is referred to as 'supraspinatus tendinitis'.
Tendon ?a strong, fibrous band or cord which anchors muscle to bone.
Therapeutic arthroscopy ?the treatment of a problem in a joint using keyhole surgery. Several shoulder problems can be treated this way and more such treatments are being developed for the future.

Therapeutic exercises:
The rotator cuff is a frequent site of injury.  Although the supraspinatus muscle and tendon is most commonly involved, it is important to rehab all four muscles of the cuff.  Regular exercises to restore normal shoulder motion, flexibility and proper scar formation, promote a gradual return to everyday work and recreational activities which is important for your full recovery. Your orthopaedic surgeon, chiropractic physician or physical therapist may recommend that you exercise from 10 to 15 minutes 2 or 3 times a day during your early recovery period.
The below exercises are for the initial rehabilitation. This guide should help you better understand your exercise and activity program. All exercises should be performed with slow methodic movements, and they should be performed in a relatively pain free arc of motion.
   Pendulum, Circular - Bend forward 90 degrees at the waist, using a table for support. Rock body in a circular pattern to move arm clockwise 10 times, then counterclockwise 10 times.Do 3 sessions a day.
   Shoulder Flexion (Assistive) - Clasp hands together and lift arms above head. Can be done lying down (drawing A) or sitting (drawing B). Keep elbows as straight as possible. Repeat 10 to 20 times. Do 3 sessions a day.
   Supported Shoulder Rotation - Keep elbow in place and shoulder blades down and together. Slide forearm back and forth.Repeat 10 times. Do 3 sessions a day.
   Walk Up Exercise (Active) - With elbow straight, use fingers to "crawl" up wall or door frame as far as possible. Hold 10 seconds. Repeat 3 times. Do 3 sessions a day.
   Shoulder Internal Rotation (Active) - Bring hand behind back and across to opposite side. Do not force the movement.Repeat 10 times. Do 3 sessions a day.
   Shoulder Flexion (Active) - Raise arm to point to ceiling, keeping elbows straight. Hold 10 seconds, relax 2 seconds. Repeat 3 times. Do 3 sessions a day.
   Shoulder Abduction (Active) - Raise arm out to side, elbow straight and palm downward. Do not shrug shoulder or tilt trunk. Hold 10 seconds, relax 2 seconds.  Repeat 3 times.Do 3 sessions a day.
   Shoulder Extension (Isometric) - Stand with your back against the wall and your arms straight at your sides. Keeping your elbows straight, push your arms back into the wall. Hold for 5 seconds, relax for 2 seconds. Repeat 10 times.
   Shoulder External Rotation (Isometric) - Stand with the involved side of your body against a wall. Bend your elbow 90 degrees. Push your arm into the wall. Hold for 5 seconds, relax 2 seconds. Repeat 10 times.
   Shoulder Internal Rotation (Isometric) - Stand at a corner of a wall or in a door frame. Place the involved arm against the wall around the corner, bending your elbow 90 degrees. Push your arm into the wall. Hold for 5 seconds, relax 2 seconds.Repeat 10 times.
   Shoulder Internal Rotation (Against gravity) - Keep elbow bent at 90 degrees. Holding light weight, raise hand toward stomach. Slowly return. Repeat 10 times.Do 3 sessions a day.
   Shoulder External Rotation (Against gravity) - Keep elbow bent at 90 degrees at side. Holding light weight, raise hand away from stomach. Slowly return. Repeat 10 times.Do 3 sessions a day.
   Shoulder Adduction (Isometric) - Press upper arm against a small pillow alongside your body. Hold 5 seconds. Repeat 10 times. Do 3 sessions a day.
   Shoulder Abduction (Isometric) - Resist upward motion to the side, push arm against back of chair. Hold 5 seconds. Repeat 10 times. Do 3 sessions a day.


After an exercise session has been completed, it is appropriate to ice the shoulder to decrease inflammation and reduce soreness.  Ice should not be placed directly on the shoulder unless it is an ice-water solution.  Re-freezable gel packs are a good option, with a thin layer of cloth between the ice pack and the skin.  Application time is 20 minutes post exercise.

Hope this helps Robert.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net