The shoulder is the most mobile joint in the body. It is a very versatile joint, has a wide range of motion and is very flexible. The shoulder is a ball and socket joint that allows the arm to move in many directions. Unfortunately all this mobility does not make it very stable and allows for a greater chance of injury. This can cause significant pain and disability with normal range of motion and/or use of the shoulder joint. Shoulder problems can be caused by acute injury, chronic overuse, or gradual aging. Shoulders are frequently injured in athletes whether they are weekend warriors or more serious athletes. They are also injured very commonly in people above the age of 50, as the decreased mobility of the shoulder can lead to early arthritis and pain over time.
The shoulder is made up of the convergence of three bones: the scapula (shoulder blade), the humerus (upper arm bone) and the clavicle (collar bone). These three bones from two joints which make up the shoulder: the glenohumeral joint and the acromioclavicular (AC) joint. The glenohumeral joint is where the ball (humeral head) and the socket (the glenoid) meet. The AC joint is where the acromion (a part of the scapula) and the clavicle meet.
The rotator cuff is a group of four muscle tendons: the supraspinatus, infraspinatus, teres minor and the subscapularis. Tendons connect muscle to bone and move bones. These four tendons of the upper arm raise and rotate the arm. The rotator cuff tendons connect the humerus to the scapula. The tendons of the rotator cuff allow the muscles to move the arm. The muscles of the rotator cuff keep the humerus tightly in the glenoid, a shallow cup/socket. The glenoid is rimmed with soft tissue called the labrum that makes a deeper socket that forms to fit the humeral head. Surrounding the shoulder joint is a capsule, which is a fluid filled sac that lubricates the joint and is made up of ligaments. The A/C joint is also held together by ligaments. Ligaments are soft tissue that hold bone to bone and give joints stability. On the outside, the shoulder is covered by the large deltoid muscle that serves to help move the shoulder away from the body. This too has a tendon that anchors it to the bone.
There are many shoulder injuries such as arthritis, instability problems, tendonitis, strain and overuse. Dysfunction with the rotator cuff is the single most common shoulder problem that I see in the office.
The rotator cuff consists of four muscles (attached to bone by their tendons) of the upper arm that raise and rotate the arm. The tendons of the rotator cuff help to move the arm. If the tendons are weakened, torn or damaged tear, the humerus can’t move as easily in the socket, making it difficult to move the arm up or away from the body. The most common tendon inured is the supraspinatus tendon, although the other three can be injured too.
Rotator cuff injuries occur most often in people over the age of 50 as this age group tends to already have shoulder problems. As we age, our tendons and ligaments begin to degenerate and lose strength. This weakening can lead to a rotator cuff tear. This area of the body has a poor supply of blood, making it more difficult for the tendons to repair and maintain themselves. Repetitive motion to this area can lead to impingement, in which the tissue or bone in that area becomes misaligned and rubs or chafes. Work or exercise where one uses your arm overhead puts pressure on the rotator cuff tendons. Athletes that are particularly susceptible to this are swimmers, surfers (paddling), tennis players (serving), baseball players and quarterbacks. This can be due to performing a lot of overhead movements which is when the rotator cuff is in its most vulnerable in this position. Another way the rotator cuff can be injured is by falling on an outstretched arm, by lifting a heavy object while the arm is extended or by trying to catch a heavy falling object.
Symptoms of a torn rotator cuff include tenderness and soreness in the shoulder during an activity or normal range of motion action. A partially torn tendon may make it difficult to raise the arm, while a completely torn tendon may make it impossible to raise ones arm. As with most shoulder injuries, sleeping on one’s side (the injured or non-injured side), may cause one discomfort or pain in the affected side due to the pressure put on the shoulders.
When someone presents to their physician with the symptoms of a possible rotator cuff injury, traditional therapies such as exercise and physical therapy may resolve a rotator cuff injury. It may even be helped by a short course of an anti-inflammatory medicine (NSAIDS) or a natural one (Circumin, Turmeric, Boswellia, fish oils, etc.). If these resolve the problem, then no further treatment is needed. Unfortunately, if these do not help, the next step may be a steroid injection. Steroids (Cortisone) only worsen the situation, since the pain relief is usually only temporary and the steroid itself will weaken the ligaments, tendons, labrum, cartilage and
Many times the next step is a referral to an orthopedic surgeon. At a the minimum, the patient is sent for an MRI. Unfortunately, an MRI is just a road map for a surgeon. If one does not want surgery, then an MRI is usually not necessary. Needless to say, many people still get one. Many tears on MRI’s do not correlate with the physical exam; in other words, the MRI may have been over read (something stated that is actually not there; or is less than stated). Sometimes an MRI can over-diagnose rotator cuff tears even when no tear exists; or indicate a complete rotator cuff tear when in fact it is only partially torn. Even though a problem may be seen on an MRI, it is not necessarily the cause of the problem; it maybe only the effect. Since the traditional treatment for a rotator cuff tear is surgical repair, I recommend a second opinion with a physician that practices Orthopedic Medicine (non- surgical orthopedics) before getting surgery.
Surgery for a rotator cuff usually involves taking something out. If the surgeon takes tissue out such as part of a tendon, ligament or labrum, it can never be put back. If you change structure, you change function. Following rotator cuff surgery, one must wear a harness type brace that holds the arm away from the body. One must wear that for three to six weeks. Then a course of physical therapy is usually prescribed which is usually two to three times a week for from three to six months. Quite often pain medicines are also taken for many weeks on end. The total repair time could be upwards of 8-9 months. A better approach is to stimulate the repair of the rotator cuff is with Prolotherapy. Prolotherapy proliferates/regenerates fibroblasts so that the collagen tissue that makes up structure of the rotator cuff will be repaired – naturally! This makes the area more vibrant and stronger than it was when injured and most people return to full function without surgery.
I had a 69 year old patient who had just that; a rotator cuff injury caused by a torn labrum with associated tendon and ligament damage. He was told by not one, but two, orthopedic surgeons that his shoulder was too far gone and that they would not do surgery on him. He was very upset and did not know what to do. His personal trainer referred him to my office so he came to see me to get a non-surgical opinion. After taking a thorough history and doing a complete physical exam, I determined that he would be an excellent candidate for Prolotherapy. He was treated approximately every three weeks for a total of six treatments. His total treatment time treatment time was fifteen weeks. During that time he was allowed to go back slowly to his daily exercise routine as there is minimal down time with Prolotherapy. After fifteen weeks, he was back to his normal routine of weight lifting and horseback riding. He was able to bench press 200 lbs without any pain. This is a feat unto itself for a 69 year old; let alone a person that was told to just live with his injury and stop working out and riding horses.
Besides the rotator cuff, several other maladies affect the shoulder such as arthritis, rotator cuff tendonitis, impingement syndrome, A/C joint separation, chronic overuse syndromes and more.
Many of these have at their root cause weakened torn or damaged ligaments and tendons. Yes a labrum may be torn, spurs might have formed, cartilage may have started to wear away but these are the effects of years of weakness in the ligaments and tendons causing the shoulder to impinge on itself. Addressing only the effect and not the cause the problem will not fix these issues.
A special note here about arthritis in the shoulder. Beginning as early as 50 years of age, and sometimes even as early as 35 years old, some people develop osteoarthritis (degenerative joint disease or DJD). The most common cause of osteoarthritis is overuse from years and years of normal daily activity and/or sports. The weakened, torn or damaged ligaments and tendons cause painful movement and therefore restrict the range of motion. This in turn causes the smooth surfaces of the cartilage that line the bones of the shoulder joint to begin wearing away. The joint begins to wear out and limits ones use of the shoulder.
As with all the above, rest, ice, anti-inflammatory medicines and physical therapy is prescribed, but if that does not work, a complete shoulder replacement is sometimes suggested. This is one surgery that does not have a high success rate and should be avoided at all costs.
Total Prolotherapy (Dextrose, PRP and Bone Marrow-Stem Cell) is an excellent non-surgical alternative for arthritis and the other shoulder problems mentioned in this article. It not only fixes the effects (decreased range of motion and pain) but also fixes the cause of the problem.
The advantages of Prolotherapy over surgery are:
1) No infection
2) No device failure
3) No wound not healing
4) No needless time on pain meds
5) It is your own body healing itself
6) When it is fixed, it is fixed for good!
Remember that surgery can always be done; but never undone.
Peter A. Fields, MD, DC
The Athletic Doc® and 3X Ironman Triathlete
Board Certified Medical Physician and Chiropractor
Prolotherapy/PRP/Bone Marrow-Stem Cell
Orthopedic & Sports Medicine/Integrative Health
1919 Santa Monica Blvd, Suite 220
Santa Monica, CA 90404
(310) 453-1234 Fax: (310) 453-1212