There are many recurring questions that patients ask me with regard to their shoulder and the process of returning to a state of maximal function following shoulder trauma, stiffness or surgery. Here are answers to some of the most frequently asked questions about shoulder injuries and surgery.
Should I sleep on my shoulder?
It is in your best interest to prevent as much loading as possible at night, particularly if the shoulder is keeping you up awake or is moderately stiff in the morning. Compressive loading can compromise soft tissue healing and further irritate already irritable neurologic structure.
Why does shoulder night pain last so long?
Pain is conveyed to your brain via nerves and nerves are incorporated into many structures in and around the shoulder. A renowned shoulder educator once told me that there are 13 structures that can potentially generate pain in the shoulder joint. Two things occur at night to prolong the perception of pain. The first being mechanical pressure against neurologic structure that is already hypersensitive. This pain is further exacerbated with prolonged pressure occurring when sleeping on the affected side and not immediately waking up. The second issue is due to the chemical based pain occurring with the healing process. You need to burn “fuel” to heal and when you burn fuel you get “Exhaust”. This exhaust is a chemical irritant in similar fashion to pouring gasoline on a cut; it hurts. Because the volume of blood moving thru the shoulder joint at night is moderately diminished, the ability to flush out the accumulating exhaust of the ongoing healing process is impaired and thus the perception of chemical pain. One notes that this resolves with gentle motion (which subsequently increases the volume of blood moving thru the joint.)
Why is my hand numb?
During or after a period of immobilization, ie using a sling after surgery, muscles and ligaments tend to get stiff about the shoulder. This changes the inherent positioning of the ball on the socket often times pushing it subtly forward. A large branch of nerves passes just in front of the shoulder and this small amount of migration of the ball will place mechanical pressure on neurologic structure, creating a scenario like hitting your “funny bone”. As well, the capacity of neurologic structure to slide and glide between tissues is often impaired due to prolonged immobilization or trauma is shoulder dislocation. This type of impairment is often appreciated as a more global sensory impairment over a greater surface area of the shoulder.
Why am I getting a headache?
With injury or immobilization comes muscular disuse or impairment. The body tends to migrate to more of a “fight of flight” mechanism to survive and thus larger muscles that accomplish more of a gross motor function (push, pull, lift, ie power activities as opposed to fine motor function of ie threading a needle) tend to take control of functional activity about the shoulder. One of these larger muscles attaches to the base of the skull just behind the ear. This is a common spot where headaches can be appreciated due to the over workings of these muscles and subsequent pain where the tendon of the muscle attaches to the base of the skull.
Why is there pain in my mid lateral arm? Where is this coming from? Am I having a heart attack?
We all appreciate what happens when you hit your funny bone, you feel tingling in your little finger. The same concept is occurring when you perceive pain in your lateral arm with the expectation that it should be more focal in the shoulder. When you strike your funny bone you are actually hitting a nerve that is close to the surface of the skin. Your brain appreciates the pain thus derived coursing along that nerve which ends in your little finger. The same is occurring in the shoulder. A nerve is struck underneath the roof of the shoulder (where the collarbone and shoulder blade meet) with referred pain to the lateral arm in this situation. This is pain that you cannot change via one’s touch as opposed to say a strained biceps muscle that feels sore to the touch.
Left arm pain is one common indicator of a heart attack. This pain will classically be unrelenting and will not change with a change of position of the shoulder joint. Mechanical pain originating from the shoulder can undergo intensity change via the repositioning of the joint. NOTE that any odd/lingering pain into your arms should be assessed by your doctor.
My shoulder hurts, will I have to have surgery?
The frequency of shoulder surgery is quite small and becoming less frequent with time. Why? Better conservative rehab options are available and much more successful than they were 25 years ago when a high proportion of shoulder pain patients would end up having surgical intervention. Currently, about 10-15% of patients complaining of greater than 6 months of shoulder pain will end up having surgery. This is initiated after the failure of a conservative care program, ie physical therapy, after 6 months of implementation followed by shoulder injection (as applicable) that again fails to provide symptom relief after 1 or 2 attempts (generally spaced 3 months apart). Surgery implemented by a competent physician unto a motivated patient with the correct diagnosis will generally be very successful.
I have a rotator cuff tear. How can PT help me?
The interesting reality is that the majority of the population over 60 years of age has a rotator cuff tear, most don’t even know it and function well. The usual onset of shoulder symptoms due to an underlying rotator cuff tear is gradual and not due to recent trauma. This occurs due to subtle “mechanical” changes that tend to occur over time as lifestyles change. These changes directly involve functional mobility and strength: When was the last time you climbed a tree or hung on the monkey bars?
Here is where the physical therapist comes in to play. Our job is to assess current mechanical impairment and through hands on intervention and a progressive exercise (mobility and strength) restore maximal function. By keeping up with one’s home program in similar fashion as one’s diligence with brushing their teeth, further issues can be averted.
Unless there is significant impairment (If so, we would have sent you to a shoulder orthopedic specialist) there is a very good chance, greater than 80%, that the symptoms can be stabilized with the return to prior lifestyle/functional levels.
Do I need to get an x-ray or MRI immediately after shoulder injury?
Unless there has been significant trauma with the concern of a fracture, shoulder dislocation or in the case of persisting significant weakness there is no need for immediate objective radiologic studies. As well, under the care of a shoulder specialist, the examination performed will supply enough information to allow the caregiver the ability to implement a short term plan of care (ie 3-6 weeks) with expected goals to be reached at that time. This is the case for the majority of adults with shoulder pain and objective imaging rarely changes the course of care. If these are not attained and pain sx are not following a classic pattern of stabilization, objective studies will be obtained. Rotator cuff injury is commonplace for older adults and thus imaging will show impairment to tissues even though function is normal; this is defined as a false positive.
Why does progress seem to slow down as I continue with my rehabilitation?
Initial gains with rehabilitation are more significant due to in large part the moderate decrease in pain levels during this same time period. Function is highly impaired due to pain which is an inherent protective mechanism in our bodies to prevent further damage; a concept that is not commonly portrayed in the classic action movie. As pain abates, which usually occurs in 2-4 weeks following injury, “gross” function is quickly restored.
As functional mobility and strength return, you are now entering realms where you haven’t been for a long time; ie reaching the top shelf of the cupboard. For your brain and muscles to re-establish this coordinated effort, it takes thousands of repetitions to return to fluency.
Another component of this prolonged process is strength restoration. To restore necessary functional strength at the extremes of motion takes many months since there are unlimited combinations of movement and to attain full functionality, all of these need to be performing at a viable level of which one appreciates normalcy of function.
Finally, we take for granted the amazing things a shoulder girdle can do. A great example is throwing a baseball 100 mph noting that this occurs in less than a second. As well, not only the ability for a gymnast to do an iron cross, but to rotate their body parallel to the ground as well. These are extremes of course, but obviously don’t happen overnight. Even with lesser activities common to daily life that are defined as “fine” motor function, the time and effort to attain are significant and an underlying factor of why it takes a long time with a progressively slower pace to restore normal shoulder function.
When can I return to sports?
One must think of the base requirements placed on the shoulder joint during sport from basically a physics perspective to ensure safety. Joint loads, speeds and 3 dimensional mobility requirements all need to be considered.
A significant problem today is that of the efficiency of shoulder surgery. Currently many of the procedures are done arthroscopically allowing for minimal trauma to adjacent tissues as the pathologic structure is addressed and fixed. Subsequently, pain levels following surgery are decreased lending to a false sense of security that more aggressive activity can be done in safe fashion. One need appreciate that even though the shoulder doesn’t hurt that much, healing times are the same and need to be heeded to ensure long term functional success.
From a non-surgical perspective, there are commonly chronic underlying issues that have prevented function at a level necessary for a particular sport. Our body responds by sending the message of pain to the brain due to the mechanical dysfunction, unfortunately we often ignore this crucial information. Thus a process of pain resolution via the restoration of functional mobility and strength as well as the progressive sport specific loads, ranges of motion endurance levels thereof are necessary in preventing the joint from failing again, and if so allowed will only take longer to restore to normative function.
Have a question about your shoulder? Contact the TCS team at 952-922-0330.
