Why My Shoulders Hurt?

 

If you think about it, there are few daily tasks that don’t involve the use of your shoulders. Because the shoulder is the most movable joint in the body, it is somewhat unstable. Overuse and shoulder instability can lead to several different varieties of shoulder pain.

The shoulder is composed of three bones: the clavicle (collarbone), the scapula

(Shoulder blade), and the humerus (upper arm bone)(Figure 1).

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Figure 1

Motion is controlled by two joints:

The acromioclavicular joint (AC joint) and the glenohumeral joint (Figure 2).

The AC joint is located between the acromion and the clavicle while the glenohumeral joint is the ball-and-socket joint that allows the arm to rotate in a circular motion. Supported by muscles, tendons and ligaments, the rotator cuff holds the ball at the top of the humerus in the socket and provides strength and mobility to the shoulder joint. Injuries often arise from the shoulder’s soft tissue being over- or underused. In addition, the shoulder’s anatomy can also play a role in shoulder pain. Common shoulder pain causes include tendonitis, bursitis, injury/instability, arthritis, rotator cuff tears and fractures.

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Figure 2

Tendonitis often causes pain which is the result of the tendon being overused. A tendon connects the muscle to bone or other tissue.

Tendonitisis usually the result of degenerative changes that take place over several years.

This can be car characterized either as an acute (following an overuse problem) Injury or a chronic (degenerative disease due to age) injury.

 

Bursitis is another overuse disease that affects the shoulder. Excessive use often leads to inflammation of the bursa–the fluid filled sac around the joints–which may limit the use of the shoulder. The bursa is responsible for lessening the friction caused by shoulder movement.

Shoulder instability is a common problem that results in shoulder pain. Because the ball of the upper arm is larger than the socket that holds it, it is often subject to injury. This anatomical anomaly causes instability if muscles, and tendons or ligaments are disrupted.

Another common shoulder problem is a dislocated shoulder

The shoulder joint it the most commonly dislocated joint in the body and is usually has a high recurrence rate in young patients. Shoulder dislocation is usually caused by a strong force that pulls the shoulder outward, popping the ball of the humerus out of the shoulder socket. Often, this motion overwhelms the muscles because they are unprepared to resist the excessive force. Putting the shoulder back into position is accomplished through a process called reduction. This procedure is usually done while the patient is sedated or relaxed. Dislocations may be associated with nerve injuries such as the axillary nerve and brachial plexus. If a young patient is unable to lift his or her arms following reduction of a shoulder dislocation, there is usually an axillary nerve injury. However, if an elderly patient is unable to lift his or her arms following reduction of a shoulder dislocation, there is usually a rotator cuff tear. An MRI may be necessary to determine the injury.

Another shoulder injury patients often experience is a separated shoulder. A separated shoulder results when a force separates the collarbone from the shoulder blade. The shoulder blade moves downward from the weight of the arm and creates a bump or bulge above the shoulder.

Arthritis and rotator cuff tears can also occur. Arthritis involves wear-and-tear changes with inflammation of the joint causing swelling, stiffness and pain. Rotator cuff tears refer to a tear in one of the four tendons that blend together to attach to the humerus. These tendons transfer forces from the shoulder blade to the arm, providing motion and stability.

Fractures are also a shoulder injury concern. A shoulder fracture refers to a partial or total crack through one of the three bones of the shoulder. Fractures are usually the result of an impact injury. Clavicle (collarbone) fractures are usually treated conservatively, although there is a high incidence of non-union in distal third fractures. Patients with scapula (shoulder blade) fractures should be admitted and observed. Here, there is a concern of pulmonary complications. Fractures of the humerus are usually treated conservatively. Stiffness is often a concern for elderly patients. Therefore, early rehabilitation is usually necessary.

Certain signs indicate that patients should seek medical attention, including an inability to carry objects or use an arm; deformity of the shoulder joint; pain that occurs at night or while resting; pain that persists beyond a few days; an inability to raise the arm; or severe bruising or swelling around the joint.

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Figure 3

Doctors often use a variety of methods to determine shoulder pain, including x-rays, MRIs (Figure 3), injections (Figure 4) and arthrograms. While shoulder pain can be treated conservatively, surgical intervention is sometimes required to alleviate shoulder pain.

 

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Figure 4
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How To Develop Loyalty In Your Team

The head of the team is responsible for maintaining team morale and leadership. The head of the team is supposed to act as the “glue” that holds the rest of the team together.

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It is important to acknowledge the work that is done by members of your team in order to boost morale. When leadership focuses on building team morale, it creates a positive environment within the office, department or university. It is important to mention the employee by name and show them appreciation for a job well done!

Often the employee does not feel appreciated in their work when they do not receive appreciation from their leaders. Appreciation has the greatest impact on team morale.

Recognition and Appreciation

Allow the employee to feel valued for their continued hard work. Give them praise and publish recognition. Giving recognition to the employee is a positive way to inspire them to use the full extent of their talents and “go the extra mile”. Morale will increase, as well as productivity.

Communication should always occur between the leaders and the employees! Be hands on! Correspondence should not occur simply through email or other non-personal methods. It is important to maintain face to face communication.

Allow the employees the opportunity to lead and receive credit for their accomplishments. As a leader, be there to help and coach others to take responsibility and think for themselves. During times of crisis, lead from the front! During times of comfort, lead from behind!

Engaged Team

An engaged team will be better equipped to achieve the mission and objective of their work. They will believe in what needs to be accomplished with passion and enthusiasm.

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Hamate Fractures

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Fractures of the hamate bone are rare, difficult to diagnose, and routine x-rays may not show the fracture. Hamate fractures are classified as either a hook fracture or as a body fracture.

Hamate hook fractures are usually seen in individuals who participate in sports which involve a racquet, baseball bat, or from swinging a golf club.

Swinging of the golf club may cause a hook fracture of the Hamate bone. Missing the fracture can lead to persistent pain from nonunion.

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Hamate body fractures are associated with axial force trauma, such as a fist striking a hard object, a fall, or from crushing injuries. It may also be accompanied by 4th and 5th metacarpal subluxation. Coronal fractures are the most common type of Hamate body fractures.

There are three types of coronal fractures; Type A (large piece), Type B (moderate piece) and Type C (avulsion). Make sure to watch out for subluxation of the joint due to pull from the Extensor Carpi Ulnaris.

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Hook fractures of the Hamate are best seen by carpal tunnel or supination x-ray views. For hamate fractures, CT scan is the best study. A 30° pronated view is helpful for body fractures.

Clinical Evaluation

Pain will be present, especially with axial loading of the ring and little finger or by grasping an object. The patient will have dismissed grip strength. They may have ulnar and median nerve neuropathy symptoms. The most common findings are pain and tenderness on the ulnar side of the wrist, distal to the wrist joint.

The pull test has been recently described. This is when the palm of the hand is placed into supination, the wrist is in full ulnar deviation, and the fingers of the patient should be flexed. The examiner pulls on the ulnar two digits with the patient resisting the pull. A positive test with pain in the area of the hook indicates a fractures hook of hamate injury. Pain may also be felt due to compression of the ulnar nerve in the Guyon Canal.

Treatment                        

Early immobilization for acute fractures with short arm splint for 6 weeks will be used to avoid a nonunion. For symptomatic nonunion, excision of the fracture fragment will be needed.

Types A and B require open reduction and internal fixation, in addition to stabilization of the joint if needed. Type C requires closed reduction and percutaneous pinning of the fragment for stabilization of the joint. If a closed reduction of the joint is not adequate, open reduction and stabilization of the joint should be done. A displaced fragment with subluxation requires reduction of the joint and stabilization of the joint with K-wires or fixation of the fragment.

When a 4th or 5th carpometacarpal dislocation occurs, one should make special effort to find a coronal fracture of the hamate.

 

 

 

Potential Complications of Bone Fracture

When a bone breaks, the patient may be at immediate risk of acute complications. These include serious vascular or nerve injuries, which occur due to the location of the break, as well as significant blood loss, which can happen if the break injures a major blood vessel. Similarly, a break near a major organ may cause life-threatening distress, such as the compromised respiratory function that occasionally occurs as the result of a rib fracture.

Other immediate risks include fracture blisters, which develop when the surrounding skin attaches to the bone. These can interfere with proper healing and may prompt the development of infection. Physicians must be watchful for these and other injury-generated conditions, including compartment syndromes, which cause pain and potential tissue ischemia.

The most severe complications tend to occur soon after the break, but secondary issues are still possible as the bone heals. These include potentially dangerous infections as well as bone calcifications and complex regional pain syndrome. Bone calcifications primarily require pain management, while regional pain syndrome can be addressed by physiological and psychological therapy. Patients may also be at risk of bone fragments failing to join, a complex condition that may in some cases necessitate surgical intervention.

About the author:

Nabil Ebraheim

Over the course of his career, orthopaedic surgeon Dr. Nabil Ebraheim has conducted extensive research into bone fracture and healing. Dr. Nabil Ebraheim currently serves as the chair of the Department of Orthopaedic Surgery and director of the orthopaedic trauma fellowship at the Medical University of Ohio, where he draws on an in-depth knowledge of fractures and potential complications.