Marc Darrow, MD
When one thinks injections into the shoulder, steroid injections come to mind because they may achieve good short and medium-term benefits in many patients with varying types of chronic shoulder pain. However, most patients, if given the choice would opt for a more permanent solution and that choice is not clearly definined in most cases – that is Prolotherapy.
The shoulder is really a combination of several joints, combined in such a way by an intricate arrangement of muscles and tendons, that provides the arm a wide range of motion, flexibility and stability.
The rotator cuff is a group of four shoulder muscles that surround the top of the upper arm bone, the humerus, and holds it in the shoulder joint. These muscles are responsible for moving the arm in various directions, and unlike the massive deltoid muscle of the upper arm, are smaller and generally more vulnerable to injury. The four muscles and tendons of the rotator cuff are the supraspinatus, infraspinatus, teres minor, and subscapularis. It is the supraspinatus that is most commonly inflamed or torn.
The supraspinatus, and the rest of the shoulder, because they are built and expected to allow a remarkable array of motion, frequently are subjected to injuries, causing problems of instability or impingement of soft tissue and in pain. The pain may be constant, or may occur only when the shoulder is moved. In any case, any shoulder pain that persists more than a few days should be diagnosed and treated as necessary.
In the shoulder this is often an inflammation of the tendons as a result of the wearing process that takes place over a period of time. It can also occur from an unusual, awkward movement or fall.
Sometimes, excessive use or injury of the shoulder leads to Inflammation and swelling of a bursa, a condition known as bursitis. Bursas are fluid filled sacs located around the body and joints. They lessen the friction caused by movement of the shoulder. Bursitis often occurs in association with rotator cuff tendonitis. Symptoms of shoulder bursitis include mild to severe pain, limiting the use of the shoulder. In extreme cases the joint stiffens into a condition known as “frozen shoulder,” also referred to by doctors as adhesive capsulitis.
Shoulder Impingement Syndrome
Shoulder impingement syndrome involves one or a combination of problems: inflammation of the bursa located just over the rotator cuff, inflammation of the rotator cuff tendons, (tendonitis), or calcium deposits in tendons—called calcific tendonitis, (caused by wear and tear or injury.) The main problem is usually that the acromium or a bone spur puts pressure on the supraspinatus tendon.
Chronic Shoulder Instability Syndrome
Chronic shoulder instability syndrome results from trauma caused by subluxations, dislocations, from less detectable micro-trauma caused by repetitive strain on the tissues, or from congenitally loose shoulder joints. Recurrent pain or tenderness in the shoulder joint and weakness in the arm are two of the more common symptoms, but severe examples include patients whose shoulders pop in and out of joint. Frequent shoulder dislocations stretch the brachial plexus, the nerves that run from the neck down the arm. This process can cause permanent nerve damage, pain, and loss of use of the arm.
Sometimes the bones in the shoulder joint slip out of normal alignment or are forced out by injury, a condition known as subluxation—if partial in nature, and dislocation—if completely out of joint. Most shoulder sprains or, more seriously, dislocations happen when a person falls on an outstretched hand or sustains a blow to the shoulder (especially a downward blow). Approximately 95% of shoulder dislocations are anterior dislocations, in which the anterior static shoulder stabilizers are stretched or torn away from the bone.
Until recently it was common in cases of dislocation to immobilize the shoulder for long periods of time. But studies proved that while immobilization helped alleviate the pain of such injuries, it also contributed to a general weakening of the ligaments and predominance of adhesive capsulitis. In one alarming study of close to 250 patients, about half of those treated with immobilization had recurring dislocations within the 10 year period of the study. The problem is greater in younger people. This is one of the few areas where older folks have an advantage; because their connective tissue are less elastic, the risk of dislocation is less likely.
There are many types of arthritis, but most often in the shoulder, it is triggered by an initial trauma. It can also involve “wear and tear” of the tissues of the joint, causing inflammation, swelling and pain. Often people will react by instinctively limiting their shoulder movements in order to lessen the pain. This can lead to a tightening or stiffening of the soft tissue parts of the joint, resulting in yet further pain and restriction of motion. In the worst cases, adhesive capsulitis occurs and the arm can not be moved.
The musculature of the shoulder area is fertile ground for trigger points, as is evidenced by the prevalence of a “stiff neck” and referred pain radiating anteriorly, laterally or posteriorly from all three of the major scalene muscles into the arms, chest or vertebrae. Trigger points from the trapezius muscles can refer pain to the head and down the arms.
Shoulder Pain Injections
A proper diagnosis of shoulder pain is essential to determine the root cause of the problem and the proper method of treatment. Because many shoulder conditions are caused by specific activities, a detailed medical history is an invaluable tool. A physical examination should also include screening for physical abnormalities—swelling, deformity, muscle weakness, and tender areas—and observing the range of shoulder motion—how far and in which directions the arm can be moved.
Since it’s been proven to strengthen the connective tissues, and has the benefit of over fifty years of testing to back it, Prolotherapy is arguably one of the best choices of treatment in cases of dislocation, rotator cuff tendonitis, muscle tissue impingement or recurring instability.