Shoulder Pain
Table Of Contents
Understanding Shoulder Pain: What is the real root-cause of the pain?
Shoulder pain is the second most common presenting symptom that I see in my practice (after knee pain). The pain usually starts in certain positions or movements. Patients often complain that they can’t sleep on that side or have restricted range of motion. As always, it’s important to understand the root cause of pain and make a proper diagnosis of the primary pain generators.
A good place to start is to review the basic anatomy. Unlike the hip, which is a deep ball-and-socket joint, the shoulder is a very shallow ball-and-socket joint. This shallow architecture makes the shoulder the most mobile joint in the body, with the greatest range of motion. However, this mobility comes at a price; the shoulder is prone to instability. The stability, strength and movement of the shoulder is totally dependent on the ligaments, muscles and tendons that surround the shoulder. The capsular and extra-capsular ligaments are dense, whitish, fibrous tissues that surround the shoulder joint and hold it in place passively. The rotator cuff is a tough, tight-knit group of muscles and tendons that form another layer over the ligamentous capsule of the shoulder. They play a crucial role in reinforcing the capsule and actively help maintain shoulder stability while at the same time allowing a wide range of arm movements.
If any of these structures get damaged (stretched is the term we use in regenerative circles) they can develop tears/microtears at their insertions. If the capsule is stretched, this may allow the joint to subluxate (slightly dislocate) out of its normal position and pull on the attachments. These attachments are highly innervated and can become important pain generators. If damaged (or stretched) they can cause pain, restrict movement and severely impact one’s quality of life. If the capsule is stretched, the rotator cuff will often be recruited to try and splint the joint and keep it in its anatomically optimized position. This puts extra stress on the rotator cuff which may eventually cause tears or microtears at their insertion, adding to the pain picture.
The Limitations of MRI, x-ray and ultrasound evaluation of the shoulder:
Once we understand that the real root-cause mechanism of pain is instability and damaged (stretched), highly innervated, capsular and tendinous attachments we need to understand how imaging (x-ray, MRI and ultrasound) can help us understand the problem. We also need to understand the limitations of these imaging tests in helping us understand the root cause of the pain and what are the real primary pain generators.
Let’s start with x-ray. Experienced clinicians have long known that the severity of degeneration seen on x-ray is poorly correlated with pain. Some patients have very advanced OA and little pain. Others have mild changes and much more pain. Why? The key here is to understand joint health and pain in terms of stability. Yes, a severely degenerated joint on x-ray may be more likely to be more unstable but not necessarily so. Hence a diagnosis of arthritis based on x-ray should always be supplemented with an evaluation of the stability of the joint with range of motion and palpation interrogation. Arthritis means degeneration of the joint but it’s not the bony and cartilage component loss seen on x-ray that causes most of the pain but primarily the accompanying instability. The pain generators on the surrounding ligament and tendon component of the arthritis which cause looseness (instability) are much more sensitive than the pain generators on the bone or meniscus. The greater the degeneration and looseness of the capsule, the more pain is caused by pulling on damaged attachments.
MRI, because it evaluates connective tissue, is particularly useful to identify rotator cuff tears. However, one of the problems with MRI is it usually fails to identify capsular tears because of poor tissue contrast. Also, as far as the rotator cuff, MRI cannot differentiate between asymptomatic tears and clinically relevant tears. If we did MRI’s on the shoulders of a general population you would see many patients with tears, that have no pain or limitations. In addition, a very important limitation is that MRI is not sensitive enough to identify micro-tears. So what you see on MRI may be important but it also often may miss the true underlying cause of the problem. MRI is useful but a doctor requires good physical exam skills, especially palpation interrogation, to get the complete picture. Over-reliance on MRI can be misleading.
Ultrasound can also be very useful. Here you have the advantage of being able to test structures under movement. This can help us evaluate stability and if complemented with good palpation interrogation skills can be very helpful to help diagnose the root cause of pain. However, as with MRI, you may see abnormalities that are not pain generators and, on the other hand, as with MRI, it is often not sensitive enough to detect microtears that are so often a major contributor to the pain picture. Also, ultrasound misses capsular tears because they are too deep and out of the range for our current ultrasound technology.
The Forgotten Art of a Proper History and Physical Exam
Many years ago, I had the privilege of attending medical school at McGill University (McGill ‘80), one of the best schools in Canada, often called the Harvard of the North. As a student in my orthopedic rotations, my teachers would drum into me the importance of having a methodology as you assess patients. First, they would stress the importance of listening to the patient. They would say that the patient is trying to give you the diagnosis so listen carefully to their history. In the case of the shoulder, trouble lying on it or pain with certain movements suggest instability of the joint and tears/microtears in the rotator cuff. Then they would stress the importance of a thorough physical exam. In the case of the shoulder a ROM and full palpation interrogation scanning of the entire shoulder, upper back and neck complex is essential. The myofascia is all connected, and pain can refer just like nerve pain. Where you feel the pain may not be the origin of the pain. Only after this kind of systematic routine, would they suggest further testing.
Of course they didn’t have the fancy MRI, x-ray and ultrasound testing we have today, but I’m pretty sure they would disapprove of the modern surgeons who recommend surgery almost solely based on MRI without paying too much attention to basic history and physical findings. As we have discussed, x-ray, MRI and ultrasound all have their place but they also have their limitations and should not be over relied upon since they may miss critical diagnoses such as instability of a joint and /or microtears in the ligaments and tendons that are so often the main root cause of the pain.
A proper physical exam should include range of motion testing, stress testing of the components of the rotator cuff and palpation interrogation of all structures to pinpoint where they are damaged. It is also true that most patients will have multiple structures that are damaged, not just one. A proper exam includes an assessment of both the underlying joint (including the capsule and extra-capsular ligaments) and the overlying rotator cuff. Microtears in multiple structures are often present, even when a larger tear in a single structure is identified. Ignoring these microtears can lead to incomplete healing and poor results. Surgically fixing one structure (e.g. supraspinatus) with a large tear while ignoring capsular instability and other areas with microtears may yield only mediocre results and result in a high failure rate. This is where regenerating ligamentous and tendinous attachments at a cellular level as we do with stem cells and PRP, may yield a far superior outcome.
In shoulder OA, the main underlying cause of pain is instability of the joint and a loose or stretched capsule. In rotator cuff pain, the culprit is instability and tears / micro tears of the rotator cuff that surrounds and moves the joint. A good regenerative specialist can use palpation interrogation to identify both types of problems. As we have said, most patients will have multiple pain generators with both primary shoulder instability (shoulder OA) and multiple rotator cuff tears (and micro tears), only some of which will show up on MRI. The only way to make a comprehensive and proper diagnosis of all the real root causes of the joint pain is with a thorough exam including range of motion testing and palpation interrogation of all structures in the area. Of all the tests you can do, palpation interrogation done by an experienced regenerative doctor, may be the most important. Not only can it identify all the structures that are damaged and causing the pain but you can also prioritize the pain generators in order of importance.
Common Shoulder Problems
With this background, let’s explore five common types of shoulder problems and how they can be rectified with regenerative Injections of stem cells, PRP and Prolo. These problems include:
Rotator Cuff Tendon Tears
One of the most common injuries associated with the shoulder is a rotator cuff tear. These tears are often detected through MRI scans. However, it’s important to note that the presence of a rotator cuff tear on an MRI does not always correlate with pain. Research has shown that many individuals with rotator cuff tears experience no pain at all. This discrepancy highlights a common misconception in treating shoulder injuries: the assumption that the tear itself is the primary source of pain.
What makes the difference between a tear that actually causes pain and one that is asymptomatic? The key differentiating factor is the stability of the shoulder. If you have a tear that causes no instability, no pain but if it causes or is accompanied by instability, this equals pain.
In many cases, focusing solely on repairing the rotator cuff tear without addressing the underlying issues within the capsular complex is a mistake. The shoulder’s stability relies on the intricate interplay of various structures, and a comprehensive approach is necessary for effective treatment. All the damaged rotator cuff structures should be injected as well as the whole capsule.
Labral Tears or SLAP Lesions
Labral tears can occur frequently, either acutely from falling on an outstretched hand or from wear and tear over time. SLAP lesions are sometimes treated with surgery, as are tears in the biceps tendon. Both rotator cuff tears and labral tears are often seen on MRI and may or may not be causing pain. There is debate in conventional circles whether surgery is any better than conservative measures in terms of outcome. This is especially true in overhead athletes like baseball pitchers who want to return to their sport. Data suggests that they may have a better chance of returning to their sport if they avoid surgery and treat the problem conservatively with physical therapy. Augmenting these conservative measures with high-quality stem cell therapy would greatly improve the chances of a good outcome.
Osteoarthritis (OA) of the Shoulder
Osteoarthritis (OA) of the shoulder is perhaps the most common issue I evaluate. The data on shoulder replacement surgery does not show great outcomes and suggests that this surgery should definitely be a last resort. In my view, all four of these clinical groups can be excellent candidates for regenerative approaches. Why? Because in all of these cases, the primary driver of pain is shoulder instability. For those patients who have days where the shoulder hurts more, it is because the joint is more subluxated. On physical examination, instability commonly presents with snapping, crackling, or popping sounds as you move the shoulder through its range of motion.
Frozen Shoulder or Entrapment Syndrome
Frozen shoulder or entrapment syndrome refers to a severe restriction and a locking and limitation of abduction (raising the arm laterally). Frozen shoulder is caused by more significant instability and is usually accompanied by moderate to severe OA. Frozen shoulder is caused by a superior subluxation of the humeral head, which pinches the supraspinatus tendon against the acromion process. A small subluxation gives clicking on abduction; a larger subluxation jams the humeral head against the acromion. Frozen shoulder is a sign of serious capsular instability, particularly laxity of the posterior capsular ligament bundle.
AC Joint Sprain or Separation
Another fairly common problem is AC (acromio-clavicular) joint sprain or dislocation. This generally occurs from a forceful impact to the outside of the shoulder as occurs most commonly in contact sports like football. There are six grades to AC joint separation ranging from grade I where the ligament has a very small tear or is merely stretched. Grade II is a partial joint dislocation. This injury results in the acromioclavicular ligament being torn completely, though the coracoclavicular ligament is still in good shape. In Grade III: the joint is completely separated. Both ligaments (acromioclavicular and coracoclavicular) are torn. Here you can readily see a bump that appears on the shoulder. Higher grades: grades IV-VI exist, but they’re usually a result of a serious motor vehicle accident, so they’re not as common as the lower grades.
Each grade of shoulder separation will have its own set of symptoms to look out for. In Grade I the AC joint will be tender to palpation and you may feel minor pain when you move your arm. With Grade II, there is more pain and perhaps some swelling in the area. For a grade III injury, symptoms become more serious and patients may notice popping when they move the joint. At this stage there is noticeable shoulder deformity and patients may require a sling to minimize movement. Although the diagnosis is usually straightforward with obvious tenderness and swelling some doctors will likely get an x-ray to confirm the diagnosis and depending on the injury involved, to differentiate a shoulder separation from a bone fracture.
Surgery for AC joint separation or dislocation does not really work well. Fusing the joint (arthrodesis) with screws and wire doesn’t work since you need movement to use the arm properly. Surgical excision of the joint (called decompression or arthroplasty) also has a poor outcome because it results in an unstable joint where the end of the acromion floats and can interfere with other structures. A recent study in a surgical journal suggested that surgery was no better than doing nothing and maybe worse. Researchers found no clinically improvement in the group that underwent surgery for their AC joint dislocation, and no differences were found in function between the two groups. However, the conservative management group with no surgery recovered and returned to work faster. Those who had surgery had a much longer recovery and more complications.
So we can add AC dislocation surgery to a growing group of unnecessary orthopedic surgeries which result in worse outcomes than doing nothing. Like removing a piece of the knee meniscus shock absorber which results in less cushion for the joint and accelerates OA. Or fusing some lumbar spine vertebrae that ends up putting more stress on the vertebrae above and below the fusion and causes them to break down more quickly.
Treatment Options: Surgery vs. Regeneration with Stem Cells
Arthroscopic shoulder surgery or even complete replacement are often recommended as a potential treatment, but there are risks involved. Recovery may be slow, requiring several months of restricted use followed by a period of rehabilitation. In some cases, full functionality and movement are not achieved. In the case of arthroscopic repair, retear rates might be as high as 20% or more, and the incidence of post-surgical stiffness is high. Researchers attribute the high retear rate to the tendons not healing properly. This highlights a key difference between regenerating tissue at a cellular level and mechanically sewing it together. When tissues are regenerated, they have much better blood flow and are much stronger than if they are simply sewn together. This is one reason why patients should consider regenerative injections before opting for surgery. They may have a better outcome, lower risk and less downtime.
Advantages of Regenerative Therapy
Regenerative Injection Therapy with stem cells, PRP and/or Prolotherapy can be highly effective for most shoulder issues and has several advantages over traditional surgical methods:
- Comprehensive Healing: regenerative treatments can target all key structures in the shoulder, including the rotator cuff, capsule, extra-capsular ligaments, and cartilage. This comprehensive approach can address all the underlying causes of instability, those seen on MRI and ultrasound as well as the capsular laxity and multiple regions of microtearing that might not show up in imaging studies and may have been clinically overlooked.
- Improved Blood Flow: Regenerated have better blood flow compared to surgically repaired tissue. This enhanced blood flow aids in the healing process and reduces the risk of re-injury.
- Higher Success Rates: Studies have shown that regenerative approaches have an approximate 85% success rate in treating shoulder problems. This high success rate is attributed to the therapy’s ability to address the root causes of instability and promote long-term healing and joint health.
- Minimizes Retear Risk: Since stem cells and regenerative treatments rebuild tissue at a cellular level, the newly formed tissue is stronger and more resilient. This reduces the likelihood of retears compared to traditional surgical repairs.
Optimizing Regenerative Therapy and Rehab
My primary goal is to give you a deeper understanding of shoulder pain, shoulder OA and rotator cuff damage. Once you understand the root of the problem and how it is best fixed, the key is to find a good regenerative specialist who can address it properly.
I’ll share with you the protocols I use in my own practice. For milder rotator cuff damage, PRP alone or Prolo alone may be sufficient if damage is not too extensive and the patient is younger although I would expect that the average case may need three or four sessions for complete healing. In many cases, if pain is significant, we opt to use a stem cell/ PRP combo as this gets healing off to a great start and even if the patient requires a booster, six or eight weeks later, there is at least an 80% chance of at least 80% resolution of pain. I prefer autologous stem cells prepared from a patient’s own fat as I have found them much more effective than bone marrow stem cells or umbilical stem cells from a donor. It is also important that the stem cells are prepared carefully and that we inject the stem cells within an hour or two of their preparation. Freshly prepared stem cells have natural cytokines that boost healing activity but they are only present for two or three hours after preparation.
If we are dealing with a labral tear, moderate to severe OA, frozen shoulder with significant cartilage damage and instability of the capsule or AC joint dislocation I usually recommend starting with stem cells/PRP over just PRP or prolotherapy. If the patient prefers an incremental approach we can start with PRP or Prolo primers which can help relieve the pain in the short term and help set the stage for more definitive healing when they are ready to proceed with stem cells and PRP. With proper evaluation, treatment and follow-up we have an 85% success rate for lasting relief, restoring full functionality and a reduced risk of re-injury.
I want to stress that regenerative healing is a process. It’s not magic. However, it is good medicine and it may produce an elegant, superb result that may surprise the patient as well as doctors. However, proper follow-up and rehab is essential for optimal results. Some patients may notice an improvement within a week or two but some take up to six or eight weeks to notice improvement. There are different phases of the healing. Tightening of the joint can occur within days but tissue regeneration where the stem cells differentiate and become the type of cells required for healing can take weeks. Patients need to move the joint and return to activities of daily living right away but they should not overly load the attachments for at least six weeks. After the first 10 days, swimming and aquatherapy is a great rehab as it encourages full range of motion with gentle load. Light band work can help after the first two weeks or so. In all rehab activities, if it hurts the patient needs to back off and start more gently and incrementally. T-relief cream, applied and massaged into sensitive areas twice a day can help.
For patients who have a stem cell/PRP treatment please note that maybe 30% of those patients may benefit from a PRP booster, 6 to 10 weeks after their treatment. The stem cells remain alive for at least four or five months. In the case that a patient has sluggish results (i.e. less than 50-60% improvement), they may benefit from a PRP booster at the 6-10 weeks mark to reinvigorate the stem cells and give a more optimal result. In rare cases, for patients who heal very slowly, they may require an additional PRP booster or even one or two Prolo boosters at around 4 or 5 months to get the best results possible.