Shoulder pain can be caused by acute injuries such as a fall on an outstretched hand, car accident, sporting/weight training accident or it can be caused by chronic repetitive stress, lack of muscular support, ligament laxity and bad posture at work or daily activities.
The most important step in addressing shoulder pain is understanding if all or some of these variables are causing the pain or contributing to the cause of pain.
The American Academy of Radiologists now recommends Musculoskeletal Ultrasound as the first line evaluation for shoulder pain, rather than MRI or X-ray. This is partly because it allows point of care evaluation in the office that can take place as part of a larger physical exam but also because the degree of sensitivity for most types of shoulder pathology is higher or equivalent to MRI. A combination of Ultrasound and Physical exam can also point to the need to order an MRI in order to further evaluate structures inside the joint such as the labrum or cartilage.
Using a combination of History, Physical exam and Imaging modalities, we are able to gain insight into the underlying causes of shoulder pathology and this helps to determine the correct level of treatment.
Physical therapy is undoubtedly helpful in the majority of cases, but when the issue is an acute ligament sprain or larger tear of a muscle then physical therapy is likely to exacerbate these issues. Knowing when this is the case requires a robust understanding of the pathology achieved by ultrasound evaluation of the complete shoulder.
Ligament sprains require bracing but in most cases they would benefit from support with regenerative injections like Platelet Rich Plasma to heal optimally and avoid having chronic weakness in the area. The various ligaments that can lead to a loose shoulder joint include the anterior and posterior glenohumeral ligament, acromioclavicular, sternoclavicular, coracoclavicular, coracoacromial, superior glenohumeral and coracohumeral ligaments as well as the shoulder capsule and superior glenoid labral attachements. These are all sites that require sophisticated techniques and ultrasound guidance to successfully inject potent regenerative agents in just the right amount. Rehabbing after these types of injections becomes just as important as the injections themselves and using ultrasound to monitor the progress and prescribing physical therapy exercises at the correct level for the stage of healing is essential to successfully nurturing these ligaments back to full health in order to stabilize the shoulder.
Large tears may require bracing and activity modification as well and in some cases surgery is required. In order to avoid surgery, Dr. Wardwell has pioneered advanced Regenerative injection treatments to heal large rotator cuff tears using Adipose Derived stem cells where the stem cell enriched fat can be used as a scaffolding in the defect and, given time and the appropriate level of bracing, the body can regrow in even chronic large tears. These techniques are currently being studied as part of a clinical trial in order to build evidence to support these groundbreaking therapies. Smaller tears have responded well to Amniotic membrane derived growth factor injections, which can likewise provide a biologic scaffolding for the body to grow across and restart the healing process in areas that have filled in with scar tissue.
Often in the acute phase of healing or in the weeks following regenerative injections before the area has fully healed, Acupuncture, Biopuncture and Manipulation can help address soft tissue strains that are exacerbating pain and causing strains to radiate up into the neck. Physical therapy exercises prescribed at the right level for the stage of healing for the injured areas can also be synergistic to regenerative injections and provide relief from pain in areas that are being overworked or compensating for injured areas. Patient education is especially important because gaining insight into the types of activities that will exacerbate shoulder pain and learning how to modify these activities to allow the area to heal and avoid making it worse is essential to making any of the above therapies effective. Outside of physical pathology, Shoulder pain can be a result of more systemic inflammation. Often times both shoulders and the neck will be painful or even other joints in the body at the same time. This is often an indication that other issues such as poor nutrition, hormonal imbalance, food sensitivities, microbiome imbalances, metabolic disorders or poor sleep quality may be effecting systemic inflammation causing soft tissue degeneration and shoulder pain.
At the San Francisco Institute for Integrative and Regenerative Medicine, healing shoulder pain starts with a robust understanding of the pain generators and associated injuries that are exacerbating the pain generators. The treatment is tailored to the patient based on the type of pathology they present with and the services provided or referrals made are dictated by the patient’s condition as it evolves through the process of rehabilitation.