You are welcome to bring a relative or friend with you. A nurse can be made available as a chaperone if you wish - please ask at outpatient reception when you arrive. You will meet your doctor and have an opportunity to explain your complaint before being examined. The doctor will want to review a recent x-ray of your shoulder. He may then suggest an office ultrasound to look for any tearing of the tendons deep within the shoulder (these do not show on x-ray).
By this time the diagnosis has usually been made. Occasionally further tests are required such as Magnetic Resonance Imaging (MRI) or Computerised Tomography (CT) or blood tests, but your doctor will explain whether these are necessary and why.
Most shoulder problems fall into one of 3 main categories.
the shoulder is unstable which means it dislocates or almost dislocates
the shoulder is painful but not very stiff; with help and some gritting of the teeth the arm can be lifted well up above shoulder height
the shoulder is painful and stiff; the arm cannot be lifted high above the shoulder and nor will it reach to the back of your head or up your back.
However there can be many other reasons for shoulder pain and there is often a lot of overlap between the categories. These descriptions are provided for deeper understanding of your problem but should not be used for self-diagnosis.
Category 1.
Instability of the shoulder is often a problem for young adults although it can affect anyone. The assessment and treatment plan for an unstable shoulder is complicated and best performed by an orthopaedic surgeon with a special interest in problems of the shoulder.
Category 2.
This is the most common shoulder problem. It can affect anyone but usually from middle age onwards. It typically causes pain during overhead movements/work but also when reaching behind you eg to reach the back seat of the car or seatbelt, doing up a bra, pulling up trousers, getting into a back pocket. When bad it can start waking you up in the night. The pain is usually felt on the outside of the upper arm. It is most frequently due to inflammation deep inside the shoulder where the tendons which move the shoulder joint are situated within an unyielding bone/ligament arch. This problem is known as impingement. The tendons themselves are often normal however in older people they may be partially torn or even fully torn (rotator cuff tear).
Some people have similar symptoms but have worse pain reaching their arm across their body or holding their arm up high. In these cases the pain may be arising from the small joint on top of the shoulder called the acromio-clavicular joint.
Category 3.
In this group the main feature is a stiff shoulder and it may or may not be painful. There are 3 main causes for a stiff shoulder and an xray is required to distinguish between them. If the xray shows arthritis then this explains the painful stiffness. If the xray is normal and you have not suffered a significant injury to the joint then you probably have a frozen shoulder (idiopathic adhesive capsulitis). If you have had a major injury to the shoulder within the last year then the problem could be post-traumatic stiffness. If you are diabetic then the stiffness is often worse and more difficult to treat than in non-diabetics.
Injections containing a mixture of local anaesthetic and cortisone (locally acting steroid) are frequently used in the treatment of painful musculoskeletal problems. They are safe, can help with diagnosis, and often cure the underlying problem. Occasionally they need to be repeated for maximum effect. You would not usually have more than 3 or 4 injections into one area.
After the skin has been cleaned the injection itself is felt as the sharp scratch of the needle followed by an intense hot or burning sensation which lasts only a few seconds. The injection takes only a few seconds to perform. Sometimes the pain, for which the injection was given, gets worse that night and we would suggest you take simple painkillers eg paracetamol, before going to bed. It does not mean anything has gone wrong. Occasionally the injection takes several days to take effect and the good effects may last from between a few hours to several months. A small sticking plaster will be applied afterwards and can be taken off next day. Your doctor will tell you whether you need to restrict any activity after the injection.
You will be able to drive after the injection.
If you are diabetic the cortisone in the injection can upset your blood sugar levels, usually tending to make them rise for about 48 hours. You should monitor your blood sugar levels more carefully than usual and be prepared to give yourself more insulin if necessary.
A high quality, small, portable ultrasound scanner is available for use in the office. Your consultant may suggest this test would be appropriate. It is very useful for looking at 'soft' tissues such as tendons which do not show up on xray. It is the same technique as used for ultrasound scans of babies so it is completely safe and painless.
The scan will be done by your surgeon in the office and takes about 5 minutes.
You will be asked to sit down and to expose the part of the body to be scanned. Some clear cold jelly is used over the part of the body being scanned which is simply wiped away at the end of the procedure.
Many shoulder problems can be treated by simple means eg
modification of your daily activities ie bringing things down out of high shelves and cupboards so that most of your work is performed well below shoulder height
seeking advice from your sports professional ie modifying your golf swing or changing the tennis racquet handle grip
Sometimes a cortisone injection into the shoulder is helpful. Your GP may already have tried this.
Occasionally the problem is best dealt with by surgery. You will have the opportunity to discuss this with your consultant if it is advised.
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