Possible treatments for shoulder pain

author : AMSSM

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Shoulder pain persists long after humerus bone head fracture

Question from member byrdnj: Persistent shoulder pain

Hi there, After a few long years away, I'm trying to get back into the swing of triathlon. My big concern is my shoulder. I had an injury about 3 years ago in which I broke the head of my humerus bone(the "ball" of the ball and socket joint on my left shoulder). There was a bone chip that detached, and then reattached with a little edge sticking out, causing clear issues with the tendons in the area. Has never felt the same since, and though the soreness only comes and goes, the issue persists. Has anybody had this type of issue? I have heard of folks having surgery to smooth out the bone, but that it can take 3-5 months to recover. I have also heard from some that simply rebuilding the muscles around it and running the standard course of intense PT will be fine. Any thoughts welcome - thanks! Nathan

Answer from Thad Barkdull, M.D.
Member, AMSSM

Nathan,

My biggest concern is your remark that it “has never felt the same since.” If it were only a broken bone, and it healed as it should, that’s typically not a big deal. However, from what you’re describing, it sounds like the pieces didn’t fit and growth back together perfectly. When there is a rough edge left over, as you suspected, this can potentially be a direct or indirect irritation on local tendons. Also, if there was an injury that was intense enough to break your shoulder bone, there’s a chance that there were other injuries that weren’t seen or looked for. While probably not an all-inclusive list, I can think of a number of other sources for your pain:

1. The joint between the collarbone (clavicle) and the top part of the shoulder (acromion), called the AC joint, has ligaments that hold it together and the body of the shoulder blade. These could have been torn or stretched, causing motion and inflammation and therefore pain in your shoulder, or even just some arthritis that would be particularly debilitating when in a prolonged cycling position or during the reaching of your swim stroke.


2. It’s also possible that the labrum, a ring of cartilage around the edge of the “socket”, or glenoid, of the shoulder, could have frayed or torn, making the joint a little less stable, and also causing pain when it is stressed.


3. Further, the “sack”, or capsule around the shoulder joint, which is a layering of multiple ligaments around the shoulder joint, could stretch or tear, again potentially rendering the joint slightly less stable, and allowing motion in the joint which can cause pain.


4. I’d also consider the possibility of the biceps tendon getting stretched or inflamed; the biceps is interesting in that it works to flex your elbow and supinate your forearm (turn it palm up). These motions or activities would again be used a lot during the “pull” phase of your swim stroke and as you push down on your pedal when cycling (you’re pulling on the bike handle with your arms to exert the force to push down against the resistance of the pedal). Additionally, the bicep performs an auxiliary function as it goes over the top of your arm bone (humerus) and attaches on the top of the labrum—it acts like a rotator cuff muscle to hold the “ball” in the “socket” during motion. If it’s injured, the ball pushing against it can be painful.


5. It’s also possible that you injured a rotator cuff muscle. These four (or five, if you include the biceps) muscles start out on the shoulder blade or scapula (3 on the outer surface, 1 on the underside), and then envelope the “ball” of the humerus inside the capsule. When you move your arm and shoulder around, the forces against your shoulder (the bike, the water, etc.) want to pull the ball out of the socket. The forces that hold it in place include the socket (glenoid), biceps tendon, capsule, and even a slight suction created by the negative pressure in the capsule; but the strongest force comes from those four muscles. If they or their tendons are injured, inflamed, or degraded (which often occurs with more chronic injuries), then there will be pain when they’re pushed beyond their strength, and there will be pain when your “ball” slides around in the socket.


6. When the ball is moving around too much, you can sometimes get inflammation of local bursae. These are sacks usually found between two structures in the body that often rub against each other. Typically, they have a little fluid in them, and provide a buffer between, say, a muscle and bone; however, if rubbed too much, they get inflamed, and then any movement is quite painful (imagine a blister on your heel—very similar idea).


7. Additionally, when fractures occur at the neck of the humerus (right where the ball and shaft meet), you can potentially injure nerves. The axillary nerve in particular is at risk for injury in this case. It wraps around the neck of the humerus and can get stretched or even torn after a fracture. The axillary nerve provides sensory function—it provides sensation for the joint itself, as well as the lateral aspect of the shoulder/upper arm (the area where you see badges often placed on military/police uniforms; it also provides the motor function for the deltoid, teres minor (one of the rotator cuff muscles) and the long head of the triceps muscle. Injury or impairment of this nerve could result in unusual pain sensations or poor function of the musculature, resulting in weakness/fatigue/pain from those muscles (or others that have to work harder to compensate), or instability of the shoulder with motion, again causing motion and pain.

So that was the long way around to assess your situation. Given that your soreness comes and goes, I would consider starting out with some physical therapy, with focus on making sure that the muscles are as strong as they can be and have as much range of motion as they should have. The goal for your rotator cuff muscles is not to be big movers of your shoulder—the goal is for them to be symmetric and strong enough to hold the ball in the socket while the muscles of locomotion (deltoid, biceps, triceps, latissimus, pectoralis, rhomboids) do the moving. The physical therapists can also often do certain treatments that will help to calm down inflammation. Additionally, physical therapy can sometimes identify that you’re overworking the muscles of the shoulder, pushing them too far when they have not adequately recovered from the original injury or have not had time to adapt and strengthen in the course of your training. They can then guide you in a more gradual return to your full function that allows the muscles and tendons to heal and then adapt.

If you’re not having reasonable (like more than 50%) improvement over 4-6 weeks of going to physical therapy and doing their home exercises, then I would want to get an MRI of your shoulder, check for one or more of the injuries I noted above. The MRI will also allow your physician to see if there does appear to be any chronic trauma happening to one of the muscles as a result of the rough bone edge. To be honest, I think that a rough edge is a less likely problem. A loose fragment of bone could cause some issues, but I think some of the other possibilities above would be more likely problems, many of which will improve/resolve with adequate physical therapy, although some, like more severe capsule, labral or rotator cuff tears do sometimes require surgical repair—and typically a four month recovery is to be expected (this will vary depending on the nature of the problem needing to be fixed).

I hope this gives you some helpful ideas on how to proceed. Good luck with your progress back to the triathlon.

Thad Barkdull, MD, Sports Medicine
Pleasant Grove, Utah

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date: July 31, 2016