Serratus Anterior Shoulder Pain - Member Case Study

author : AMSSM

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Differentiating between the different causes of rotator cuff-related pain is not important initially, because primary treatment for all of them is the same.

Question from Andrea :

Another information-type question. I have serious wake-up-in-the-middle-of-the-night-in-tears shoulder pain. I THINK it's a serratus anterior issue, and the shoulder pain is just radiated pain. I've been in physical therapy. I've taken meds. Blah, blah, blah. It gets less bad with an absolutely stringent (NOT my mature) attention to my PT exercises, massage, yoga, and not sleeping on my side. Swimming or not swimming doesn't seem to make a difference. I've been off swimming for about 6 weeks, and nothing's really different. So I'm going back to swimming -unless someone tells me differently! But here's my question. Why one side and not the other, when everything I do is symmetrical? Or I THINK it is, anyway. Yoga is absolutely careful about balancing the sides of the body. Swimming is symmetrical -except for side stroke which I can only do on one side, so I pretty much don't do it at all anymore. If both my shoulders hurt, I surely wouldn't LIKE it, but at least I'd understand it!???

Answer:

There are several issues that come to mind with a complaint of shoulder pain that wakes someone up in the middle of the night. You don’t mention anything about shoulder trauma, previous injuries, other medical issues, etc. So, let me just give you the most likely possibilities, and you can decide if they fit your situation.

The first thing that comes to my mind is rotator cuff-related issues. These are often most painful when the arm is raised above the shoulder and very common in swimmers. Several things can happen in the rotator cuff area. The first of these is a tendonitis as a result of overuse +/- technique-related issues (how is your body roll?). Remember, when considering overuse, you need to include both sport and non-sport related activity. In the veteran athlete, chronic inflammation in this area can lead to deposition of calcium deposits in the tendons which can be very painful, and in my experience is a bit more common in women than in men. Subacromial bursitis is an inflammation of the fluid-filled sack that sits on of top of the rotator cuff tendons as they pass underneath one of the bones in the shoulder. This is also an overuse type of injury, is painful when raising the arm above shoulder height, and will often cause point tenderness on the top of the shoulder just lateral to (to the outside of) the bony part of the shoulder. A tear of the rotator cuff is another possibility. In the younger athlete, tears of the rotator cuff are uncommon and are often seen with significant trauma. However, these are much more common in the mature population, and may, or may not, be associated with a traumatic event. Rotator cuff tears can be quite painful and also often cause weakness in the shoulder. Night pain is common.

Differentiating between these different causes of rotator cuff-related pain is not important initially, because primary treatment for all of them is the same. If one of these rotator cuff-related problems seems likely, initial treatment includes:

1. Decrease pain and inflammation with ice, anti-inflammatory medication, and relative rest. Relative rest = “don’t do it if it hurts.” For many athletes, reducing the volume and intensity of training by 50% is a good starting point, and then advance as tolerated by about 10%/week. If you cannot tolerate the reduction in training, then you need to find alternative activity during rehab.

2. Correct technique deficiencies (i.e. have a coach watch you).

3. Begin an appropriate rehabilitation program. In the shoulder this generally starts with exercises geared towards “scapular stabilization”. This is where the serratus anterior (as you mentioned), rhomboids and others come to play. These muscles are very important in stabilizing the shoulder and help provide a solid platform for arm motion. Once the rotator cuff tendons have “quieted down,” then you can begin a rotator-cuff program. I find many programs simply address the rotator cuff, without initially addressing any scapular stabilization issues that might be present.

4. Other options: If you don’t have improvement after several weeks of almost-daily compliance with a home regimen, other options should be considered. (Remember, these problems may take months to resolve, so you are basically looking for continuing improvement rather than a miraculous turn-around). These other options include:

   a. Corticosteroid injections: Sometimes sooner, rather than later, for subacromial bursitis and calcific tendinitis.
   b. Further studies (i.e. MRI): To assess for a rotator cuff tear that is causing persistent pain and/or weakness, or other possibilities.

Another issue that can be seen in the mature shoulder is an adhesive capsulitis (a.k.a. frozen shoulder). This causes pain and loss of range of motion (especially when reaching up or down your back). Nobody really knows what causes adhesive capsulitis, but it is seen with greater frequency among diabetics. Treatment for frozen shoulder includes home exercises focusing on re-establishing full range of motion. You mentioned that you are not particularly good with therapy, but this is one area where compliance with a good home rehabilitation program makes a world of difference.

Another possibility is that the pain is not coming from the shoulder at all. The shoulder is a common site of referred pain from the neck and certain internal organs. If my descriptions do not ring true, or if you are not slowly improving when complying with a rehab program, then you need to see your health care provider to assess other possibilities. Best wishes and hope you find this information of assistance.
 

Michele LaBotz MD FAAP
University of Hawaii at Manoa
Member AMSSM

www.amssm.org
 

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date: April 9, 2005