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Shoulder pain. Tendinitis. Cuff tear.
These are problems we expect to see in professional athletes. Unfortunately, they are problems we see also in today's baby boomers trying to "stay (or get) in shape" and even in younger members of the population.
Today's active population - baby boomers and members of Generation D alike
 - wants to be active playing sports and working out, but acute injuries from direct or indirect trauma and from overuse activities of repetitive microtrauma can cause a quick detour from the starting line to the side line.
The typical baby boomer athlete is one who is active playing weekend sports and perhaps playing occasionally during the week but who does not have the time or facilities (or maybe the finances) to participate daily in sports. It is not uncommon for this "weekend warrior" to try to make up for lost time by not warming up properly or by playing harder and longer, and this makes him or her more susceptible to injury.
HISTORY
The middle-aged athlete's muscle tissue is more susceptible to injury with less direct trauma and microtrauma than the tissue of a younger athlete because it is less elastic with less overall blood supply. Typically, by the time we see this patient in the office his or her history is of shoulder pain that developed gradually (unless there was a precipitating acute traumatic injury) over a period of several weeks. The patient notes that the pain frequently occurs with overhead activities or with moving the arm in certain positions, and it is not unusual for the pain to occur at nighttime when the patient rolls onto the shoulder.
The Generation D athlete is more resistant to injury than the "more seasoned" veteran but even younger patients can develop pathologic conditions about the shoulder with sufficient trauma or chronic overuse.
In patients who have developed shoulder pain gradually, without an acute injury, the differential diagnosis would include tendinitis of the rotator cuff or biceps tendon, rotator cuff strain, rotator cuff tear, adhesive capsulitis, subtle instability, tears of the labrum (thickening of the capsule around the socket), or arthritis. If a patient has had an acute injury to the shoulder with the sudden onset of pain, weakness and loss of motion, a complete rotator cuff tear is suspected.
Younger patients typically do not develop complete rotator cuff tears, rather, they develop inflammation of the tendon (tendinitis) or bursa (bursitis), subtle instability about the shoulder (which can put more stress on the tendons and ligamentous structures about the shoulder), or partial tears of the rotator cuff.
EXAMINATION/TREATMENT
Physical examination by a physician is helpful for determining a diagnosis, but it is not unusual for the physician initially not to know the precise diagnosis. X-rays can be helpful in determining if arthritis is present; unfortunately, routine x-rays do not show inflammation or tears and frequently do not help in diagnosing subtle instability.
Conservative treatment initially is appropriate unless an acute rotator cuff tear is suspected. Once again, a diagnosis of acute rotator cuff tear is more commonly associated with an acute traumatic injury followed by significant pain, particularly at nighttime, with loss of strength and some loss of motion. A complete rotator cuff tear can also occur with chronic impingement and microtrauma.
Conservative treatment would consist of range of motion exercises, rotator cuff strengthening exercises and different types of physical therapy modalities to the shoulder. Nonsteroidal anti-inflammatory medication oftentimes is helpful, and an occasional cortisone injection into the subacromial bursal space can seem "miraculous."
If a patient begins to respond to conservative treatment, it may take up to six to nine months for symptoms to completely subside, but if the patient does not respond to conservative treatment within six to eight weeks, a further diagnostic test such as MRI or arthrogram/post arthrogram MRI of the shoulder would be very reasonable. The MRI shows soft tissue problems such as tendinitis, rotator cuff tears and labral tears; unfortunately, it is not 100% accurate for all of these diagnoses. Adding the arthrogram to the MRI does increase the accuracy of diagnoses of rotator cuff and labral tears but it requires an injection of dye into the shoulder. If a patient is diagnosed with a rotator cuff tear, surgical repair is indicated. If the tear is small, part or all of the surgery can be performed arthroscopically, or frequently, a "mini-repair" is performed. This means that some of the surgery involving removal of bone is performed arthroscopically and a small incision is made to repair the rotator cuff. If the rotator cuff tear is large, some surgeons will choose an open - without arthroscopy - technique for performing the operation. Early results comparing these different techniques suggest a similar end result but probably less initial pain when more of the procedure is performed arthroscopically.
AN OUNCE OF PREVENTION
Prevention of shoulder injuries should be an important part of your overall health maintenance regimen. Warm-up range of motion exercises and rotator cuff strengthening exercises can be extremely helpful in keeping you fit and ready for action.
Exercising your body AND exercising common sense by avoiding overuse trauma to your shoulder will go a long way in keeping you off of the bench and out of the doctor's office.
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