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Common Misunderstandings around the Shoulder Joint

Arthritis

Many patients will be sent by their GPs for an X-ray of their shoulder when they first present. In most cases the X-ray will be normal because arthritis as a cause of shoulder pain is relatively unusual. However the x-ray report will often mention that there is degenerative change or early arthritis in the acromioclavicular joint. This is not the shoulder joint. This is the “joint” where the collar bone (clavicle) and the shoulder blade (acromion) meet. Many patients present to their specialist telling the surgeon that they have arthritis.

Frozen Shoulder

Mr Codman in his book on shoulder problems written in the 1950’s coined the phrase “frozen shoulder”. He listed the typical symptoms that included pretty much every symptom ever experienced in the shoulder. As a result the diagnosis of Frozen shoulder is often used as a generic for “shoulder” problem. Most patients that are told that they have a frozen shoulder do not actually have what is more correctly called Adhesive Capsulitis.

Steroid Injections

Many patients come with the fear that steroid injections are bad for you. It is true that to inject your Achilles tendon when you have tendonitis can increase your risk of rupturing the tendon. Similarly injecting a young professional sportsman’s joint to relieve his pain and get him back on the sportsfield without a diagnosis could do irreparable damage to his joint.

It is also true that patients that suffer from conditions such as asthma or ulcerative colitis or similar that require long term daily systemic steroid tablets do develop complications.

However the injections given around the shoulder are very useful as diagnostic tests since if the local anaesthetic that is injected at the same time, relieves the patients pain then this helps to confirm the location of the problem. In addition the dosage and frequency of the injections is far below the kinds of exposure that patients on long term steroids receive.

The other misunderstanding is that many patients feel that these injections are painful. The reason that most injections are painful is because a small volume of fluid is inserted into tissue that has to be stretched in order to accommodate this new volume. This stretching is not dissimilar to stretching your skin or somebody standing on your leg. Uncomfortable to very painful.

However the shoulder injections are given in one of 3 places. The 1st is into the shoulder joint. The 2nd is into the bursa beneath the acromion and the 3rd is into the ACJ. With the exception of the later these spaces all readily accommodate additional fluid without discomfort. The ACJ is a much smaller space and a little more difficult to enter, especially when it has new bone formation around it. (Degenerative change) However in all these injections careful technique should mean that the experience is nothing more than mild discomfort. Nothing like going to the dentist!!!