Online Health Chat with Eric Ricchetti, MD
March 5, 2014
Shoulder pain is a common condition—whether due to aging, overuse, trauma or a sports injury. Shoulder pain and injuries alone account for nearly 20 percent of visits to the doctor’s office. When the shoulder pain interferes with carrying groceries, participating in your favorite activities or getting a good night’s sleep, it’s time to seek medical advice.
Shoulder pain has many causes. Some of the most common conditions include:
- Arthritis osteoarthritis—This condition is due to the wearing down of cartilage that allows bones to glide smoothly within the joints, and can occur with aging, trauma or overuse injury.
- Rotator cuff injuries—These include tendonitis and rotator cuff tears, and are the most common causes of shoulder pain and activity restriction.
- Bursitis—This is the inflammation of the bursa, and is most often caused by repetitive motions (overuse), or repeatedly bumping or putting pressure on the area.
Effective treatment options are available today that include the use of medications, physical and occupational therapy, and surgery when needed to help stop the pain and help the patient return to an active lifestyle.
About the Speaker
Eric Ricchetti, MD is a board-certified orthopaedic surgeon in the Department of Orthopaedic Surgery in the Orthopaedic and Rheumatology Institute at Cleveland Clinic. Dr. Ricchetti completed his fellowship in shoulder and elbow surgery at Thomas Jefferson University Hospital, the Rothman Institute, in Philadelphia. He also completed a year of dedicated research in the McKay Orthopaedic Research Laboratory at the University of Pennsylvania, and completed his residency and internship at the Hospital of the University of Pennsylvania, in Philadelphia. He received his medical degree from the University of Pennsylvania School of Medicine, in Philadelphia. His undergraduate degree was completed at Yale University, New Haven, CT.
Dr. Ricchetti's interests in shoulder pathology include joint replacement and arthroscopy, rotator cuff tears and other tendon and ligament problems, sports injuries, and trauma. Dr. Ricchetti currently sees patients at Cleveland Clinic main campus.
Let’s Chat About Shoulder Pain Answers
Diagnosis of Shoulder Conditions
petes: My left shoulder pain started suddenly about four months ago. I did not have any obvious injury or motion that I thought would have been the cause. I am using heat and massage now, but cannot raise my arm all the way straight up like the right one will. I am thinking it is a strained muscle/ligament/tendon and will just take time, but what is your opinion, please?
Eric_Ricchetti,_MD: If your function is being limited to the point that it is impacting your daily life, it may be best to have the shoulder evaluated to determine what the problem is and how to best treat it. It may be as simple as some exercises for the shoulder.
nazrijesh: I have had shoulder pain for one month, and I am afraid it is something serious. What do I have to do to analyze what is happening now with my left shoulder? I had a little pain last year especially during the time of seasonal viruses, but the shoulder pain was gone once the virus was gone. For two months now I cannot carry a shoulder bag. I live in a city where there isn’t much fresh air. (The city is near a mountain and the air is dry.)
Eric_Ricchetti,_MD: The best place to start is to have your shoulder evaluated by a shoulder specialist. Examination and x-rays of the shoulder will help determine the problem and the best treatment for it.
CoraLu: I have had pain in both shoulders and upper arms for a year with pain originating in the shoulder blade area and coming on suddenly. It is unrelated to injury. When it began, it was roughly equal on both sides. Over the course of the year, it has become very severe on my left side—to the point that I can't do anything with my left arm. It extends down into my hand and I can barely type. I have to sleep with my arms folded across my chest in a corpse-style or else the pain awakens me. I have seen many doctors. One shoulder and hand specialist said it was a rotator cuff impingement, a torn ligament in my finger, and polymyalgia rheumatica (PMR). I was sent back and forth from doctor to doctor as the pain grows worse. Now, a year later, it's getting more painful on the right side. I am afraid this will wind up crippling me. Nothing helps. I do have osteoarthritis and have had both hips and knees replaced before the age of 50 years old, but this feels like a different kind of pain.
Eric_Ricchetti,_MD: These symptoms sound like they could be a problem in the shoulder, such as a rotator cuff problem or arthritis, or a problem coming from the neck. Neck problems can often cause pain that goes down the entire arm and into the hand. Seeing a shoulder and spine specialist would help to differentiate the problem and further tests—such as an MRI—may help with this.
Ceaper: My pain is more in my deltoid near the shoulder. Are there some exercises I can do to strengthen my surrounding muscles? I can easily do the wide stance version of the perfect push up (rotating handles that stabilize the upper body), but the more I bring my arms in closer to my body the more difficult the push up and the more pain I get doing the push up.
Eric_Ricchetti,_MD: Feeling pain in the deltoid is common when there is a rotator cuff problem. It is a referred pain. The best exercises are those targeting the rotator cuff muscles, deltoid, and shoulder blade muscles. Push-up and press-type exercises are often aggravating to the shoulder.
TJ12345: With a bone spur in right shoulder, I avoid doing a lot of things to keep pain manageable. When my muscles flare up from stress, typing too much, or driving too far, it causes pain and numbness all the way through my arm and hand, and extend up through my neck with headaches. Is this because it is pinching on a nerve or could this be something more? A nerve test did not show any nerve damage. I had a spinal fusion in June 2013. I consulted a doctor for pain relief of my shoulder. Via MRI, the doctor found my spinal stenosis was half of what it should be. I also had a bad C4/C5 disc with bone spurs and signs of arthritis. I am still waiting to get the bone spur shaved, which was original problem. Will this fix my shoulder problem? I have had pain in my neck and shoulders since probably 2003 or so. I went to a chiropractor for years who told me women carry their stress in the neck and shoulders. Until my neurosurgeon told me my desk was too high and caused all of this, I believed that was the problem.
Eric_Ricchetti,_MD: These do sound more like symptoms of a pinched nerve from the neck and not a problem in the shoulder. Your neck surgeon would be able to determine if any of these symptoms could be shoulder related, and whether you would need to see a shoulder specialist.
Marilyn Ann: I have occasional left shoulder pain, when raising or moving that arm. It also occurs after I have gently exercised my legs and arms in the swimming pool. (I'm a Florida wintertime “snowbird” and exercise daily in the pool.) I have no problems in my right shoulder; I am right-handed and conclude that I strengthened that shoulder over the years by carrying pocketbooks and other things on the right side. I am 73 years old and also have osteoarthritis in the knees that was successfully treated with a left knee replacement five years ago at Cleveland Clinic Florida. The pain does go away if I stop the exercises, but I wonder what this is. What should I do or not do? I have not consulted a doctor yet, as the pain does go away. It's never severe, just annoying.
Eric_Ricchetti,_MD: This sounds like it is most commonly pain from the rotator cuff and can be treated with exercises for the shoulder. These can be prescribed by your doctor.
Spartanjim: Three months ago while driving a golf cart I hit a curb while having a very firm grip on the steering wheel. My deltoid muscle is still sore. Do you have any suggestions for relief?
Eric_Ricchetti,_MD: That typically is a sign of rotator cuff pain. If it is bothersome enough, you may need some more directed treatment at this point, such as physical therapy. Your doctor can evaluate you for this.
JonCas: I have right shoulder pain radiating up from my neck, limited movement, swollen soft tissue around the clavicle bone, experience dizziness regardless of position, and have had left frontal headaches daily for the past two weeks. I am on Coumadin® (warfarin) and cannot take over-the-counter pain medications.
Eric_Ricchetti,_MD: This does not sound like an isolated shoulder problem and could be a problem in the neck or head. It can be evaluated by your doctor to determine the best course of action.
circusman: When I go to bed my right shoulder does not bother me. About halfway through the night I wake up to sharp pain in my right back shoulder. I fall back to sleep, and wake up with the pain. I fall back to a restless sleep again until morning when I wake up and get up with the shoulder pain subsiding after I move around for awhile. Tylenol® (acetaminophen) doesn't help and this has been a problem for the past month. I do not notice the pain during the day, but only after I have been asleep awhile (on my side—never on back or stomach) and about halfway through the night. Would physical therapy exercises be helpful? I already take a variety of heart medications. I had a coronary stent placement in 2011.
Eric_Ricchetti,_MD: Physical therapy may be helpful and may be enough to address the problem. It would be good to be seen by a shoulder specialist to evaluate the shoulder and figure out what the problem is.
Dufresne: Is it better not to sleep on one's side if there has been some type of shoulder injury? I have pain at times when I sleep on my side with my arm outstretched. Also, would a "gel-type" mattress be better than a "normal" mattress?
Eric_Ricchetti,_MD: It can be irritating to sleep on the same side of an injury and may be better to sleep in another position until it is improved. A different mattress may help.
NOGRITS: I have pain in my right shoulder (it seems like muscle). My motion is limited and sometimes it is worse to the point I have to put my right arm in a sleeve first because I can't use that arm. Also, feels like sometime I have a frozen joint. Are there specific exercises to correct this?
Eric_Ricchetti,_MD: This could be a rotator cuff problem, but could also be a problem called a “frozen shoulder,” where the entire shoulder joint stiffens up. Both problems will respond to exercises, but the type of exercises to use are different. Being evaluated by a shoulder specialist would help to differentiate which problem you have.
turt21: I have pulmonary sarcoid with bone involvement. I have been told I have "frozen shoulder." The X-ray does not show any sarcoid. I get injections of cortisone into the shoulder, which does provide some relief. How often can I get these injections? Does the fact I have been on prednisone for 23 years and get injections at other sites have a bearing on this? I should also mention I am a pre-lung transplant patient.
Eric_Ricchetti,_MD: A frozen shoulder is best treated by stretching out the shoulder with exercises, as well as cortisone injections. The injections are limited to every three to four months at most. This problem will usually completely resolve by using both of these treatments. Injections without the stretching routine may not be enough. The steroids elsewhere typically do not impact the frequency they can be done in the shoulder.
Jsweetie: I have been evaluated by an orthopedic doctor as having “frozen shoulder.” I'm in physical therapy, but when the therapist manipulates my arm sometimes the pain is severe. Do you have to suffer such severe pain to get better?
Eric_Ricchetti,_MD: The best exercises for a frozen shoulder are typically frequent stretching exercises. If you stretch regularly—two to three times per day—you will not have to push to this point of severe pain. You will be able to better tolerate the exercises. A steroid injection can also be very helpful for a frozen shoulder.
Association of the Shoulder with Back and Neck Pain
pilatesgirl: How do the shoulders effect neck pain and health?
Eric_Ricchetti,_MD: Shoulder pain or injuries in the shoulder can potentially create muscle pain and strain in the nearby muscles, the muscles of the shoulder blade, and the muscles of the neck. If the primary problem is in the shoulder, this will typically correct the problem in the adjacent areas.
aFarrell: What is the likeliness that shoulder pain is associated with stress and tension in back muscles?
Eric_Ricchetti,_MD: It can be this or vice versa. Pain directly in the shoulder can impact the back or pain in the back and neck can impact the shoulder.
pilatesgirl: Can you describe the names of the rotator cuff muscles, and how we differentiate which is injured?
Eric_Ricchetti,_MD: There are four rotator cuff muscles: supraspinatus, infraspinatus, subscapularis, and teres minor. Degeneration can occur in the tendon attachment of any of these muscles along where they attach on the ball of the shoulder, but this is most common for the muscle on top—the supraspinatus. This is where rotator cuff tears most commonly start.
Treatment for Rotator Cuff Injury
geewhiz82: What is the treatment for a rotator cuff injury? How long does it take for the injury to heal? Is there any long-term damage to the shoulder area?
Eric_Ricchetti,_MD: It depends on the injury. A rotator cuff injury that is not a tear is most commonly treated with rehabilitation and may not cause any long-term problem. A rotator cuff tear may require surgery and can lead to problems over time.
jc7: Has there been any progress towards a rotator cuff surgery that doesn’t require such a long, painful recovery time?
Eric_Ricchetti,_MD: There are newer and better ways to help with the immediate surgical pain after surgery, but the process of healing that occurs over many months is still the same. We have not yet figured out a way to make a tendon heal faster.
Treatment for Type II SLAP Tear
Barney4121: After an acute shoulder injury resulting in a type II SLAP (superior glenoid labrum lesions) tear, is there a best timeframe to seek medical intervention that can determine a positive outcome?
Eric_Ricchetti,_MD: There is no definitive evidence regarding timing for that injury. It is commonly treated without surgery initially. Surgery is then performed if people fail nonoperative treatment. This delay in surgical treatment has not been shown to cause a negative impact.
NSAIDs (Nonsteroidal Anti-inflammatory Drugs) and Corticosteroid Injections
Sigbien: What over-the-counter products would you recommend to help with shoulder pain?
Eric_Ricchetti,_MD: Non-steroidal anti-inflammatory drugs (NSAIDs), like Motrin® (ibuprofen) or Aleve® (naproxen). Topical analgesics, such as capsaicin, may also help.
meme9: I have osteoarthritis in left shoulder. My doctor suggested stretching exercises to help relieve the pain. Are there any other suggestions?
Eric_Ricchetti,_MD: Oral nonsteroidal anti-inflammatory drugs (NSAIDs), like Motrin® (ibuprofen) and Aleve® (naproxen) and cortisone injections can be very helpful.
5jake925: Other than surgery, what are the treatment options when there is a bone-on-bone problem in both shoulders? I am especially concerned about surgery due to my age. (I am 82 years old.) What are the risks of doing nothing until the situation forces some choices?
Eric_Ricchetti,_MD: The most commonly nonoperative treatments are oral anti-inflammatory drugs (NSAIDs), like Motrin® (ibuprofen), Aleve® (naproxen), etc., and steroid injections. Both can be helpful and offer pain relief. Occasionally, a lubricant-type injection can be given in the shoulder if cortisone does not work. If nothing is done, the most common risk is a gradual increase in pain that can occur as the arthritis slowly worsens.
ejoannie: I have twice suffered a rotator cuff injury as well as a ruptured biceps muscle. I received physical therapy and was fairly good. I was told that my biceps muscle could not be repaired. In December, I injured my shoulder again by pulling on the cord of my mulching mower. I have had foot surgery and would not be able to do physical therapy until a few months from now. Is there anything that can be done now? I can barely raise my arm to comb my hair.
Eric_Ricchetti,_MD: A cortisone injection can be very helpful to relieve pain and inflammation if you are unable to do any exercises at this time.
harbour18: I am 65 years old. I am active and work through chronic pain due to osteoarthritis and fibromyalgia. I also have some lupus markers, with a diagnosis firm of discoid. However, it is not yet systemic lupus erythematosus. Examination of my chronic right shoulder pain showed, "a tear, fluid, and inflammation". Physiotherapy, exercise, and QiGong all have shown little—if any— benefit. My mobility is so restricted now that I use an extender when I go to the bathroom as my arm cannot reach back. Pain wakes me and interferes with my basic daily functions. What are some alternatives to surgery, please?
Eric_Ricchetti,_MD: The one other common treatment to consider is a steroid injection. These can be very helpful to relieve pain and inflammation and improve function.
sareptatj: I am an 84-year-old female with severe pain in my right shoulder following a bad fall many years ago. I did not have an x-ray until four years ago. I was told by an orthopedic specialist at that time that the joint was simply completely destroyed and steroid injections wouldn't help. The only possibility is complete shoulder replacement, which is not an option for me because of heart disease. Also, I cannot take NSAIDs (nonsteroidal anti-inflammatory drugs) because of heart risks, so I am taking hydrocodone. Can you offer any suggestions for options? Is it possible that glucosamine and chondroitin supplements could help? You speak of a lubricant type injection—what is it called? What type of specialist would I consult to find out about it?
Eric_Ricchetti,_MD: The supplements may help. Even for bad arthritis, steroid injections can be helpful. I think these are worth trying if surgery is not an option. The viscosupplementation injections are considered as the next option if the steroid injections do not work.
brayden14: I have severe shoulder pain caused by "bone-on-bone " arthritis. I have had three steroid shots and physical therapy with short-term relief. Other than shoulder replacement, is there any other option ( i.e., a lubricant similar to what they do for the knee)?
Eric_Ricchetti,_MD: There is a lubricant similar to the knee that can be tried. This is not commonly done in the shoulder because the results have not been shown to be any better than steroid injections for the shoulder. It can be worth trying in someone who cannot or will not consider shoulder replacement surgery.
brayden14: What is the lubricant-type injection called? What type of doctor performs this injection?
Eric_Ricchetti,_MD: The lubricant is called viscosupplementation. For shoulders it should be performed by an orthopaedic shoulder specialist.
BETHELMOM: My mother is 88 years old and has rotator cuff injuries in her right shoulder. According to her doctor, she is not a candidate for surgery. She is in extreme pain. They try to alleviate the pain with cortisone and steroid shots, which of course they have to limit the amount of shots. Also, the shots sometimes work and sometimes they do not. Is there anything else that can be done/used for her constant pain? She is not a candidate for surgery, and we need to know other specific options, such as medications.
Eric_Ricchetti,_MD: I would consider viscosupplementation injections as the next step. They do not always help anymore than cortisone injections, but in some people they provide better relief that is more long lasting. This is an option in someone that is not a surgical candidate.
Surgical Procedures for the Shoulder
jenna1014: I am a 35-year-old female with recurrent left shoulder instability due to a fall. I have had one failed arthroscopic repair and one failed open Latarjet due to reabsorption. I have greater than 40 percent glenoid bone loss, but I am otherwise active and healthy. I don't have any pre-existing joint or bone conditions. I have one surgical opinion to use an iliac crest autograft and one opinion to use a distal tibia allograft. What other options are there? What is the “right” answer? Does this require a special surgeon? If so, who and where? My shoulder is extremely unstable, painful, and unpredictable. My function is severely limited. My end goals are decreased pain, increased functionality, and improved quality of life.
Eric_Ricchetti,_MD: The two options you have been given at this point are the most common. Both have been shown to work—without a clear difference between the two. The choice to use one or the other is often surgeon preference. This is not a routine surgery, so it should be done by a shoulder specialist that has experience with the procedure.
canuck: What are the surgical options for a 29-year-old active female with mild diffuse humeral head chondrosis with high pain levels after a full capsular release, debridement, and biceps tenotomy? I have had a history of Latarjet for recurrent dislocations that caused severe axillary nerve palsy, but I have since recovered after two and one half years. I have one remaining screw that is 2 cm too long posteriorly irritating the suprascapular nerve, and the screw head is embedded in the bone near the brachial plexus. Aside from attempting screw removal, can anything be done for the degenerative changes at 29 years old?
Eric_Ricchetti,_MD: This is a complex problem that is best evaluated by a shoulder surgeon with experience in revision surgery. Your x-rays and other imaging studies would be evaluated and your shoulder examined to determine what the best surgical option is. Other options are potentially available.
Delayne: I have chronic pain in my shoulder due to arthritis in my acromioclavicular joint and damage to the biceps tendon that radiates pain to the biceps muscle. Injections have not helped. What might help reduce my pain?
Eric_Ricchetti,_MD: There can be surgical options to treat both of these problems that can be performed arthroscopically or in a minimally invasive procedure. A shoulder specialist can determine if you would be a good surgical candidate.
Delayne: I've been told that recovery from shoulder surgery is very difficult. Is it any easier if it is done arthroscopically or in a minimally invasive procedure?
Eric_Ricchetti,_MD: Typically, arthroscopic and minimally invasive mean the same thing.
Barney4121: What are the advantages and disadvantages between a bicep tenodesis and a bicep tenotomy?
Eric_Ricchetti,_MD: There is no clear evidence to say one is better than the other. Both are done successfully. The concern with a biceps tenotomy is it can shorten the biceps muscle more and create bothersome muscle cramping in some patients. The risk of muscle cramping is potentially increased in more active people that have to do a lot of repetitive lifting. Biceps tenodesis would decrease this risk.
Graeters: In 2011, I was told I will need a complete shoulder replacement. Is it possible to wait too long to have this procedure done – so long that a replacement would not be able to be done at all?
Eric_Ricchetti,_MD: Occasionally that can happen if the arthritis was to wear away enough bone that it would not be possible to securely hold the parts of the replacement. However, this is not common. Additionally, with more severe arthritis, the functional improvement after a shoulder replacement may not be as great.
Side Effects of Surgery
canuck: Is it becoming more common to see patients who have had tenodesis or tenotomy that have recurrent pain after surgery? What is the solution for these patients? Is there a certain surgical technique or surgical omission that leads to continued pain and dysfunction? Which has better outcomes, interference screw, endobutton, or soft tissue? Which the worst? Does reattaching in the groove result in recurrent pain?
Eric_Ricchetti,_MD: There is not a clear reason why people have pain after these procedures. It is not common, and it can be difficult to determine what the problem is. Sometimes it can be a sign that another problem is also present—not just the biceps—and also needs to be treated. There is no evidence that one type of screw or fixation is better for a biceps tenodesis. They all work well.
pilatesgirl: What are the best exercises to keep shoulders healthy? How does your posture influence shoulder health?
Eric_Ricchetti,_MD: You should do exercises that maintain strength and coordination of the rotator cuff, deltoid, and shoulder blade muscles. Poor posturing can created muscle strain and pain all along the neck and shoulder blade. This can also potentially impact the normal coordination of these muscles.
writer53: Does a tight, achy shoulder from a repetitive-use injury ever actually resolve or is this a chronic condition for life?
Eric_Ricchetti,_MD: It can resolve—it may just require a more directed treatment at this point. Therapy exercises directed at the shoulder—with or without cortisone injection—can be all that is needed.
aFarrell: I'm also curious to know the best exercises and stretching. I have a lot of tension in my neck and shoulder, and find it difficult to exercise without increasing pain. I also notice that increased stress levels generate isolated pain in my shoulders. What are good stretching exercises for my shoulders, neck, and shoulder blade region?
Eric_Ricchetti,_MD: It may be best to get a formal exercise program from a physical therapist that can target your problem areas. This can be prescribed by your doctor.
morning glory: I am a 71-year-old female and have been diagnosed with two rotator cuff tears. I was advised that small tears are common in my age group. With rest and guarding use of the arm, it should heal itself in eight to 18 months. I am supposed to keep my arm close to my body and not use it above my head, which is near impossible. I do well, but if I forget, I have renewed pain for days. Do you have any advice? Does this seem normal? Will this heal itself?
Eric_Ricchetti,_MD: Other treatments can help besides rest and avoidance. Most commonly this involves learning a set of exercises for the shoulder. Another option is cortisone injection.
surjitbisht: I cannot sleep sideways on my shoulder. If I do, I feel pain in my shoulder within five to 10 minutes in that position.
Eric_Ricchetti,_MD: You can try different sleep positions, but you may need the shoulder evaluated by your doctor to see if other treatments may be helpful, such as physical therapy.
Dina2345: Where can I find videos of exercises that my doctor has prescribed? There are many on YouTube, but I don't know how to evaluate their accuracy.
Eric_Ricchetti,_MD: We are in the process of developing a site for this on our webpage. Your doctor may have another reliable website for exercises.
Exercising and Shoulder Health
thelmonk11: I am 69 years old, and have been lifting weights for about 20 years. I don't lift heavy stuff, but from time to time I have messed up my shoulders. I have not sought medical attention and time has taken care of the problem in the past. I had a problem since last fall with my left shoulder due to lifting and have a couple of questions.
- What causes the pain in the shoulder when you sleep on it? During the day there is no pain.
- What is the best course when a person thinks the shoulder has come along and wants to resume lifting? Is it better to continue with resting it or can you begin using light weights? If a person does resume lifting what if the best way to start increasing the weight?
- With all the wear and tear over the years would it be better to say, “adios” to the weights and take up checkers?
Eric_Ricchetti,_MD: 1) Most commonly, it would be a problem in your rotator cuff or shoulder arthritis. 2) Resuming lifting can be helpful if it is kept at light weights. Heavy weight-lifting will likely re-aggravate the problem. 3) If you are still lifting heavy weights, it is better to stop. Light weights can be helpful and a good way to maintain strength and function.
morning glory: I just started practicing Qigong. Is this safe to do with a torn ligament? I want to keep my shoulder moving and fear a recurrence of frozen shoulder, which I dealt with in 1996. I had to wait for it to heal on my doctor’s recommendation.
Eric_Ricchetti,_MD: It should be safe and will probably help maintain good shoulder motion to avoid a recurrence of your frozen shoulder.
Moderator: I am sorry to say that we are at the end of our chat. We appreciate your participation and hope you will join us for other chat topics in the future. Thank you Dr. Ricchetti for sharing your expertise and answering questions today.
Eric_Ricchetti,_MD: Thank you for your questions today. I hope the responses were helpful.
To make an appointment with Dr. Ricchetti or any of the other specialists in our Department of Orthopaedic Surgery at Cleveland Clinic, please call 866.275.7496. You can also visit us online at clevelandclinic.org/ortho.
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