“Hey Doc, what does it mean when my shoulder hurts on the front, and wakes me up at night? Or when I reach my arm overhead?”
This is a question that shoulder specialists hear on a daily basis, and is asked by both patients in the clinic, as well as by random interactions in hallways at work and social gatherings with family and friends. As a young surgeon, I used to quickly look for a structural problem that could only be corrected by surgery. I have learned that many shoulder conditions are best managed by avoiding surgery.
To answer this question for our patients, we need a construct to help structure an appropriate history and physical examination. This construct has been provided to us by Matsen, Sidles, Lippitt, and Harryman in their 1994 publication: “Practical Evaluation and Management of the Shoulder”. These University of Washington innovators crafted a framework that could be called the
4 Pillars of Normal Shoulder Function.
with the 4 pillars related to shoulder
stability, strength, smoothness, stiffness
Many shoulder problems lead to pain on the side and the front of the shoulder. Many will wake you up at night. And most will be caused by a problem that falls into one particular “S”. Although overlap is possible, by trying to identify which “S” is the issue, we can develop the most appropriate treatment plan to help restore both comfort and function to the shoulder.
For example, one of the more common problems that I see is a condition that many people call “impingement” of the shoulder. It often presents with a loss of normal internal rotation of the joint (stiffness) – thus the essential element of treatment is geared at restoration of proper mobility. When this return of normal motion occurs, the symptoms usually resolve.
I encourage you to consider this approach to your evaluation of shoulder pain. Determine if the problem is a problem related to stiffness, to strength, to smoothness, or to stability. Patients will often tell you what the problem is, and your exam can be focused to confirm your suspicion. Develop a treatment plan oriented at repairing a breakdown in the faulty pillar. Sometimes that means surgery. But often the knife can be avoided.
My next few posts will provide a cursory overview of each of these pillars, what they mean, how things can break down, and what we as Shoulder Specialists can do to help. Additionally, patients might find helpful information about why their shoulder doesn’t work.
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