An Interesting Study on Shoulder Pain

For this week’s blog I thought I’d address a research paper published in the American Journal of Roentgenology.  I have found that I frequently reference this study in my day to day practise so it’s probably time that I mention it in our clinic blog.

Shoulder Pain Study

A 2011 study published in the American Journal of Roentgenology examined 51 patients who did not have shoulder pain.  The authors of the paper were using diagnostic ultrasound of the shoulder to see how many “normal” asymptomatic patients had significant findings on their ultrasounds.  A very interesting endeavour!

The authors of the study examined 51 men between the ages of 40-70.  The mean age of the subjects was 56 years old.  None of the subjects had shoulder pain and the side of the ultrasound was random (25 right shoulders and 26 left shoulders).  Interestingly, the results showed that 96% of the study participants had abnormalities in their shoulders.  The specific breakdown is as follows…

  • Bursal Thickening – 78%
  • A-C Joint Arthritis – 65%
  • Supraspinatus Tendinosis / Tendinopathy – 39%
  • Subscapularis Tendinosis – 25%
  • Partial Thickness Tear of the Supraspinatus (Bursal Side) – 22%
  • Posterior Glenoid Labrum Abnormality – 14%

Keep in mind that this is only one study and future research might contradict these findings.  At the same time, this study seemed well designed and there were a reasonable number of subjects. I’ve heard different opinions regarding the significance of the results.  For example, I’ve heard that the results of this study should remind us to take imaging reports with a grain of salt and not put too much weight on ultrasound findings.  Perhaps this is a matter of opinion but for the most part, I agree.  I was always taught in radiology class to treat the patient and not the image.  It’s an understood fact that many people walk around with degenerative arthritis in joints (visible on x-ray) yet they have no pain.  There are also people with significant arthritic pain yet their imaging looks relatively fine. Perhaps a fair way to illustrate this is to think about a patient with absolutely no symptoms, no dysfunction in day to day life but has a large rotator cuff tear visible on ultrasound as was found in the study.  It probably wouldn’t make sense to undergo a treatment that carries substantial risk (like surgery). What is to be gained? When no pain or dysfunction is present, conservative treatment like a careful home strengthening program would probably make more sense.

Let’s face it…we change with age.  An increased rate of shoulder injury with age (like tears in the rotator cuff) has been found in many studies (2,3,4). Like the tread on the tires of our car, certain things wear down over time as we use them.  We accept that our hair will turn grey, our skin will wrinkle and even that our joints wear down.  Why not accept the reality that the tissues in our shoulder seem susceptible to structural change over time?  Not all injuries are caused by older age but many are influenced by it.  From my clinical experience and the results of this study, I think the shoulder is a good example.

Resistance Training

Resistance training is often linked to the injuries seen in this study.  I want to be clear that I’m not suggesting we stop resistance training as we age. I’m suggesting that we should all exercise wisely, modifying our programs and routines as we age so that we’re acknowledging the natural changes that occur in our body over time.  Resistance training is an important aspect of good health throughout life.  If your goal is to see how much weight you can press over your head, go ahead and do that. If you’re in your early twenties there’s a good chance you’ll be able to do this without injuring yourself or feeling pain.  On the other hand, if you’re in your fifties or sixties and you’re doing maximum overhead press exercises on a regular basis, it wouldn’t be shocking if you experience shoulder pain (and injury) at some point.  Although shoulder injury is often related to variables like poor scapular control, strength imbalances in the shoulder and poor exercise technique, I think it’s fair to say that some tissues are subject to wear and tear over time and will have a reduced tolerance to certain demands that are different from when we were younger.

If you disagree, perhaps this exaggeration will help illustrate the idea…

Would you recommend that a person in their nineties go to the gym on a regular basis and do their maximal overhead press?  Why not?  Is it because you believe their tissues “aren’t what they used to be” and they would likely get injured?  So at what age do we start to re-examine our exercise selection and tailor a program that caters to a normal level of age-related degenerative change?  Perhaps around the age of forty we should re-evaluate the goals of our fitness programs and whether the risk of injury related to those goals has changed over time.  Maybe it has, maybe it hasn’t.

If you are in need of Shoulder Physical Therapy? Contact Burlington Sports Therapy in you live in Burlington, Ontario, or in nearby locations like Oakville or Hamilton.

References

  1. Girish G, Lobo L, Jacobson JA et al. Ultrasound of the shoulder: asymptomatic findings in men. AJR 2011; 197: W713-W719.
  2. Oschman Z, Janse van Rensburg C et al. Ultrasound study of the asymptomatic shoulder in patients with a confirmed rotator cuff tear in the opposite shoulder. South African Journal of Sports Medicine 2007; 19:23-28.
  3. Worland RL, Lee D, Orozco CG et al. Correlation of age, acromial morphology and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients. J South Orthop Assoc 2003; 12: 23-26.
  4. Fialka C, Krestan CR et al. Visualization of intraarticular structures of the acromioclavicular joint in an ex vivo model using a dedicated MRI protocol. AJR 2005; 185:1126-1131.

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