Question

Chronic Pain Treatment

Why is it difficult to treat chronic shoulder and elbow pain?

A Answers (2)

  • AMatthew C. Evans, MD, Sports Medicine, answered on behalf of Intermountain Healthcare

    Chronic shoulder and elbow pain can be difficult to treat because of the nature of the underlying cause. Most commonly, this is caused by a type of tendonosis. Tendonosis is different than tendonitis, which refers to tendon inflammation. When the tendon pain is chronic the inflammation has come and gone and left behind a tendon with areas of degeneration. This does not mean that the tendon is almost falling apart, but that some parts of the tendon have lost their normal collagen architecture and have filled in with areas of abnormal tissue that is similar to scar tissue. These areas are painful and do not respond well to anti-inflammatory medications. Many other treatments are helpful, but there is not one that is always successful. Relative rest is a good place to restart. Physical therapy is often helpful. Stretching, range of motion, and eccentric strengthening are mainstays. Another type of treatment that is helpful goes under trade names like Graston or ASTYM. These are types of deep massage using metal or plastic tools to break up scar tissue and incite inflammation. The theory is that this inflammation may start the body’s own repair process so that the degenerative tendon can be repaired. Some providers use slightly different techniques like ART. 

    Injections are sometimes used to either increase inflammation or add growth factors to injured tendon. Platelet Rich Plasma (PRP) is one of these techniques. In PRP blood is drawn from the patient and then the platelets and growth factors are removed and concentrated for injection into the injured tendon. A few providers are even harvesting a person’s own stem cells from their bone marrow and injecting them. Many patients have good results, but large, quality studies are lacking.

  • ARick Olderman, Physical Therapy, answered
    Shoulder pain can be one of the most difficult problems to fix in the body. Unless a tear or bone spur shows up on an MRI or X-ray, many health care practitioners become stumped with regards to resolving chronic or nagging shoulder and elbow pain. One reason for this is the shoulder's unique anatomy and mechanics, which are unlike any other joint in the body.

    Shoulder and elbow problems usually come in the form of rotator cuff tendonitis, bursitis, impingement problems, tennis elbow, or golfer's elbow -- you name it. I refer to these as structural diagnoses because they describe a specific painful tissue that has been injured. Typically, these diagnoses are followed up with advice to stretch, rest, or ice the involved tissue. While this may calm the irritation, an identical problem will resurface down the road or take the guise of an injury in an adjacent area. While these diagnoses pinpoint the tissues that are most affected, they don't indicate the conditions that lead to the problems in the first place. I liken this to seeing an X-ray of a broken left thumb and appropriately casting it to heal without realizing that the right hand is continually hitting it with a hammer. Until we can make the right hand stop, the left thumb will continue to be reinjured, if it ever really heals at all. Yes, the broken bone is painful, but the right hand continues to deliver more pain and injury, preventing true healing from occurring. I believe something similar is happening that causes these recurring structural issues in the body.

    I interpret the presence of these structural diagnoses as evidence of functional problems. Functional problems are those in which muscles or joints don't move optimally and thereby create stress to the surrounding tissues. In my experience, functional problems lead to structural diagnoses and pain. This may occur due to poor movement patterns, weakness, limited range of motion, old injuries, or all of these factors. I believe the repeated stress from functional problems leads to physical changes in the body such as bursitis, arthritis, rotator cuff tendonitis, or epicondylitis -- in other words, structural diagnoses. Structural diagnoses, once again, don't describe the roots of the pain but instead symptoms the root problems create.
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