calcific tendonitis

Why is calcific tendonitis so painful?

Like the majority of shoulder-related injuries and conditions, one of the main symptoms of calcific tendonitis is severe pain. Occurring when calcium builds up around the muscle or tendon, the condition can be excruciating to deal with.

Now, new research has potentially highlighted the cause of pain in calcific tendonitis. The researchers are hopeful the results of the study could lead to the development of new ways to treat the pain caused by the condition.

What is calcific tendonitis?

Calcific tendonitis is a painful condition that occurs when calcium deposits build up around the tendon. As they accumulate, the tissues located around the deposits can start to become inflamed. This is what then causes the severe pain associated with the condition.

Previously, the exact cause of calcific tendonitis is unknown, although it isn’t thought to be linked to osteoporosis, diet or injury. As the calcium deposits build up, they also cause pressure which decreases the space between the rotator cuff and the acromion. This then leads to impingement.

There are actually two different types of calcium tendonitis, referred to as reactive calcification and degenerative calcification. The condition mostly affects patients over the age of 40. While it can occur in several parts of the body, it most commonly presents within the shoulder.

What did the research reveal?

The recent study, published within the Journal of Bone and Joint Surgery, has potentially identified the cause of the pain experienced by those with the condition. Patients who experience calcific tendonitis have been discovered to have an increase in pain receptor and blood vessel growth.

The fact more blood vessels have been found in patients with the condition, suggests this could be a leading cause of the pain. A total of 30 patients underwent an ultrasound during their arthroscopic surgery. The images captured showed that compared to patients who had simple rotator cuff tears without signs of calcification, there was increased nerve growth and increased blood vessel growth.

Those who were found to suffer from calcific tendonitis, found it difficult to sleep because of the pain. The findings of this study were similar to those which were carried out on patients with frozen shoulder.

What treatment options are available?

Patients who are suffering from calcific tendonitis, are usually treated with a combination of physical therapy and medication. Anti-inflammatory drugs can help to reduce the swelling and therefore decrease some of the pain. Corticosteroid injections can also be provided to reduce swelling and pain.

If medication and physical therapy don’t work, there are other treatment options available. These include several types of shockwave therapy, therapeutic ultrasound and surgery. It’s important that patients understand their options, along with the risks and complications of each procedure before deciding whether or not to undergo the treatment.

Patients who suspect they may be suffering from calcific tendonitis should book a consultation with a shoulder specialist. The specialist will be able to diagnose the issue and address its severity before deciding upon the appropriate course of treatment. While the condition can be extremely painful, there are treatments available to reduce the pain until the deposits can be eliminated.

If you’re concerned you’re suffering from this shoulder condition, call 0203 195 2442 to arrange your appointment with the London Shoulder Specialists.

frozen shoulder

Could a pregnancy hormone melt away frozen shoulder?

A new study has suggested that a hormone which is commonly created during pregnancy, could be the key to treating frozen shoulder.

Frozen shoulder is a very common condition. It affects over nine million people in the US and one million people in the UK. Causing severe, sudden shoulder pain and a feeling that the arm is locked into place, it can be a debilitating condition which has so far proved very tough to treat.

The findings of the latest study carried out by a scientist from Boston University, and his research team at The Grinstaff Group, could provide a much easier treatment process. Here, we’ll look at what the study found and whether a pregnancy hormone really could be the key to melting away frozen shoulder.

How was the research conducted?

The research was inspired by Edward Rodriguez, an orthopaedic surgeon from the Beth Israel Deaconess Medical Centre. He discovered some of his female patients experienced relief from frozen shoulder when they were pregnant. He wanted to establish whether biochemical changes that occurred during pregnancy could help treat frozen shoulder.

The research team began by reading everything they could relating to pregnancy hormones. They discovered a hormone known as Relaxin, which helps to stretch the tissues and ensure they aren’t too rigid. Interestingly, both men and women create the Relaxin hormone, but pregnant women produce more of it to prepare the body for birth.

To test whether the hormone was indeed responsible for melting away frozen shoulder, the team injected it into rats that had stiff shoulder joints. They injected the Relaxin hormone directly into the shoulder joint.

What were the findings?

The team discovered that by injecting the hormone directly into the shoulder joint of rats, it managed to restore full range of motion.

It is a particularly exciting discovery given that the hormone is naturally present in the body. It poses hope for a cure for frozen shoulder. Further research will need to be carried out to determine whether the hormone has the same effect on humans. However, researchers are hopeful they have found a potential cure.

How is frozen shoulder currently treated?

At the moment, there are several forms of treatment patients can undergo to treat frozen shoulder. Physical therapy, medications, ice packs and surgery are the most common treatments prescribed to patients.

Surgery is used as a last resort when other approaches have failed to provide relief. Physiotherapy is also used after surgery to regain motion and strengthen the shoulder. There are risks which come from any surgical procedure, so these do need to be discussed with the surgeon beforehand.

Frozen shoulder largely affects those over the age of 50. It can vary significantly in severity and can prove to be debilitating, affecting sleep and the ability to carry out daily activities. While there are effective treatments available, the condition currently has a painful and often long recovery time. So, this new research provides hope for a cure which could speed up healing and significantly reduce the pain of the condition.

shoulder sport injuries

Mountain bikers most susceptible to shoulder sport injuries

The largest medical study into mountain biking has revealed bikers are most susceptible to shoulder and collarbone injuries. Carried out by researchers from the Edinburgh Napier University and funded by the Enduro World Series, the three-year study was carried out to determine rider health and injuries.

Here, we’ll look at how the study was carried out and what it revealed about the risks of shoulder sport injuries.

What did the study involve?

The researchers looked at injury information from more than 2000 athletes who took part in 10 different Enduro World Series events from 2017 to 2018. The injury rate was just 8.9%, which is a fairly low rate compared to figures from the RIO Olympic Games 2016 and of those seen in other sports such as rugby.

They also looked at a different study, which covered a wider participation base. They looked into another almost 2000 riders who came from 60 different countries. These varied from recreational riders, to amateur riders and those who competed in Enduro World Series races. This gave the researchers a much broader look into injury occurrence at all ability levels.

Which sport injuries were found to be most prevalent?

Although the injury incidence rate was fairly low, there were some sport injuries found to be more common than others. It was revealed that shoulder and collarbone injuries were the most common in riders, particularly during Enduro World Series races.

It was discovered that 71% of injuries bikers suffered, were caused due to coming into contact with the ground. Other causes included recurrence injuries and overuse injuries. The most common type of injury included lacerations, bruising and fractures.

Interestingly, the study revealed that concussion rates were low. It was estimated that a rider would need to compete in approximately 263 professional biking events to suffer just one concussion. It also showed that women were more likely than men to suffer a concussion. This is something which could benefit from further research.

In response to the findings, the Ensuro World Series has released informational documents. These include information on how riders can prepare for the challenges of events, along with key information for event staff. They are also working on providing more education regarding concussions and giving medical event staff more in-depth training.

The importance of building up shoulder strength

The findings of this latest study show the importance of building up shoulder strength in bikers. Although it can’t prevent damage caused by direct trauma to the joint, developing upper body strength is essential to keep you in control and for effective bike handling which will stop you crashing even when fatigue sets in.

Shoulder sport injuries can be particularly difficult to recover from. They typically feature a long recovery time and can cause a lot of pain and suffering to the biker. By building up the strength in the shoulder, it could help bikers avoid these potentially nasty injuries.

If a shoulder or collarbone injury does occur, seeking treatment quickly is crucial. The earlier the injury is treated, the less chance there is it could worsen. Seeking early treatment also means less invasive methods may be used to correct the problem.

shoulder tendinosis

Shoulder tendonitis or shoulder tendinosis?

If you’ve been suffering from a burning, painful sensation in the shoulder, it could be down to a number of conditions. As the shoulder is one of the largest and most mobile joints in the body, it’s prone to injury and may generate the same types of symptoms.

Two of the most confusing causes of burning and pain in the shoulder include Tendonitis and Tendinosis. These conditions are often confused with one another, but they do have their differences. Here, we’ll look at how Tendonitis and Tendinosis differ and the treatment options available.

What is shoulder tendonitis?

Tendonitis is a short-term condition, caused by a direct injury of the tendon. This causes inflammation, pain, warmth, redness and swelling. There are different types of the condition, with the most common affecting the rotator cuff of the shoulder.

Most commonly, it occurs due to overuse of the tendon. It’s especially common in athletes and labourers who frequently use the shoulder. Injuries can range from mild to severe and patients may find they have trouble moving the arm into specific positions.

What is shoulder tendinosis?

Tendinosis presents the same type of symptoms of Tendinitis, although it’s a completely different condition. It’s considered a chronic condition, which means it is either recurring or persistent. It is usually caused by repetitive trauma and unlike Tendinitis, it doesn’t lead to inflammation.

As inflammation isn’t present, you won’t experience symptoms such as warmth or redness in the area. It can occur anywhere in the body, but it is particularly common in the shoulder.

New study provides insight into why shoulder tendinosis occurs

A recent study has provided valuable insight into why Tendinosis may occur. The study carried out by the Philadelphia University and Thomas Jefferson University, discovered how tendon injuries in humans develop and the processes that occur.

The researchers analysed tendon tissue taken from patients, which would typically be discarded after surgery. After seeing the different processes at work, they then began experimenting, manipulating the oxygen levels within the tendon. They also discovered that if they could raise Rac1 production, they could potentially prevent Tendinosis from occurring, helping the cells of the tendon retain their shape.

Understanding how the tendon cells change their shape, allows the researchers to potentially manipulate them. However, further research is required to better understand how the pathways work and how they could be manipulated.

What treatment options are available?

In both Tendonitis and Tendinosis, the first point of treatment is typically rest and physiotherapy. With Tendonitis, ice packs and cortisol injections can also prove useful to treat the inflammation. However, these treatments aren’t useful with Tendinosis.

In mild cases of Tendinosis, physical therapy and rest are the best treatment options. However, if the injury is more severe, surgery may be required. This does mean the recovery period will be quite lengthy.

If you’re concerned you may be suffering from Tendonitis or Tendinosis of the shoulder, it’s important to seek an accurate diagnosis. From there, you’ll be provided with a suitable treatment plan based upon the type and severity of the condition.

shoulder wear and tear injury

Why is the shoulder so prone to wear and tear injury?

The shoulder joint is one of the most complex and most used joints of the body. Unfortunately, this means it is prone to a lot of different injuries. In order to understand why the shoulder is so prone to injury and wear and tear, it’s important to understand its structure.

Here, you’ll discover more about the structure of the shoulder and the different types of injuries that can occur.

Understanding the shoulder’s anatomy

As it’s the largest ball and socket joint in the body, the shoulder has a fairly complex structure. It combines three bones, two joints, elastic cartilage, soft tissues, and numerous muscles and tendons.

The three bones of the shoulder are the scapula, or shoulder blade, the clavicle or collarbone, and the humerus or upper arm bone. The two joints include the acromioclavicular joint, where the shoulder blade meets the collarbone, and the glenohumeral joint where the ball of the upper arm bone slots into the glenoid socket.

All of these unique components of the shoulder can be injured. This makes it easier to see why shoulder injuries and problems are such a common occurrence.

Why is the shoulder prone to wear and tear injury?

Due to its complex structure, the shoulder provides an excellent range of mobility. It’s used far more than you might realise, and this exposes it to daily wear and tear. Those who work within a manual profession, as well as athletes, are even more susceptible to wear and tear.

Daily strain placed onto the shoulder, largely from overhead motions, can lead to wear and tear over time. A wear and tear injury typically occurs when the cartilage lining thins or wears away completely. This then leads to a number of potential injuries and conditions, such as tears and arthritis.

Common shoulder injuries

There are a lot of common shoulder injuries patients may experience due to wear and tear. Labral tears are by far one of the most frequent complaints, typically occurring in the top of the labrum. The tear stretches from the front of the cartilage to the back and it’s commonly referred to as a SLAP tear. It impacts the biceps tendon and the glenoid, affecting their attachment. Understandably, this type of injury can result in extreme pain and if left untreated, the biceps tendon can rupture.

Shoulder instability is another common injury, often caused when the ligaments and muscles are stretched more than they should be. If left untreated, these ligaments could tear, leading to shoulder separation or full dislocation.

These are just a couple of the most common shoulder injuries relating to wear and tear. The key is to seek treatment as soon as you experience any symptoms. When caught early, treatment will usually consist of physical therapy and rest. However, if left to become more severe, surgery may be required which would result in a much longer downtime.

If you’re concerned you may be suffering from a wear and tear injury, book a consultation with a shoulder specialist today.

sports shoulder injury

HIIT workouts increase sports shoulder injury risk according to new study

Did you know HIIT workouts could be increasing your risk of a sports shoulder injury? A new study has revealed that these extreme exercise routines, which have become extremely popular in recent years, have an especially increased risk of both shoulder and knee injuries.

The results of the study, published within the Journal of Sports Medicine and Physical Fitness, revealed these high-intensity workouts do dramatically increase the risk of injury. Here, you’ll discover what the new study found and why patients need to be careful if they are thinking of taking up these intensive workouts.

What did the study reveal?

Researchers from the Rutgers University analysed records from the National Electronic Injury Surveillance System dating back from 2007 to 2016. They discovered over a staggering three million injuries which resulted from the use of exercise equipment and callisthenics such as push-ups and burpees.

The records showed that injuries increased at a gradual rate of around 50,944 per year. The majority of injuries affected white males aged 20 to 39 years old. The study also found that this increase in injury rate also coincided with an increase in workouts which were searched for on Google at the time, including HIIT workouts.

Even athletes who have exceptional levels of fitness have an increased risk of shoulder injury if participating in high-intensity workouts unsupervised.

The importance of carrying out HIIT workouts properly

What this research shows is that those who are looking to enhance their training program with high-intensity workouts should be wary of the increased risk they pose to the shoulders, knees, and ankles. These types of workouts certainly aren’t a ‘one size fits all’ solution.

In order to reduce the risks posed by high-intensity workouts, patients need to make sure they first build up their core muscles. Understanding the proper form will really help to limit the strain placed upon the joints, significantly reducing the risks. Experts particularly recommend patients partake in neuromuscular training, along with pre-strengthening programs to enhance their flexibility.

What types of shoulder injuries can occur?

If patients do attempt high-intensity workouts without first building up the core muscles, a number of injuries can occur. In terms of the shoulder, impingement syndrome tends to be the most common injury sustained by those partaking in HIIT workouts. Impingement occurs when there has been repetitive microdamage caused to the rotator cuff. It leads to a sharp pain within the shoulder when carrying out the activity.

Alternatively, if the patient is experiencing pain which reaches from the elbow, the injury could instead be related to tennis elbow. This often occurs due to repetitive gripping of gym equipment, along with poor posture while lifting weights. It tends to occur due to degeneration of the muscle, so regular treatment options may not work if this is found to be the cause.

Overall, high-intensity interval training can have significant health benefits when carried out correctly. However, patients do need to be aware that they can pose an increased risk of a sports shoulder injury. If you suspect you have damaged your shoulder while exercising, contact a shoulder specialist today – call 44 (0) 203 195 2442 to book a consultation.

shoulder steroid injections

Steroid injections and your shoulder

Before undergoing shoulder surgery, many patients are recommended steroid injections in a bid to prevent the need for surgery. While they can prove to be effective at resolving mild injuries, sometimes surgery is required to fix more severe shoulder issues.

Here, we’ll look at why timing is everything when undergoing steroid injections and everything you need to know to lower the risks.

What are shoulder steroid injections?

Steroid injections, or cortisone shots, are given to patients in an attempt to reduce inflammation and minimise pain. They tend to include a local anaesthetic, along with corticosteroid medication.

While they can be very effective, they do pose some risks and complications. Joint infections (1 in 10,000), a temporary flare-up of inflammation and pain within the joint (1:20), and nerve damage (very rare) are all potential side effects of these injections. For this reason, the number of injections patients can have within one year are usually restricted. Additionally, numerous injections are thought to potentially weaken the tendon.

Are steroid injections harmful before shoulder surgery?

There has been a number of negative news stories in the media recently, highlighting the dangers of having steroid injections prior to shoulder surgery. However, it is important patients realise the truth behind the news coverage as it isn’t always 100% accurate.

In light of the case of a patient who went to the doctor complaining of shoulder pain, only to be given steroid injections which made the problem worse, there are a few important factors to point out. The first was the patient received the steroid injection by their GP, not a shoulder specialist. If the patient were to have visited a shoulder specialist, investigations would have been provided to determine the cause of the pain and to establish the best course of treatment.

Shoulder specialists have a lot more extensive training into both diagnosing shoulder injuries and recognising the indications for steroid injections. So, the risks of anything going wrong are dramatically reduced. They are also able to determine the best form of treatment, eliminating unnecessary injections.

If steroid injections are required before surgery, there is a set period of time you should wait before having the surgery once the injection has been administered.

How long should you wait before undergoing shoulder surgery?

In order to reduce the risks, patients are advised to wait at least one month after having a steroid injection, before undergoing surgery. However, this varies dependent on the nature of the surgery. In the case of a shoulder replacement, this would be three months, whilst for arthroscopic procedures, this is usually four weeks but intervention dependent.

A recent study carried out by the Rush University Medical Centre in Chicago, revealed that previous steroid injections do not increase the risks of shoulder surgery provided the injection was administered more than a month beforehand.

If you are concerned about having shoulder surgery after a steroid injection, it’s a good idea to talk to a shoulder specialist. They will be able to help you identify whether a steroid injection is needed, or whether another alternative treatment would be most effective. It is also really important to ensure you’re choosing an experienced specialist when having steroid injections administered.

future of shoulder surgery

The Future of Shoulder Surgery 

Shoulder surgery is usually considered as a last resort for most conditions, though in some circumstances it is unavoidable.  The recovery process after some interventions can be long. However, advancements have been made within the industry to make surgical repairs faster, more accurate and less invasive.

Technological advancements have led to much better surgical options. While the sector has already improved dramatically, it is still undergoing development to boost the future of shoulder surgery. Here, we’ll look at how the sector has already improved and what the future holds in terms of shoulder surgery options.

More technological options available to patients than ever before 

There have already been major developments within shoulder surgery over the past decade. The techniques used have helped to minimise recovery times and provide more accurate repairs.

As well as the surgical methods themselves, other advancements have been made with anaesthesia. While not always suitable, regional anaesthesia can sometimes be used instead of local or general anaesthetic. Often regional anaesthesia is combined with general anaesthesia, as it provides good pain relief following the operation. This results in patients being able to leave the hospital the same day as the surgery. However, regional anaesthesia isn’t appropriate for all patients: it largely depends upon the nature of the injury and the type of surgery required.

More recent developments in the field of shoulder surgery, include virtual simulation. Pre-operative planning tools and software are being developed which help surgeons to look at the patient’s shoulder anatomy in clear detail before planning the best course of treatment. It has proven especially effective at aiding with glenoid placement accuracy in shoulder replacements. This drastically reduces the risks of complications and improves the survival rate of implants.

These are just a couple of advancements that have been made. However, developments still continue, with impressive technology currently being developed to aid in the future of shoulder surgery.

What does the future hold for shoulder surgery?

There are a few advancements being made within the industry, such as huge investment into rotator cuff tear technology.

Stryker have recently completed an acquisition of OrthoSpace, a private Israeli company. This has given them ownership of InSpace, which includes the use of a balloon system in order to disable bone friction, enabling faster recovery and reduced pain.

The InSpace technology is currently being studied in the US, though it has so far been used in more than 30 countries, on a total of 20,000 patients. Now that Stryker has taken control of the technology, it plans to invest $220m to get it fully onto the market.

In the UK, a national trial is underway to assess its effectiveness.

This isn’t the only exciting development currently planned in the shoulder surgery sector. Tendon healing is also being focused on, with specialists looking into developing an advanced biological device. Bone marrow stem cell studies are being carried out in order to see whether a biological device would be feasible.

The future of shoulder surgery is certainly looking promising given the current study and development into shoulder surgery technology. In the meantime, patients experiencing shoulder pain have numerous treatment options available to them. Book a consultation with an experienced shoulder specialist in London today to find out whether surgery is the right option for you.

surgery for rotator cuff injury

When is surgery absolutely essential for rotator cuff injury? 

When it comes to treating shoulder injuries, patients are usually presented with non-surgical options first. This is because surgery on the shoulder can be quite complex; meaning a lengthy recovery time and potential risks and complications. However, in some cases, surgery cannot be avoided.

Rotator cuff injuries can be particularly tricky to repair. Therefore, depending upon their severity, surgery may be the only treatment option available. Here, we’ll look at when surgery is normally recommended for rotator cuff injuries.

Understanding the severity of the injury

One of the major factors which determine whether shoulder surgery is required for rotator cuff injuries is the severity of the injury itself. If the patient is suffering from a partial tear or a small full thickness tear, this may be monitored and treated non-surgically, through physiotherapy or non-invasive treatment options. The age of the patient is a factor in decision making, as it is known that the natural history of tendon tears is that they progress in size.

If the problem is a full tear, and particularly if the patient is considered to be young, surgery is generally the best treatment option. It is highly unusual for rotator cuff tears to heal themselves. So, the surgeon will always look at the severity of the tear before deciding whether or not surgery is the best way forward.

Extreme pain and loss of motion

Another factor to consider is how much pain and loss of motion the patient is experiencing. Pain levels can be hard to monitor in patients, as each individual has a differing pain threshold. However, if it is causing significant pain, obviously it is within the patient’s best interest to treat it as quickly as possible. High levels of pain can also make alternative treatment options more difficult, such as physiotherapy.

Similarly, if there is a loss of motion which cannot be improved via physiotherapy or minimally invasive treatments, surgery would be required. Leaving the injury untreated when it’s causing a loss of motion, could lead to further degeneration of the shoulder, such as muscle loss.

Lifestyle considerations

Lifestyle considerations also need to be taken into account when coming up with the best treatment plan. If the rotator cuff tear is moderate to severe and it’s causing issues for patients not being able to carry out daily tasks, surgery may be essential.

For those with fairly inactive lifestyles, provided the pain isn’t too unbearable, they may be able to benefit from a non-surgical approach. However, for those with an active lifestyle, particularly athletes, getting back into the sport they love is essential, so surgery could be the best treatment choice for those who require full shoulder fitness in everyday life.

To find out what your best treatment options are, it is important to undergo a consultation with an experienced shoulder specialist. The sooner patients seek treatment for rotator cuff injuries, the more likely it is they will be able to benefit from non-surgical treatment, depending upon the severity of the injury.

treatment of rotator cuff tears

Study into stem cell formation provides insight into challenge of rotator cuff tears

A new study published within the Journal of Bone & Joint Surgery has provided an insight into the challenge inherent in the treatment of rotator cuff tears. It was discovered that stem cells within the rotator cuff more frequently turn into fat cells, rather than muscle cells in the event of a tear.

Here, we’ll analyse the findings and what it means for the future treatment of rotator cuff tears.

Understanding the research into rotator cuff tears

The research was carried out on mice, with numerous experiments performed to identify the characteristics of a group of stem cells known as satellite cells. Found between muscle fibres, satellite cells are crucial in the repair of muscle injuries.

Rotator cuff tears are known to be one of the most difficult to repair due to extensive fat accumulation. Chronic tears are especially susceptible to excess fatty build-up and the researchers wanted to determine whether there was a genetic basis which would explain why this particular area is prone to excess fatty deposits.

The researchers carried out DNA-level studies. These managed to identify hundreds of differing gene activations in comparison to the stem cells in calf muscles. It was discovered that the stem cells within the shoulder were programmed to develop into fat cells more easily than those in the calf muscles. It was also discovered that rotator cuff stem cells were 23% less likely to develop into muscle cells.

Why does it matter?

This study is the first of its kind to assess the DNA modification of rotator cuff disease. At present, rotator cuff tears can be notoriously difficult to treat. This is largely down to the fact that there is excess fatty build-up surrounding the muscles. Therefore, researching into why this occurs is crucial for the development of more effective treatments.

The researchers claim this study has opened the doors for a lot of additional studies. It shows that through further studies, newer, more effective clinical and therapeutic treatments could be developed. This would prove revolutionary for patients suffering from rotator cuff tears in the future.

How future research could improve clinical and therapeutic treatment of rotator cuff tears

In terms of therapeutic treatments, with the research discovered, it could be possible to take muscle stem cells from a patient’s body, then insert them into the rotator cuff muscle for improved repair. This could help to decrease the amount of fatty build-up and increase muscle repair within the area.

The researchers are already undertaking additional research into the nature of the fat accumulation in patients with rotator cuff tears. They are also trying to identify how immune and stem cells are working together to alter the muscle after surgery.

So, this new research is promising that newer, more effective treatments can be developed to treat rotator cuff tears in the future. While the tears can currently be successfully repaired via surgery, the fatty build-up can prove problematic for effective healing.

If you suspect you are suffering from a rotator cuff tear, it’s important to seek a correct diagnosis. Book a consultation with a shoulder specialist to determine the cause and most effective treatment option available.