A. Frozen Shoulder (Adhesive Capsulitis)
Starting with the simplest of such painful conditions is the frozen shoulder, which is a simple condition but may be difficult to manage well. The condition may arise spontaneously or secondary to some underlying malfunction and can be associated with diabetes. It is a self-limiting condition but if mismanaged, it can lead to considerable misery over a protracted period of up to two years. Typically, it is very painful with limitations of movement in all directions. In a worst-case scenario, the shoulder can become so stiff eventually that a manipulation under general anaesthesia is necessary; this involves, in a defined sequence, the surgeon's manipulation of the joint so as to break down the adhesions and at the same time avoiding fracturing a bone.
Understanding the patient and judicious use of medications are important in its management. Where necessary, careful guidance of the physiotherapists is also important in dealing with this condition; overly vigorous stretching whilst it is in the acute inflammatory phase will be counterproductive.

B. Shoulder Impingement Syndrome
Another common cause of shoulder pain is the impingement syndrome, which can affect anyone over the age of 40 years. It results from pressure on the rotator cuff tendons from part of the shoulder blade (the scapula) as the arm is lifted. The patient typically has sharp shoulder pain whenever they lift their arm above the horizon. They may notice it first when they are putting on or removing clothes. Another common symptom is shoulder pain at night when they turn to sleep on that particular side. A common cause of this is an overgrowth of bone similar to an osteophyte inside the shoulder, under the acromium, which rubs on the tendons that control overhead arm movements. The irritation from that bone spur on the tendon causes pain, bursitis, later tendon inflammation and eventually tendon rupture. Irritation of the tendon may cause the complex tendon movements to become disorganised. This may cause more self-damage as the tendon is then less able to function properly.

Different stages of the problem require different approaches that include physiotherapy exercises, judicious use of steroid injections, and in the severe cases, surgical treatment.

C. Rotator Cuff Disease
In the normal population, the shoulder joint is much less prone to developing severe osteoarthritis, as compared to the knee joint which is a weight-bearing joint. However, wear and tear is still a problem because the upper limb is used non-stop in all daily activities.

Rotator cuff tear is a common cause of pain and disability in the adult population. The rotator cuff is made up of four muscles and their tendons. These combine to form a "cuff" over the upper end of the arm (the head of the humerus). The rotator cuff helps to lift and rotate the arm and stabilize the ball of the shoulder within the joint.
Wear and tear of the rotator cuff tendon may be due to impingement, trauma and general disuse. The tendon tear may be partial thickness meaning only affecting one side or it may be full thickness meaning that there is a complete hole through the tendon. It may present non-specifically with pain and weakness, like many painful shoulder conditions.

A careful examination is required to reveal the diagnosis. A magnetic resonance scanning (MRI) of the shoulder may be useful in some cases but may not be sensitive enough for detecting the lesion in others. A special MRI whereby a contrast liquid is injected to the shoulder joint may enable detection of some subtle abnormalities.

Cuff disease can be very disabling, not only does it affect recreational activities, it can also interfere with even simple activities such as using a chopstick to eat. In the more active younger patients, such interference with recreational activities may prompt the patient to seek treatment much earlier. The less active middle-aged patient may unfortunately put it down to general aging and thus seek treatment much later on when the cuff disease is much more severe.
Conservative treatment with physiotherapy may abate the symptoms temporarily; surgical treatment has a better and predictable outcome. Special screws with sutures attached are often necessary for repairing the cuff tear, and bio-absorbable (non-metallic) screws are now available as an alternative.

D. Shoulder Dislocations
Accidental falls is a common problem in the older patient. This may occur at home or whilst out and about in the street. Such falls on the shoulder may lead to an unsuspected dislocation of the shoulder joint which is a very painful condition. Senior and young patients alike may seek bonesetter treatment, believing that it is straightforward trauma, and the more senior patients in particular, are more likely to delay medical consultation.

In the less experienced, it may be difficult to diagnose without an x-ray. Such a situation may lead to a delay in appropriate management of the shoulder dislocation and development of serious complication. If left untreated, chronic persistent dislocation of the shoulder joint may mean that the shoulder joint cannot be reduced without major surgical intervention, as the golden window of opportunity is missed.

Conclusion
Missing a diagnosis for a shoulder problem at any stage can only lead to a painful delay. Where surgery is required, conventional open technique remains a traditional approach which utilises a large surgical wound. Nowadays, the minimally invasive arthroscopic surgery offers an option to open surgery to various shoulder lesions, with only two or three small surgical incision holes (<1cm) being required. Although it is a technically demanding orthopaedic procedure, this novel arthroscopic technique offers the patients the advantage of much less post-operative pain, a speedier recovery and the ability to resume shoulder movements much earlier with significant improvement in the quality of life when compared with open surgery. It can now be done as day surgery, and the patients can return to light office work or normal daily activities within one week after surgery.

In addition, in cases such as shoulder dislocation that are left with a rotator cuff tendon rupture, open surgical repair can be difficult if not impossible in cases where delayed management have led to tendon ends retracting deep inside the shoulder. In such cases, minimally invasive arthroscopic surgery may be the only chance of treating the condition.

Despite the various advantages with arthroscopic surgery, it has to be noted that this does require the latest surgical expertise as well as up-to-date operative equipment.