Shoulder

Impingement Syndrome

What is impingement syndrome?

The shoulder roof — formed by the acromion, the coracoid process and the ligament stretched between them, the so-called coracoacromial ligament — represents a natural narrow space in the human body.

Immediately beneath this roof, the tendon of the supraspinatus muscle runs to its insertion on the upper arm. To minimise friction between bone and tendon and to improve the tendon's ability to glide, there is a bursa at this point (the subacromial bursa). Mechanical irritation — from possible calcium deposits in the tendon tissue, or from additional narrowing of the space by bone spurs on the lower edge of the acromion or the lateral collarbone — leads to inflammation of the bursa (subacromial bursitis). This usually causes the bursa to swell, which further aggravates the problem of the narrow space. If the symptoms persist for a longer period, impingement syndrome can lead to stiffening of the shoulder joint (a so-called secondary frozen shoulder).

Symptoms and diagnosis

Clinically, severe pain and restricted movement in the shoulder region — particularly when lifting the arm — are the main features. There is also local tenderness on pressure and possibly warmth around the shoulder. A further symptom is pain at rest, especially at night, as well as an inability to sleep on the affected side.

In addition, X-rays are taken to rule out bone spurs and calcium deposits, and an ultrasound examination is performed to assess the bursa and the tendons. In the case of pronounced symptoms or specific questions, an MRI may also be carried out.

Treatment

Initially, a conservative treatment attempt is made through cooling and the use of pain-relieving and anti-inflammatory medication (NSAIDs), or local infiltrations with local anaesthetics and cortisone into the inflamed bursa.

In addition, physical measures such as ultrasound and salicylate iontophoresis as well as therapeutic exercises aimed at centring the head of the upper arm can be carried out. Shock-wave therapy (ESWT) may also be used. This is indicated above all for the calcium deposits of a so-called calcific shoulder, which is frequently associated clinically with impingement syndrome.

Only if conservative therapy does not lead to an improvement in symptoms is surgery in the form of a shoulder arthroscopy advisable. During this procedure the bursa is completely removed and the underlying rotator cuff is inspected and, if necessary, sutured. If a calcium deposit is present, it can be located and then removed. Should a bone spur be present on the underside of the shoulder roof (acromion), this can likewise be removed by a so-called acromioplasty.

After surgery, depending on the extent of the procedure, usually only a sling is needed for a few days. Physiotherapy and passive exercises should begin as early as the first day. As recovery progresses, active movement exercises should be carried out to strengthen the rotator cuff and thereby centre the head of the upper arm as well as possible within the socket. Overhead movements should still be avoided during the first weeks. If a repair of the rotator cuff is required during the shoulder arthroscopy, the aftercare is correspondingly more restrictive and means a considerably more demanding path back to everyday life for the patient. In most cases a shoulder brace with an abduction cushion is prescribed for 4–6 weeks. Initially passive and later active-assisted exercises are the priority. Full mobility and load-bearing capacity of the shoulder is usually achieved only after about 6 months.

Calcific Shoulder (Calcific Tendinitis)

What is a calcific shoulder?

The calcific shoulder, or so-called calcific tendinitis, describes calcium deposits at the tendon insertions of the rotator cuff (the muscles surrounding the shoulder, consisting of the supraspinatus, infraspinatus, subscapularis and teres minor muscles).

Symptoms and diagnosis

On the X-ray image there is usually a clump-like density in the tendon region of the rotator cuff (most commonly in the area of the supraspinatus tendon). These calcifications are often discovered incidentally during radiological examinations and may cause no symptoms at all. During their formation, and frequently also during their resorption, they can however — through an apparent rupture of the calcium deposit — cause irritation and thereby inflammation of the bursa (subacromial bursitis). Clinically the picture resembles that of subacromial bursitis or shoulder impingement. The calcification can also be visualised, albeit somewhat less easily, on ultrasound (sonography) and on magnetic resonance imaging (MRI). Sonography and MRI also make it possible to identify any accompanying damage to the rotator cuff.

Treatment

Initially, a conservative treatment attempt is made through cooling and the use of pain-relieving and anti-inflammatory medication (NSAIDs), or local infiltrations with local anaesthetics and cortisone into the inflamed bursa.

In addition, physical measures such as ultrasound and salicylate iontophoresis as well as therapeutic exercises aimed at centring the head of the upper arm, and shock-wave therapy, can be carried out.

Only if conservative therapy does not lead to an improvement in symptoms is surgery in the form of a shoulder arthroscopy indicated. During the arthroscopy the calcium deposit is located and then removed. Any accompanying pathologies, such as the presence of an acromial spur or damage to the rotator cuff, can be addressed during the same procedure.

Rotator Cuff Tear

What is a rotator cuff tear?

The rotator cuff is a tendon cap that surrounds the head of the upper arm. It is formed by four muscles — the subscapularis, supraspinatus, infraspinatus and teres minor. Tears (ruptures) of this structure can occur either after trauma (post-traumatic) or as a result of wear (degenerative). Combinations of the two also frequently occur.

Symptoms and diagnosis

Clinically, a rotator cuff tear is characterised by pain and a loss of strength in the affected shoulder. Depending on which tendon is affected, certain movements can no longer be carried out or only with reduced strength.

A traumatic tear typically causes sudden pain and weakness following an accident. A degenerative tear, by contrast, often develops gradually, so that the symptoms increase slowly over time.

In addition to the clinical examination, ultrasound (sonography) and magnetic resonance imaging (MRI) are the key imaging methods for assessing the extent and location of the tear. X-rays serve to evaluate the bony structures and the joint space.

Treatment

Whether a rotator cuff tear is treated conservatively or surgically depends on several factors — in particular the type of tear (traumatic or degenerative), its size, the age and demands of the patient, and the quality of the tendon tissue and the muscle.

Smaller, degenerative tears can often be treated conservatively. The focus here is on physiotherapy with targeted strengthening of the remaining intact muscles, in order to compensate for the function of the damaged tendon. Pain-relieving and anti-inflammatory measures support this treatment.

Fresh, traumatic tears in particular — as well as larger tears in younger, active patients — should as a rule be treated surgically. The earlier the repair is carried out after a traumatic tear, the better the tendon tissue can usually be reattached.

The repair is generally performed arthroscopically. The torn tendon is reattached to the bone using small anchors. Any accompanying pathologies can be addressed during the same procedure.

Aftercare following a rotator cuff repair is comparatively demanding. In most cases a shoulder brace with an abduction cushion is prescribed for 4–6 weeks. Initially passive and later active-assisted exercises are the priority. Full mobility and load-bearing capacity of the shoulder is usually achieved only after about 6 months.

Shoulder Osteoarthritis (Omarthrosis)

What is shoulder osteoarthritis?

Shoulder osteoarthritis (omarthrosis) refers to wear of the shoulder joint, in which the cartilage layer covering the joint surfaces of the head of the upper arm and the socket is increasingly worn down. As the disease progresses, the cartilage can be lost entirely, so that bone rubs directly against bone. Wear can be a consequence of age, of previous injuries, or of chronic overuse.

Symptoms and diagnosis

Clinically, shoulder osteoarthritis is characterised by load-dependent pain, which over the course of the disease can increasingly also occur at rest and at night. The mobility of the shoulder decreases, and movements are often accompanied by an audible or palpable grinding.

An X-ray is the key imaging method: it shows the narrowing of the joint space, bony attachments (osteophytes) and changes in the bone close to the joint. An MRI can additionally assess the condition of the cartilage and the surrounding soft tissues, in particular the rotator cuff.

Treatment

In the early stages, shoulder osteoarthritis is treated conservatively. The focus here is on physiotherapy to maintain mobility and strength, on pain-relieving and anti-inflammatory medication, and on physical measures. Local infiltrations can relieve symptoms.

If conservative measures are exhausted and the symptoms severely limit quality of life, joint replacement (a shoulder endoprosthesis) may be considered. Which type of prosthesis is used depends, among other things, on the condition of the rotator cuff.

The exact procedure and the appropriate timing are discussed individually at the practice.

Frozen Shoulder

What is a frozen shoulder?

A frozen shoulder is a painful stiffening of the shoulder joint, in which the joint capsule becomes inflamed, thickened and shrunken. As a result, the mobility of the shoulder becomes increasingly restricted.

A distinction is made between a primary frozen shoulder, which arises without an identifiable cause, and a secondary frozen shoulder, which develops as a consequence of another condition — for example after an injury, after surgery or in the context of impingement syndrome.

Symptoms and diagnosis

A frozen shoulder typically progresses in phases. In the first phase, pain is the main feature, increasing over time and also occurring at night. In the second phase, the pain decreases somewhat, but the stiffness reaches its peak — the shoulder is now severely restricted in movement. In the third phase, mobility gradually improves again.

The whole process can last many months and, in some cases, well over a year.

The diagnosis is made primarily clinically, on the basis of the characteristic restriction of both active and passive movement. Imaging (X-ray, MRI) serves mainly to rule out other causes.

Treatment

Treatment of a frozen shoulder is in most cases conservative and requires above all patience, as the course of the condition is lengthy. In the painful phase the priority is pain relief — through medication, local infiltrations and gentle physiotherapy.

As the pain subsides, physiotherapy increasingly focuses on regaining mobility. The exercises should be carried out consistently but without force.

Only in rare cases, when the stiffness persists despite consistent conservative treatment, may a procedure to release the capsule be considered. The exact approach is discussed individually.