Shoulder injuries – therapy and treatments

How is it determined?

The diagnosis is not always clear and often can only be made correctly by a specialist. Proper screening is critical, as there are a great many screening tests, but few are goal-directed. In general, if a detachment of the labrum-biceps tendon complex (SLAP lesion) is suspected, only an MRI with contrast medium (arthro-MRI) should be performed. All other pathologies are diagnosed purely clinically.

How to treat the discomfort?

Conservative therapy with activity modification, pain medication, and especially physical therapy should always be tried first. The main focus is on stabilizing and strengthening exercises for the shoulder blade muscles and stretching the posterior shoulder capsule.

In the case of a completely detached long biceps tendon or its rupture, surgical therapy is usually necessary. In the context of shoulder arthroscopy, there are 3 treatment options depending on the pathology, claim, age, and profession of the patient:

1. To refix the long biceps tendon origin with labrum back in place anatomically. This usually entails a rehabilitation period of more than 6 months and pain may occur for up to a year.
2. Simply cutting the long biceps tendon and allowing it to scar in its groove (tenotomy). Immediate loading is possible; sometimes, especially in muscular individuals, cramping and cosmetic impairment (“Popey sign”) may occur.
3. To cut the long biceps tendon and reattach it to the upper arm in a bone canal (tendodesis). The rehabilitation period is about 6-8 weeks, a rare occurrence of cramps or slipping of the muscle belly is possible.

A decision on the choice of surgical procedure should be made together with the patient.

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How is it determined?

Clinical examination first reveals limited mobility. An X-ray then confirms the diagnosis and other causes can be ruled out. Magnetic resonance imaging is used exclusively to assess the condition of muscles and tendons.

How to treat the discomfort?

Primarily the therapy is conservative

• with the intake of painkillers,
• Physical therapy to improve mobility and strengthen muscles,
• and, in the beginning, occasional cortisone injections to suppress the inflammatory stimulus.
• Regenerative therapy with injections of a combination of hyaluronic acid and blood plasma (PRP or ACP) or also stem cell concentrates are the most sensible method to avoid or postpone surgery.

If conservative therapy no longer helps, joint replacement is recommended. Depending on the age of the patient and the condition of the muscles and tendons, there are several options:

• In young patients or with circumscribed cartilage damage or moderate osteoarthritis, the cartilage defect can be covered with metal during a shoulder arthroscopy. This method was developed in Austria and is unique worldwide. Patients can leave the hospital the same day or the next day and move the arm fully depending on the pain.

• If the wear is already significantly advanced, but the muscles and tendons are preserved, a so-called anatomical shoulder prosthesis can be implanted. In this procedure, the humeral head is replaced with metal and the glenoid cavity is replaced with a plastic socket.
• If the muscles and tendons are equally worn out, a special type of shoulder prosthesis can be installed, called an inverse prosthesis. The head and socket are inverted and the center of rotation is shifted to the center of the body, resulting in a longer lever arm and the arm can be moved using only the deltoid muscle.

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Causes of impingement syndrome:

1. Dynamic factors (muscle imbalance of the scapula muscles, non-physiological movement rhythm and shoulder capsule shrinkage):

• continuous microtraumas lead to a thickened, inflamed, painful bursa and further to inflammation and swelling of the tendons of the rotator cuff (tendinitis).
• more persistent microtrauma can cause tears of the rotator cuff and thus thickened scarring (tendinosis).
• Microtrauma can also cause the formation of a bony spur at the base of the coraco-acromial ligament, which exacerbates these symptoms.

2. Static factors (changes in the bony structures of the scapula roof can lead to constriction symptoms):

• different scapula roof shapes
• Bone spur formation
• degeneratively altered acromioclavicular joint
• rarely an unstable, non-fused bony part of the acromion (mesacromion).

How is it determined?

Impingement syndrome is often a diagnosis of exclusion, so a thorough clinical examination, especially of scapula mobility, is enormously important. X-rays may then reveal constricting bony obstructions. Magnetic resonance imaging is crucial, as it is here that the tendon damage, whether pure inflammation or already partial tearing, can be determined.

How to treat the discomfort?

The treatment depends on the cause, duration of the symptoms, existing restrictions and already performed treatment methods.

In principle, 90% of all impingement syndromes can be treated conservatively. The decisive factor is the correct diagnosis. The therapy is mainly done by specialized physiotherapy with modification of the movement pattern and muscle strengthening as well as stretching of the shoulder capsule. The initial pain can be relieved by taking anti-inflammatory analgesics exceptionally 1 – 2 cortisone infiltrations into the subacromial space.

If, contrary to expectations, conservative therapy does not bring about any improvement, arthroscopic surgery can be performed. In this procedure, bony or soft tissue obstructions are removed, thus widening the subacromial space again.

Postoperatively, active movement exercises can be started immediately. A shoulder bandage is not required. Strengthening exercises can be performed after 4 weeks, once the shoulder joint has regained approximately full range of motion. The operation has a success rate of 90%. Surgery-specific risks include infection (<0.3%), cutaneous nerve injury, postoperative frozen shoulder, and incomplete pain relief.

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Frozen shoulder usually offers 3 phases: Pain phase, Stiffening phase, Resolution phase. The duration of the disease can be 18 – 24 months. The phases are not of the same length or the same severity in all patients.

The pain phase is characterized by capsulitis with a chronic background pain, especially at rest and at night. Initially, this non-specific pain without a clear stiffening easily leads to confusion with other clinical pictures, such as impingement syndrome. The pain phase can last up to 6 months.

The stiffening phase is characterized by loss of shoulder mobility in all planes. It is impossible for the patient to gain a greater range of motion even with the help of the healthy arm. Chronic posterior palate pain gradually disappears; only pain on exertion remains (such as end-grade or reflex movements). Sleeping on the shoulder can cause pain as well. Patients compensate with movements from the scapula, but this can lead to overloading of the cervical-neck region.

The resolution phase usually occurs spontaneously 12 months after the onset of pain and is characterized by a gradual improvement in mobility. Most patients regain full range of motion. Residual stiffness usually remains with risk factors such as diabetes, hyperthyroidism, or after fractures.

How is it determined?

Diagnosis is made primarily from history and clinical examination. As imaging examinations, the only useful one is an x-ray in 2 planes to rule out osteoarthritis, calcium depot or fracture. MRI only extremely rarely provides additional necessary information and is therefore not required.

How to treat the discomfort?

Because of the known course of the disease, treatment is usually conservative. Treatment includes pain management and preservation of mobility. Pain can be relieved with analgesic and anti-inflammatory drugs (NSAIDs), as well as cortisone injections into the joint in exceptional cases. A special form of joint injection, hydrodilation, generally provides the greatest benefit. In this procedure, cortisone and a local anesthetic are injected into the joint beforehand, followed by large amounts of fluid (NaCl). The large amount of fluid stretches the capsule and loosens adhesions, sometimes tearing the joint capsule. As a rule, the earlier joint injections are given, the better they help. Other measures, such as acupuncture, electrotherapy or massages can bring short-term improvement. Mobility should be maintained with use of the arm. Painful stretching should be avoided at all costs, as it can prolong the duration of the disease.

Rarely, it is necessary to perform surgery, specifically shoulder arthroscopy. In patients with severe loss of function, no support in daily life, or threat of job loss, arthroscopic mobilization of the shoulder can be considered no earlier than 6 months after the onset of pain. Furthermore, if the onset of the resolution phase is significantly delayed (longer than 18 months) or the quality of life is highly compromised, arthroscopic capsule removal and ligament release can be performed. But even after surgery, constant exercise of the shoulder is necessary. Ideally, patients begin movement exercises immediately after surgery while still in the hospital under a blockage of the arm nerve plexus, as this allows them to still perform them without pain.

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Symptoms depend mainly on the crack size and extension. The pain is essentially due to the inflammation caused by the torn tendon and is greater the smaller the tear. Weakness and loss of motion depend on how much tendon material is torn; the greater the tear, the greater the loss of function. Small rotator cuff defects may have a self-healing tendency, whereas a complete tear that is already retracting will continue to progress.

How is it determined?

First and foremost, a thorough clinical examination is necessary to determine which of the rotator cuff tendons is torn. A dynamic ultrasound examination right in the office helps to determine the extent of the damage. Radiographs are important to rule out possible shoulder osteoarthritis or calcific deposit. Crucial, especially for surgical planning, is magnetic resonance imaging to determine the extent of tendon damage and muscle atrophy.

How to treat the discomfort?

Especially in the case of small tears and pain with little loss of function, conservative therapy should always be used in the beginning. The goal is to control the symptoms. With proper therapy and acceptance of limitations, up to 90% of patients with this condition can live well, as exemplified by the large population with silent rotator cuff tears.

The therapy essentially includes:

• Regenerative measures such as blood plasma injections (PRP or ACP) to restart tissue regeneration. Small cracks or partial cracks can thus be brought to healing.
• and, as the most important support, exercise therapy so that the healthy muscles learn to take over the function of the damaged muscles.

It may take 3 to 6 months for conservative therapy to show improvement.

If you should not respond to conservative therapy or if the tear is already so large from the outset that there are considerable functional limitations, a surgical procedure is generally the best option. Shoulder arthroscopy is the gold standard for the treatment of tendon ruptures in the shoulder, and only in exceptional cases can an open procedure be chosen (e.g., muscle-tendon transfers for irreparable rotator cuff tears).

In and of itself, any rotator cuff tear can be treated and sutured arthroscopically nowadays. Depending on the existing crack size and tissue quality, the healing rate is between 60% and 90%. The larger the tear and the longer the time between initial symptoms and therapy, the poorer the chance of healing. With the surgical options available nowadays and good results, symptomatic rotator cuff rupture is an urgent reason for surgery. In my own patient population, I have been able to demonstrate 90% tendon healing in published studies.

Although it is a standard procedure, the operation is comparatively major and entails a long rehabilitation period of at least 6 months. Regardless of the surgical approach, as studies have demonstrated, the success of tendon healing depends on numerous factors beyond the surgeon’s control, such as tissue quality, muscle atrophy, inadequate tendon material, diabetes, nicotine abuse, and so on.

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How is it determined?

AC joint blast is primarily detected by an examination for the first time. A X-ray image with weight loading (water beam image) in lateral comparison then shows the extent of the vertical instability. In order to be able to assess the extent of the horizontal instability, a special X-ray image, the so-called Alexander image, must be taken. The injury is classified into 7 stages depending on the severity of the dislocation (according to Rockwood), and surgery should only be performed from stage 4. Magnetic resonance imaging provides little additional information.

How to treat the discomfort?

Stages 1-3 can be treated conservatively with temporary immobilization and use of pain medication.

If one decides to perform surgery, it should be done within the first 3-4 weeks, otherwise the success rate decreases significantly.

During shoulder arthroscopy surgery, various implants are used to bring the clavicle back close to the bony acromion, allowing the joint capsule and injured ligaments to heal.

If the surgery is performed later than 3-4 weeks, the reconstruction must be reinforced with a tendon, usually from the knee joint, because too much time has already passed and the torn ligaments of the clavicle are already scarred and cannot heal.

Postoperatively, the shoulder must be immobilized for 6 weeks, after which physiotherapy should be performed. Contact sports are only allowed again after 6 months.

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The disease progresses in 4 phases and often the calcium dissolves spontaneously, but this can take up to 18 months or more. Many patients do not experience any limitations and often a calcium deposit on X-ray is an incidental finding. However, if discomfort does occur, it is usually excruciating pain that hardly improves even in response to painkillers and injections.

How is it determined?

The quickest and most effective method of detecting a calcium deposit is to take X-rays, preferably in 4 planes, so that the calcium can be localized immediately. Magnetic resonance imaging is not necessary.

How to treat the discomfort?

At first, the focus is always on conservative therapy with immobilization and activity modification. The performance of a maximum of 3 cortisone infiltrations, preferably ultrasound-targeted into the calcific deposit, is allowed to contain the massive pain. A promising therapy is the so-called “needling” of the calcium deposit. In this process, the lime is pricked with a needle so that it dissolves.

Shock wave therapy is also a very effective procedure to dissolve the calcium, but only if high-energy focused shock wave therapy is used.

The safest way to get rid of the calcium is to remove it during a shoulder arthroscopy. The procedure takes 20 minutes, can be performed as a day case, and the patient is allowed to move the shoulder immediately. Under good physiotherapeutic guidance, the operated arm can be almost fully used again after 2 weeks. The operation has a success rate of over 95%.

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How is it determined?

A dislocated shoulder joint can usually only be put back into place with medical assistance. An x-ray examination is important to confirm the correct fit after the humeral head has been set. A computed tomography scan is necessary to determine the extent of possible bone loss. A magnetic resonance imaging scan shows the detachment of the labrum from the glenoid cavity.

Any shoulder dislocation (shoulder luxation) should be evaluated by a specialist.

How to treat the discomfort?

If activity is not changed after the initial shoulder dislocation, surgical stabilization is usually the treatment of choice. In the most common cases, the surgery is performed arthroscopically, refixing the capsular ligamentous apparatus back into place. Rarely, an open capsular shift may be necessary if the shoulder capsule volume is extensive. Bony glenoid reconstruction is indicated for bone loss at the glenoid cavity. In this procedure, a bone is removed from the iliac crest and folded over a slit in the glenoid cavity to restore the bony from. The advantage is that no screws need to be used (J-span plastic). In skilled hands, the procedure can also be performed arthroscopically.

Postoperatively, the shoulder should be immobilized in a bandage for 6 weeks. Afterwards, the full range of motion is trained again under physiotherapeutic guidance. Endurance sports can be resumed after 3 months, contact sports after 6 months.

Remember:

• Every shoulder dislocation must be medically clarified.
• The younger the patient, the higher the recurrence rate.
• The more often a shoulder luxates, the greater the risk of arthrosis.
• If there is overmovement, there is a greater risk of shoulder dislocation.

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