Dr. Philipp Heuberer – Shoulder Specialist Vienna

Thrower’s shoulder: diagnosis

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.

Thrower’s shoulder: treatment & therapy

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 head of 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. 1. To refix the long head of biceps tendon origin 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. 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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Shoulder joint arthrosis: diagnosis

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.

Shoulder joint arthrosis: treatment & therapy

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.
• Therefore, 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. 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. 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).

Impingement syndrome: diagnosis

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.

 

Impingement syndrome: treatment & therapy

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 presents with 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 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 constant 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.

 

Frozen Shoulder: Diagnosis

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.

 

Frozen Shoulder: Treatment & Therapy

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. 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, 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. Stretching of the joint capsule under extracorporeal shock wave therapy usually provides the greatest benefit.

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.

 

Rotator cuff rupture: diagnosis

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.

Rotator cuff rupture: treatment & therapy

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, ACS or Stem cell injections) to restart tissue regeneration. Small cracks or partial cracks can heal. Small cracks or partial cracks can heal.
• 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 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 an open procedure needs to be chosen (e.g., muscle-tendon transfers for irreparable rotator cuff tears).

Nowadays any rotator cuff tear can be treated and reconstructed arthroscopically. Depending on the existing tear 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 surgery, 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 over 90% tendon healing in published studies.

Although it is a standard procedure, the operation is comparatively major and entails a long rehabilitation period of 3 to 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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Acromioclavicular joint arthritis: diagnosis

Typically, there is definite tenderness over the AC joint and reaching to the opposite shoulder is painful.

 

X-ray shows significant wear and magnetic resonance imaging may show fluid in the bones of the AC joint (bone marrow edema) or disintegration of the end of the clavicle (osteolysis).

 

Acromioclavicular joint arthritis: treatment & therapy

Generally, therapy is non-surgical with the use of pain medications, activity modifications, and cortisone injections into the AC joint.

 

If the symptoms are persistent, the degenerated parts of the joint need to be resected during a shoulder arthroscopy. The procedure can be performed in the day clinic and takes about 20-30 minutes. Despite the brevity of the surgery, the patient may still experience discomfort over the end of the clavicle for up to 6 months afterwards.

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Acromioclavicular joint dislocation: Diagnosis

AC joint dislocation is primarily detected by physical examination. An X-ray image with weight-bearing compared to the unijured side 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 3 on. Magnetic resonance imaging provides little additional information.

 

Acromioclavicular joint dislocation: Treatment & Therapy

Stages 1-2 and sometimes 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 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 should be reinforced with biologic material such a tendon, usually taken 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 4 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 deposit 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.

 

Calcified shoulder: diagnosis

The quickest and most effective method of detecting a calcium deposit is to take an X-ray, preferably in 4 planes, so that the calcium can be localized immediately. Magnetic resonance imaging is not necessary. On ultrasound the deposit can also be detected and treated subsequently.

 

 

Calcified shoulder: treatment & therapy

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 bursa, is allowed to contain the massive pain. The most promising therapy is the so-called “lavage or ballotage” of the calcium deposit. In this process, under ultrasound control and local anesthesia the calcification is aspirated and removed. If it is too hard an electrolysis can induce the repair process.

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 most effective 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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Shoulder instability: diagnosis

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.

 

Shoulder instability: treatment & therapy

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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