The shoulder is a complex joint.
It allows a very wide range of movement in different planes.
It is an unstable joint in terms of its bony anatomy, often compared to a golf ball on its tee.
It is the muscles attached to the bony reliefs by the tendons that stabilise the joint and allow such great amplitudes of movement.
When the arm is raised, the scapula, which slides over the rib cage, also participates in the movement.
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Consultation and Surgery
Anatomy
The tendons of the rotator cuff are:
The biceps muscle has a main tendon, the short head of the biceps, which attaches to the coracoid, another area of the scapula. This short head of the biceps gives us strength when we bend our elbow. The long head of the biceps is a much thinner tendon that does not contribute significantly to strength. When it ruptures, it causes an asymmetry in the shape of the biceps (known as Popeye's sign). The rupture may cause cramp-like pain for a few weeks, without causing any long-term deficit. The only long-term consequence is therefore aesthetic (Popeye sign). For this reason, although it is located in the shoulder joint, it is not part of the rotator cuff.
Causes
Tendon rupture can be caused by trauma or by progressive wear and tear (degenerative origin). Degeneration of the tendons and muscles of the rotator cuff occurs naturally over time. It can also be of mixed origin. A lesion of degenerative origin may worsen and enlarge as a result of trauma.
In the event of shoulder dislocation, people over the age of 40 are at increased risk of associated cuff damage. The risk is extremely low in people under 40.
Symptoms
A ruptured cuff tendon can cause pain, loss of mobility and/or a feeling of lack of strength. The pain is generally localised in the lateral aspect of the arm and may radiate as far as the elbow. Night-time pain is also common. It is important to note that some patients with cuff tendon tears may be asymptomatic.
The tendons of the rotator cuff are:
- The supraspinatus tendon: which is involved in elevating the shoulder
- The infraspinatus and small round tendons: which enable the external rotation movement to be carried out and therefore position and maintain the hand in space (when cuffing oneself, drinking or using the computer mouse, for example).
- The subscapularis tendon: used for internal rotation (e.g. to place the hand behind the back).
The biceps muscle has a main tendon, the short head of the biceps, which attaches to the coracoid, another area of the scapula. This short head of the biceps gives us strength when we bend our elbow. The long head of the biceps is a much thinner tendon that does not contribute significantly to strength. When it ruptures, it causes an asymmetry in the shape of the biceps (known as Popeye's sign). The rupture may cause cramp-like pain for a few weeks, without causing any long-term deficit. The only long-term consequence is therefore aesthetic (Popeye sign). For this reason, although it is located in the shoulder joint, it is not part of the rotator cuff.
Causes
Tendon rupture can be caused by trauma or by progressive wear and tear (degenerative origin). Degeneration of the tendons and muscles of the rotator cuff occurs naturally over time. It can also be of mixed origin. A lesion of degenerative origin may worsen and enlarge as a result of trauma.
In the event of shoulder dislocation, people over the age of 40 are at increased risk of associated cuff damage. The risk is extremely low in people under 40.
Symptoms
A ruptured cuff tendon can cause pain, loss of mobility and/or a feeling of lack of strength. The pain is generally localised in the lateral aspect of the arm and may radiate as far as the elbow. Night-time pain is also common. It is important to note that some patients with cuff tendon tears may be asymptomatic.
cuff injury
Clinical examination
The clinical examination reveals any loss of mobility or strength, and assesses which tests trigger the pain described by the patient.
Complementary examinations
Standard X-rays, although they do not show the tendons, are necessary. They can reveal any associated lesions, such as calcification or osteoarthritis. They can also provide indirect evidence of chronic and irreparable damage to the cuff. A shoulder with irreparable cuff damage will have a deformed shoulder joint. In such cases, an MRI scan is not necessary.
An ultrasound scan is not systematically necessary. It is an examination that can only be interpreted by the doctor who carries it out, and the quality of the analysis depends on the specialist's level of expertise. What's more, an ultrasound scan cannot be used to assess whether a lesion is surgically repairable, as the quality of the muscle is not visible. It is therefore essential to carry out an additional assessment, such as an MRI scan, before considering surgical repair. Ultrasound can be useful for targeting infiltration by examination. There are 4 different areas that can be targeted for infiltration, and ultrasound can increase the precision of the procedure.
MRI is the gold standard for quantifying tendon damage and assessing its reparability (by evaluating the quality of the muscle). In some cases, arthro-MRI may be prescribed (for better analysis of small lesions or partial tendon injuries).
Treatment
There are 2 types of treatment for transfixing-type cuff injuries (involving the entire thickness of the tendon): surgical treatment and conservative treatment.
Conservative treatment is the first-line treatment for partial injuries to the cuff tendons (involving only part of the thickness of the tendon) or for transfixing injuries in older people, who are particularly bothered by the pain associated with the cuff injury. The patient receives physiotherapy to strengthen the other muscles of the shoulder girdle and allow the shoulder to ‘compensate’ for the torn tendon. Infiltration may also be discussed at the start of treatment, depending on the intensity of the pain.
Surgical treatment is suitable for:
It consists of repairing the torn tendon(s). Surgery is performed by arthroscopy (small incisions). Post-operatively, the upper limb is immobilised for 6 weeks. It should be noted that the type of splint used during the immobilisation period depends on the injured tendon(s). The patient receives physiotherapy from the day after the operation. He or she is allowed to move the hand, wrist and elbow according to pain.
and pectoral, depending on the injured tendon(s)).
Post-operatively, the shoulder stiffens temporarily. It is therefore necessary to make the shoulder more supple before considering muscle strengthening, which will come later. Indeed, any stiffness can cause residual pain. It is therefore important to recover full range of movement in the shoulder.
Biological healing of the tendon takes 6 months (at 6 months, the tendon is 80% stronger than a healthy tendon). It is therefore normal for shoulder re-education to take several months. It is therefore essential to carry out progressive rehabilitation and avoid carrying loads or making major efforts at the start of rehabilitation. In fact, exerting yourself too early in your rehabilitation will cause the repaired tendons to re-rupture or not heal. The risk factors for non-healing are: diabetes, smoking, muscle quality and the degree of retraction of the tendons during repair, and poor compliance.
In the event of irreparable damage to the cuff tendons, the surgical options are: most often a total shoulder prosthesis of the inverted type, or in rare cases tendon transfers (greater dorsalis, lower trapezius or pectoralis major, depending on the damaged tendons).
The clinical examination reveals any loss of mobility or strength, and assesses which tests trigger the pain described by the patient.
Complementary examinations
Standard X-rays, although they do not show the tendons, are necessary. They can reveal any associated lesions, such as calcification or osteoarthritis. They can also provide indirect evidence of chronic and irreparable damage to the cuff. A shoulder with irreparable cuff damage will have a deformed shoulder joint. In such cases, an MRI scan is not necessary.
An ultrasound scan is not systematically necessary. It is an examination that can only be interpreted by the doctor who carries it out, and the quality of the analysis depends on the specialist's level of expertise. What's more, an ultrasound scan cannot be used to assess whether a lesion is surgically repairable, as the quality of the muscle is not visible. It is therefore essential to carry out an additional assessment, such as an MRI scan, before considering surgical repair. Ultrasound can be useful for targeting infiltration by examination. There are 4 different areas that can be targeted for infiltration, and ultrasound can increase the precision of the procedure.
MRI is the gold standard for quantifying tendon damage and assessing its reparability (by evaluating the quality of the muscle). In some cases, arthro-MRI may be prescribed (for better analysis of small lesions or partial tendon injuries).
Treatment
There are 2 types of treatment for transfixing-type cuff injuries (involving the entire thickness of the tendon): surgical treatment and conservative treatment.
Conservative treatment is the first-line treatment for partial injuries to the cuff tendons (involving only part of the thickness of the tendon) or for transfixing injuries in older people, who are particularly bothered by the pain associated with the cuff injury. The patient receives physiotherapy to strengthen the other muscles of the shoulder girdle and allow the shoulder to ‘compensate’ for the torn tendon. Infiltration may also be discussed at the start of treatment, depending on the intensity of the pain.
Surgical treatment is suitable for:
- young patients (up to 60 years of age or more, depending on the patient's level of activity)
- patients who are mainly hampered by the lack of strength associated with the cuff injury
- patients for whom conservative treatment has been ineffective.
It consists of repairing the torn tendon(s). Surgery is performed by arthroscopy (small incisions). Post-operatively, the upper limb is immobilised for 6 weeks. It should be noted that the type of splint used during the immobilisation period depends on the injured tendon(s). The patient receives physiotherapy from the day after the operation. He or she is allowed to move the hand, wrist and elbow according to pain.
and pectoral, depending on the injured tendon(s)).
Post-operatively, the shoulder stiffens temporarily. It is therefore necessary to make the shoulder more supple before considering muscle strengthening, which will come later. Indeed, any stiffness can cause residual pain. It is therefore important to recover full range of movement in the shoulder.
Biological healing of the tendon takes 6 months (at 6 months, the tendon is 80% stronger than a healthy tendon). It is therefore normal for shoulder re-education to take several months. It is therefore essential to carry out progressive rehabilitation and avoid carrying loads or making major efforts at the start of rehabilitation. In fact, exerting yourself too early in your rehabilitation will cause the repaired tendons to re-rupture or not heal. The risk factors for non-healing are: diabetes, smoking, muscle quality and the degree of retraction of the tendons during repair, and poor compliance.
In the event of irreparable damage to the cuff tendons, the surgical options are: most often a total shoulder prosthesis of the inverted type, or in rare cases tendon transfers (greater dorsalis, lower trapezius or pectoralis major, depending on the damaged tendons).
The main shoulder joint is the glenohumeral joint (between the head of the humerus and the scapula (glenoid). In the event of trauma, or in hyperlax patients, the shoulder may dislocate (‘dislocate’).
During this dislocation phenomenon, 2 lesions appear:
Bankart lesion: disinsertion of the anteroinferior labrum (present in > 90% of cases).
In the most severe cases, a fracture of the glenoid (articular part of the scapula) may occur in addition to the lesion of the labrum (and ligaments).
Hill Sachs lesion: notch in the posterosuperior part of the humeral head which impacts against the glenoid of the scapula during impact (present in >80% of cases, varying in size).
In a first episode, the dislocation usually needs to be reduced in emergency. X-rays must be taken before the dislocation is reduced in order to rule out an associated fracture. This may alter the way in which the shoulder is reduced (light sedation versus general anaesthetic).
For a first episode, surgery is not necessary (except in the case of an associated fracture, depending on its displacement). Immobilisation with an orthopaedic waistcoat is necessary for 3 weeks (depending on the patient's age; the risk of re-luxation decreases with age, so it is no longer necessary to immobilise patients for so long after the age of 35). Physiotherapy is then prescribed to restore range of movement and strengthen the muscles of the shoulder girdle.
In the event of recurrence, even without trauma, immobilisation is no longer necessary (except in the case of a fracture) and surgical treatment is discussed.
The risk of re-luxation is correlated with the age at which the 1st episode of dislocation occurred. Patients under 20 years of age at the time of the 1st dislocation have a 90% risk of recurrence.
Other risk factors for new dislocations are: contact sports, hyperlaxity, bone loss at the glenoid >20-25% of its articular surface.
Complementary examinations play an important role in assessing instability. Standard X-rays are used to assess bone damage caused by dislocation episodes and to look for any signs of incipient osteoarthritis. Arthro-MRI is used to assess labrum and ligament lesions.
Following a dislocation, physiotherapy is prescribed to restore shoulder mobility and strengthen the dynamic stabilisers of the shoulder and scapula.
There are historically 2 types of surgery:
Bankart repair
This type of surgery repairs the ligaments and labrum. It requires longer post-operative immobilisation. This type of surgery can only be performed in isolated cases (e.g. when the Hill Sachs lesion is small, when the labrum is repairable, and when constitutional hyperlaxity is excluded).
Stabilisation by Latarjet bone block
This type of surgery currently offers the best results in the literature. The coracoid bone (the other part of the scapula) is removed and 2 tendons inserted (the short head of the biceps and the coracobrachial). The coracoid is fixed against the glenoid in order to increase the articular surface of the glenoid, and therefore the contact surface between the head of the humerus and the scapula when mobilising the shoulder. In addition, this new configuration allows the 2 tendons (biceps and coracobrachial) to create a ‘hammock’ effect and prevent the humeral head from dislocating during movements that could cause dislocation (cocking or throwing movements).
Postoperatively, the upper limb is immobilised with an orthopaedic waistcoat for pain relief, and physiotherapy is started the day after surgery. Fixation of the coracoid requires 3 months to consolidate (heal).
Sports such as rugby and ice hockey can be resumed at around 4 months post-operatively. For patients practising this type of sport, a specific test (isokinetic test) may be carried out at 3-4 months post-operatively to assess the muscle strengthening still required for full recovery.
After this type of surgery, the risk of re-luxation is <5%.
Other risks of this surgery include: hardware discomfort (2 screws used to fix the coracoid; need to remove these screws in <5% of cases), neurological injury (traction injury to the musculocutaneous nerve, which can lead to a lack of strength in the biceps; rare, usually transient), infection.
In cases of revision surgery, or in the rare cases where the coracoid cannot be used, autograft or allograft bone transfer may be considered, with harvesting from the iliac crest.
During this dislocation phenomenon, 2 lesions appear:
Bankart lesion: disinsertion of the anteroinferior labrum (present in > 90% of cases).
In the most severe cases, a fracture of the glenoid (articular part of the scapula) may occur in addition to the lesion of the labrum (and ligaments).
Hill Sachs lesion: notch in the posterosuperior part of the humeral head which impacts against the glenoid of the scapula during impact (present in >80% of cases, varying in size).
In a first episode, the dislocation usually needs to be reduced in emergency. X-rays must be taken before the dislocation is reduced in order to rule out an associated fracture. This may alter the way in which the shoulder is reduced (light sedation versus general anaesthetic).
For a first episode, surgery is not necessary (except in the case of an associated fracture, depending on its displacement). Immobilisation with an orthopaedic waistcoat is necessary for 3 weeks (depending on the patient's age; the risk of re-luxation decreases with age, so it is no longer necessary to immobilise patients for so long after the age of 35). Physiotherapy is then prescribed to restore range of movement and strengthen the muscles of the shoulder girdle.
In the event of recurrence, even without trauma, immobilisation is no longer necessary (except in the case of a fracture) and surgical treatment is discussed.
The risk of re-luxation is correlated with the age at which the 1st episode of dislocation occurred. Patients under 20 years of age at the time of the 1st dislocation have a 90% risk of recurrence.
Other risk factors for new dislocations are: contact sports, hyperlaxity, bone loss at the glenoid >20-25% of its articular surface.
Complementary examinations play an important role in assessing instability. Standard X-rays are used to assess bone damage caused by dislocation episodes and to look for any signs of incipient osteoarthritis. Arthro-MRI is used to assess labrum and ligament lesions.
Following a dislocation, physiotherapy is prescribed to restore shoulder mobility and strengthen the dynamic stabilisers of the shoulder and scapula.
There are historically 2 types of surgery:
Bankart repair
This type of surgery repairs the ligaments and labrum. It requires longer post-operative immobilisation. This type of surgery can only be performed in isolated cases (e.g. when the Hill Sachs lesion is small, when the labrum is repairable, and when constitutional hyperlaxity is excluded).
Stabilisation by Latarjet bone block
This type of surgery currently offers the best results in the literature. The coracoid bone (the other part of the scapula) is removed and 2 tendons inserted (the short head of the biceps and the coracobrachial). The coracoid is fixed against the glenoid in order to increase the articular surface of the glenoid, and therefore the contact surface between the head of the humerus and the scapula when mobilising the shoulder. In addition, this new configuration allows the 2 tendons (biceps and coracobrachial) to create a ‘hammock’ effect and prevent the humeral head from dislocating during movements that could cause dislocation (cocking or throwing movements).
Postoperatively, the upper limb is immobilised with an orthopaedic waistcoat for pain relief, and physiotherapy is started the day after surgery. Fixation of the coracoid requires 3 months to consolidate (heal).
Sports such as rugby and ice hockey can be resumed at around 4 months post-operatively. For patients practising this type of sport, a specific test (isokinetic test) may be carried out at 3-4 months post-operatively to assess the muscle strengthening still required for full recovery.
After this type of surgery, the risk of re-luxation is <5%.
Other risks of this surgery include: hardware discomfort (2 screws used to fix the coracoid; need to remove these screws in <5% of cases), neurological injury (traction injury to the musculocutaneous nerve, which can lead to a lack of strength in the biceps; rare, usually transient), infection.
In cases of revision surgery, or in the rare cases where the coracoid cannot be used, autograft or allograft bone transfer may be considered, with harvesting from the iliac crest.
anterior glenohumeral instability
© Arthrex
Injuries to the acromioclavicular joint are common, mainly in contact or collision sports (football, hockey, rugby, judo) and other sports where the risk of falling is higher (cycling, skiing). This injury affects the ligaments of the joint between the clavicle and the scapula. It is caused by a direct impact on the lateral part of the shoulder, which results in significant stress on the acromioclavicular joint until the ligaments are torn. This causes a deformity of the upper part of the shoulder due to the elevation of the clavicle, known as a ‘piano key’. There are several ligaments holding the distal clavicle in place. The degree of displacement depends on the number of ligaments affected.
Pain is felt in the deformity of the acromioclavicular joint and may radiate along the trapezius muscle and cervical spine.
The number of torn ligaments can be quantified by clinical examination and X-rays. X-rays of the shoulder and clavicle are essential to rule out an associated fracture.
If there is little displacement of the clavicle (and therefore little deformity), conservative treatment is instituted with a brief period of immobilisation, followed by physiotherapy to restore mobility to the shoulder and strengthen the muscles. Resumption of normal activities takes an average of 3 months.
In the event of more extensive displacement, surgical treatment is indicated.
The type of surgery will depend on the time between the trauma and the surgery. The ligaments can heal if the surgery is performed within 2-3 weeks of the trauma. The aim is therefore to allow the ligaments to heal by repositioning the clavicle in its anatomical position using a system of ‘cables’, which attach the clavicle to the scapula (at the level of the coracoid and acromion). Post-operatively, the upper limb is immobilised in an orthopaedic waistcoat for 6 weeks. Physiotherapy rehabilitation began in the 3rd postoperative week. The hand, wrist and elbow can be moved freely. However, weight-bearing is prohibited for 3 months.
If the injury is older, a ligament plasty (with grafting) is necessary to reconstruct the torn ligaments, which no longer have the capacity to heal. The type and duration of immobilisation and rehabilitation are similar to ligament repair. However, this type of surgery has a lower satisfaction rate. The graft used to reconstruct the ligaments tends to ‘relax’ a little in the first few months, causing slight deformation of the acromioclavicular joint. What's more, as this is a chronic situation, slight pain may persist.
It's important to remember that the acromioclavicular joint is biomechanically complex. For this reason, it is impossible with surgery to achieve the level of stability equivalent to the ‘native’ state, i.e. before any injury.
Pain is felt in the deformity of the acromioclavicular joint and may radiate along the trapezius muscle and cervical spine.
The number of torn ligaments can be quantified by clinical examination and X-rays. X-rays of the shoulder and clavicle are essential to rule out an associated fracture.
If there is little displacement of the clavicle (and therefore little deformity), conservative treatment is instituted with a brief period of immobilisation, followed by physiotherapy to restore mobility to the shoulder and strengthen the muscles. Resumption of normal activities takes an average of 3 months.
In the event of more extensive displacement, surgical treatment is indicated.
The type of surgery will depend on the time between the trauma and the surgery. The ligaments can heal if the surgery is performed within 2-3 weeks of the trauma. The aim is therefore to allow the ligaments to heal by repositioning the clavicle in its anatomical position using a system of ‘cables’, which attach the clavicle to the scapula (at the level of the coracoid and acromion). Post-operatively, the upper limb is immobilised in an orthopaedic waistcoat for 6 weeks. Physiotherapy rehabilitation began in the 3rd postoperative week. The hand, wrist and elbow can be moved freely. However, weight-bearing is prohibited for 3 months.
If the injury is older, a ligament plasty (with grafting) is necessary to reconstruct the torn ligaments, which no longer have the capacity to heal. The type and duration of immobilisation and rehabilitation are similar to ligament repair. However, this type of surgery has a lower satisfaction rate. The graft used to reconstruct the ligaments tends to ‘relax’ a little in the first few months, causing slight deformation of the acromioclavicular joint. What's more, as this is a chronic situation, slight pain may persist.
It's important to remember that the acromioclavicular joint is biomechanically complex. For this reason, it is impossible with surgery to achieve the level of stability equivalent to the ‘native’ state, i.e. before any injury.
acromioclavicular instability
© Arthrex
Osteoarthritis is the progressive wearing away of the cartilage that covers the bony surfaces of the shoulder joint (glenohumeral joint).
When the wear is severe and the cartilage has disappeared, this causes :
Pain is not proportional to the severity of osteoarthritis. Some people have little pain despite a lot of wear and tear on the joint, while others with little wear and tear will have more pain.
The diagnosis is made on the basis of X-rays.
In cases of early osteoarthritis, conservative treatment may include physiotherapy and pain relief (painkillers or infiltration, depending on the case).
Treatment is adapted to the degree of osteoarthritis. Infiltration will not be effective in cases of severe osteoarthritis.
In cases of severe osteoarthritis or osteoarthritis refractory to conservative treatment, surgery may be proposed.
When the wear is severe and the cartilage has disappeared, this causes :
- a progressive reduction in range of movement
- pain when moving or resting. In the most symptomatic cases, the pain can be sleepless.
Pain is not proportional to the severity of osteoarthritis. Some people have little pain despite a lot of wear and tear on the joint, while others with little wear and tear will have more pain.
The diagnosis is made on the basis of X-rays.
In cases of early osteoarthritis, conservative treatment may include physiotherapy and pain relief (painkillers or infiltration, depending on the case).
Treatment is adapted to the degree of osteoarthritis. Infiltration will not be effective in cases of severe osteoarthritis.
In cases of severe osteoarthritis or osteoarthritis refractory to conservative treatment, surgery may be proposed.
glenohumeral osteoarthritis
There are 2 types of shoulder prosthesis. The type of prosthesis depends on the type of osteoarthritis.
Anatomical prosthesis:
As its name suggests, this reproduces the anatomy of the shoulder with a convex (rounded) part on the humerus side and a concave (curved) part on the glenoid (shoulder blade) side.
This type of prosthesis gives excellent results, but requires the rotator cuff tendons (the muscles that enable the joint to move) to be intact.
Reverse prosthesis:
This reverses the natural anatomy of the shoulder, with a rounded part on the glenoid side and a curved part on the humerus side.
In cases where the rotator cuff is damaged, the shoulder can no longer function ‘normally’. We therefore modify the anatomy to allow another muscle, the deltoid, to take over and replace the role of part of the rotator cuff.
This prosthesis also gives excellent results but, depending on the patient's anatomy, studies show that internal rotation (the ability to put the hand behind the back) may be limited.
This type of prosthesis is also indicated when wear and tear on the joint is extremely severe.
Anatomical prosthesis:
As its name suggests, this reproduces the anatomy of the shoulder with a convex (rounded) part on the humerus side and a concave (curved) part on the glenoid (shoulder blade) side.
This type of prosthesis gives excellent results, but requires the rotator cuff tendons (the muscles that enable the joint to move) to be intact.
Reverse prosthesis:
This reverses the natural anatomy of the shoulder, with a rounded part on the glenoid side and a curved part on the humerus side.
In cases where the rotator cuff is damaged, the shoulder can no longer function ‘normally’. We therefore modify the anatomy to allow another muscle, the deltoid, to take over and replace the role of part of the rotator cuff.
This prosthesis also gives excellent results but, depending on the patient's anatomy, studies show that internal rotation (the ability to put the hand behind the back) may be limited.
This type of prosthesis is also indicated when wear and tear on the joint is extremely severe.
© Medacta
Causes
Subacromial impingement is a mechanical problem that causes irritation and inflammation of the rotator cuff tendons. It may be caused by insufficient musculature in the scapula, intratendinous calcification reducing the subacromial space or reworking of the acromion (calcification of the coracoacromial ligament, which can cause mechanical impingement during certain movements). In the most severe cases, damage to the cuff may occur.
Symptoms
Subacromial impingement mainly causes pain, initially during certain movements. Subsequently. The pain may worsen and become constant. In the context of this inflammation, pain may also be present at night. Over time, a loss of mobility (mainly caused by the pain) may set in. It is important to note that the intensity of the pain is not necessarily proportional to the severity of the tendon damage.
Diagnosis
Subacromial impingement is a clinical diagnosis. In fact, it is a dynamic pathology, appearing with movement.
Complementary examinations (X-rays, ultrasound or even MRI; to be adapted according to the clinical examination) enable us to exclude other pathologies (osteoarthritis), to look for certain causes of impingement (large intratendinous calcification, calcification of the coracoacromial ligament) and to look for impingement-related complications (cuff lesions). Complementary examinations alone are not sufficient to diagnose subacromial impingement. There may be significant impingement, but no rupture of the cuff tendons is present.
Treatment
Treatment of subacromial impingement is mainly conservative. Physiotherapy rehabilitation is necessary. In some cases, depending on the intensity of the pain and previous treatment, infiltration may be indicated.
Depending on the cause of the subacromial impingement, a specific treatment is instituted. In the case of an associated cuff lesion, surgical treatment may also be indicated (depending on the type of lesion; see article on cuff lesions).
Translated with DeepL.com (free version)
Subacromial impingement is a mechanical problem that causes irritation and inflammation of the rotator cuff tendons. It may be caused by insufficient musculature in the scapula, intratendinous calcification reducing the subacromial space or reworking of the acromion (calcification of the coracoacromial ligament, which can cause mechanical impingement during certain movements). In the most severe cases, damage to the cuff may occur.
Symptoms
Subacromial impingement mainly causes pain, initially during certain movements. Subsequently. The pain may worsen and become constant. In the context of this inflammation, pain may also be present at night. Over time, a loss of mobility (mainly caused by the pain) may set in. It is important to note that the intensity of the pain is not necessarily proportional to the severity of the tendon damage.
Diagnosis
Subacromial impingement is a clinical diagnosis. In fact, it is a dynamic pathology, appearing with movement.
Complementary examinations (X-rays, ultrasound or even MRI; to be adapted according to the clinical examination) enable us to exclude other pathologies (osteoarthritis), to look for certain causes of impingement (large intratendinous calcification, calcification of the coracoacromial ligament) and to look for impingement-related complications (cuff lesions). Complementary examinations alone are not sufficient to diagnose subacromial impingement. There may be significant impingement, but no rupture of the cuff tendons is present.
Treatment
Treatment of subacromial impingement is mainly conservative. Physiotherapy rehabilitation is necessary. In some cases, depending on the intensity of the pain and previous treatment, infiltration may be indicated.
Depending on the cause of the subacromial impingement, a specific treatment is instituted. In the case of an associated cuff lesion, surgical treatment may also be indicated (depending on the type of lesion; see article on cuff lesions).
Translated with DeepL.com (free version)
subacromial impingement
The labrum is a fibrocartilage bulge (similar to the meniscus in a knee) that helps improve the stability of the glenohumeral joint (shoulder joint). This structure can be damaged by trauma or repeated micro-trauma, as in certain sports.
An injury to the labrum can cause pain during certain movements, limited movement and even a lack of strength. This lesion tends to occur in younger patients.
It is the clinical examination that enables us to determine whether or not such a lesion is present, and to determine the type of further examination required to diagnose it.
Treatment depends on the extent of the lesion, but may involve surgery if the lesion is extensive. The type and duration of immobilization depends on the location of the lesion (anterior versus posterior part of the labrum).
An injury to the labrum can cause pain during certain movements, limited movement and even a lack of strength. This lesion tends to occur in younger patients.
It is the clinical examination that enables us to determine whether or not such a lesion is present, and to determine the type of further examination required to diagnose it.
Treatment depends on the extent of the lesion, but may involve surgery if the lesion is extensive. The type and duration of immobilization depends on the location of the lesion (anterior versus posterior part of the labrum).
labrum lesion
© Arthrex
© Arthrex
In some people, one or more calcifications (calcium deposits) may form in a rotator cuff tendon. These calcifications are located inside the tendon and “push” the tendon fibers.
This pathology generally affects people between the ages of 30 and 60, and more often women. The most common anatomical location is the supraspinatus tendon. The origin of this pathology is unknown.
Calcifications may remain asymptomatic for months or even years.
However, they can become painful in 2 ways:
- When a calcification resorbs (self-destruction of the calcification): this causes significant inflammation in the shoulder, which can lead to shoulder pain and stiffness.
- When a calcification is large (e.g. 1cm): it can cause mechanical conflict and inflammation when the shoulder is mobilized (mainly when the arm is raised forward (flexion) and to the side (abduction)).
Standard radiographs are the best way to diagnose and monitor calcifications. They can also identify the density and stage of calcification (stable versus resorbing).
The indication for an MRI is not systematic and should be assessed on a case-by-case basis, depending on the patient's clinical examination and the radiographic appearance of the calcification. MRI is not systematically required for this pathology. It is only indicated when an associated tendon tear is suspected.
Treatment is then adapted according to the size and evolution of the calcification. Treatment is usually conservative, and includes pain relief combined with appropriate physiotherapy. In the case of large calcifications with no signs of resorption, needle “trituration” may be performed under radiological control. This involves fragmenting the calcification and aspirating its contents with a needle. This procedure is performed by radiologists under local anaesthetic.
Rarely, calcifications do not respond to conservative treatment, and surgical management is required. In the case of large calcifications causing subacromial impingement, the calcification can be surgically resected, thus removing the painful mechanical impingement.
Quelque soit le traitement, le temps de récupération peut varier et durer quelques mois.
calcification
A frozen shoulder, also known as “retractile capsulitis”, is a stiffening of the shoulder. The joint capsule, the envelope that surrounds and seals the joint, thickens and stiffens as a result of a major inflammatory process. This pathology is 2 times more common in women, and most often affects people between the ages of 40 and 60, although it can occur at any age.
Stiffness can set in following trauma or surgery. More often, however, the cause of stiffness is not identified (what we call “idiopathic” stiffness).
Known risk factors include diabetes, hypo- and hyper-thyroidism and hormonal changes (e.g. menopause).
Frozen shoulder evolves in 3 phases:
Stage 1:
Insidious onset with diffuse pain at rest and on movement, associated with nocturnal pain. Pain intensity is highly variable. In the 2nd stage, shoulder movements diminish.
Stage 2:
Significant limitation of movement, affecting activities of daily living. At this stage, pain gradually diminishes.
Stage 3:
Disappearance of pain and gradual recovery of shoulder mobility.
The evolution of this pathology is slow and progressive, and can take up to 1.5-2 years for full recovery.
The diagnosis is made on clinical examination.
Complementary examinations (X-rays, US, MRI) are adapted to the history and clinical examination of each patient. They are performed to look for associated lesions (e.g. after trauma), but are not necessary to confirm the diagnosis of frozen shoulder.
Depending on symptoms, cortisone infiltration may be performed. However, this is not systematically performed (nor is it necessary). In fact, it can reduce the intensity of pain when conventional analgesics fail. However, it does not accelerate recovery of amplitude.
Treatment consists mainly in managing pain and gradually regaining mobility.
Liotard's protocol (a series of self-stretches to be performed within the pain threshold) has proved effective in this field.
Depending on the degree of stiffness, the treatment may be supplemented by physiotherapy, e.g. in a swimming pool.
Stiffness can set in following trauma or surgery. More often, however, the cause of stiffness is not identified (what we call “idiopathic” stiffness).
Known risk factors include diabetes, hypo- and hyper-thyroidism and hormonal changes (e.g. menopause).
Frozen shoulder evolves in 3 phases:
Stage 1:
Insidious onset with diffuse pain at rest and on movement, associated with nocturnal pain. Pain intensity is highly variable. In the 2nd stage, shoulder movements diminish.
Stage 2:
Significant limitation of movement, affecting activities of daily living. At this stage, pain gradually diminishes.
Stage 3:
Disappearance of pain and gradual recovery of shoulder mobility.
The evolution of this pathology is slow and progressive, and can take up to 1.5-2 years for full recovery.
The diagnosis is made on clinical examination.
Complementary examinations (X-rays, US, MRI) are adapted to the history and clinical examination of each patient. They are performed to look for associated lesions (e.g. after trauma), but are not necessary to confirm the diagnosis of frozen shoulder.
Depending on symptoms, cortisone infiltration may be performed. However, this is not systematically performed (nor is it necessary). In fact, it can reduce the intensity of pain when conventional analgesics fail. However, it does not accelerate recovery of amplitude.
Treatment consists mainly in managing pain and gradually regaining mobility.
Liotard's protocol (a series of self-stretches to be performed within the pain threshold) has proved effective in this field.
Depending on the degree of stiffness, the treatment may be supplemented by physiotherapy, e.g. in a swimming pool.
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FROZEN SHOULDER
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Société européenne de chirurgie de l'épaule et du coude.
Société francophone d’arthroscopie
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Dr Sandrine Mariaux
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