Shoulder

Shoulder pain is common and can have many causes. A careful clinical examination, supplemented by appropriate radiological imaging (X-ray, MRI, CT), is the basis for a correct diagnosis. Following this a decision can be made on whether further conservative or operative treatment is necessary. Depending on the nature of the injury or damage, we can offer state-of-the-art minimally invasive, arthroscopic or open operative procedures. The most frequent pathologies and their appropriate operative therapy are explained below.

---

Rotator cuff

The rotator cuff of the shoulder is formed by four muscles with their corresponding tendons. These connect the shoulder blade with the humeral head. Their function allows the arm to be lifted sideways, forwards and backwards and rotated inwards and outwards, whilst remaining centered in the “socket”.

In addition to clinical examination, sonography and magnetic resonance imaging (MRI) are used as diagnostic tools. For the specific therapy it is important to assess the exact cause, extent and quality of the muscle-tendon unit.

For the surgical reconstruction of the rotator cuff modern minimally invasive and arthroscopic procedures are available. In these procedures, the torn tendons are reattached to the humerus using small suture anchors.

After the operation, the shoulder is placed in a shoulder abduction cushion so that the freshly sutured tendon is not under tension, allowing it to heal.
Physiotherapy of the shoulder begins immediately on the day after the operation.

After discharge ongoing physiotherapy can follow on an ambulatory basis or during inpatient rehabilitation.

Normally, the post-operative treatment plan stipulates that the shoulder abduction cushion is to be worn for 6 weeks. After this period, active mobility is gradually increased.

From the 3rd-6th month after the operation, depending on the diagnosis and the operation, sports that put strain on the shoulder can be started again.

Impingement syndrome

Injuries to the rotator cuff can be associated with a so-called impingement syndrome.

In this syndrome, tendons of the rotator cuff are trapped between the humeral head and bony roof of the shoulder, which can lead to pain and tearing of the rotator cuff. If conservative therapy for partial tears of the rotator cuff is unsuccessful, the impingement caused by bone or soft tissue can be removed in an arthroscopic procedure using a precise shaver.

The rehabilitation period after such operations is short and patients are usually largely free of symptoms and able to work again after 3-6 weeks.

Tendinosis calcarea (calcific tendinitis of the shoulder)

Calcific tendinitis is a disease process in which calcium deposits form in the inflamed tendons of the rotator cuff. The causes of this are not yet fully understood. The disease progresses in different phases. Alternating periods of little pain and severe pain are found. The disease is usually self-limiting, although the exact duration cannot be predicted and in some cases this can plague the patient for years.

We initially recommend conservative therapy. This can include treatment with anti-inflammatory and analgesic medication, physiotherapy and occasionally shock wave therapy.

If conservative therapy fails to be successful over a longer period of time, we recommend arthroscopic removal of the calcium deposits. This usually leads to a rapid postoperative recovery and elimination of the symptoms. The rehabilitation takes between 3-6 weeks, depending on the extent of disease and requires intense physiotherapy.

Shoulder instability

In shoulder instability, a distinction must be made between congenital (habitual) and traumatic instability (following an injury).

Congenital or habitual instability is characterized by a hyperlaxity of the joints. In these patients, minor trauma can lead to dislocation, or dislocation of the shoulder may even be able to be initiated by the patient spontaneously. Only in a few specific cases is an operation indicated here; rather, in this case, emphasis must be placed on intensive physiotherapy to strengthen the muscles and improve proprioception (= self-perception of the joint position).

Traumatic dislocation results in an injury of the lip (labrum) at the front of the socket and an impression on the humeral head (Hill-Sachs lesion).

The therapy of these injuries depends on age, since young patients more commonly suffer recurrent dislocations and shoulder instability.

Since recurrent dislocations can lead to injury of the cartilage  and thus to premature arthritis, early surgical therapy is recommended.

Elder patients display more stable connective tissue due to scarring of the joint capsule and thus a lower risk of recurrent dislocations.

In arthroscopic stabilization, the injured joint lip (labrum) together with the joint capsule is reattached to the socket using small suture anchors to restore good stability of the shoulder joint. In the case of a bony injury to the glenoid cavity (socket), open procedures with, in some cases, bony reconstruction may be necessary.

For 6 postoperative weeks, certain movements are not allowed and for comfort, the arm is initially immobilised in a sling. A complete return tooverhead sports and sports with full contact are only recommended after about 5-6 months.

Acromioclavicular joint dislocation (AC-joint dislocation)

In AC-joint dislocation, the joint encompassing ligaments between the clavicle (collar bone) and acromion (roof of the shoulder blade) and the stabilizing ligamentous structures between the coracoid process of the scapula and the clavicle tear. The instability of the joint causes a relative elevation of the clavicle in relation to the acromion. Severe instability should be treated surgically to restore normal shoulder function.

In the surgical treatment of fresh injuries, the anatomical joint position is restored in an arthroscopically supported procedure.

In the case of chronic injuries to the AC joint, an allogenic tendon (patients own, usually hamstrings) must also be used to ensure that the reconstruction remains permanently stable under load.

During follow-up treatment, movements above horizontal (90°) and lifting of heavy objects are not permitted for the first 6 weeks. Here again, full load-bearing capacity (overhead sports, sports with full contact) is achieved after approx. 5-6 months.

Pathologies of the long head of biceps tendon (LHB)

The long head of biceps tendon (LHB) runs through the shoulder joint and can lead to painful symptoms in several places. Tears can occur at the origin of the tendon in the joint (SLAP), along the tendons length through or at its exitthrough the rotator cuff. The guide loop (pulley) of the long biceps tendon may also be frayed or torn. Pathology of the long biceps tendon often occurs in combination with other injuries of the shoulder joint. A conservative therapy is usually not very promising, so that the surgical treatment of LHB is carried out according to the type of injury. This may be performed either with a suture at the origin of the tendon or by cutting the damaged tendon off at its base, allowing it to retract out of the joint, with or without reattachment to the humerus.

Arthritis of the shoulder joint

Shoulder arthritis causes considerable pain on movement and at rest and causes a restriction of the range of movement of the joint.

Conservative treatment can only control the symptoms to a certain extent. Arthroplasty (implantation of artificial joints) has become established to restore a good pain-free shoulder function. A wide range of modern prostheses models are available for all needs.

Anatomical shoulder protheses:

The anatomical shoulder prosthesis is based on the original form and function of the shoulder joint. The humeral head is replaced by a prosthetic surface, which often no longer requires the insertion of a long shaft in the humerus. This can be combined with an artificial glenoid cavity, if necessary (total endoprosthesis). In some cases, particularly for younger patients, the original glenoid cavity can be left without replacement (hemiprosthesis). Anatomical prostheses are suitable for patients with an intact and well-functioning rotator cuff.

Reverse shoulder arthroplasty:

In a reverse shoulder prosthesis the usual configuration of “ball and socket” is changed, so that the ball structure (hemisphere) is now attached to the shoulder blade and the socket is inserted into the humerus. Thus, an adapted center of rotation of the joint and inherent stability allows shoulder movement even without an intact and rotator cuff. This type of shoulder prosthesis is especially useful in the treatment of the (sometimes very severe) pain caused by an irreparable rotator cuff tear or arthritis with associated rotator cuff pathology, allowing for good everyday function.