The shoulder is a complex articulation that joins the scapulothoracic joint to the superior member. It is formed by four separate joints and a muscle group. 

 

The joints are:

The glenohumeral joint, attaching the humeral head to the glenoid fossa;

The acromioclavicular join, attaching the clavicle to the acromion;

The sternoclavicular joint located between the clavicle and the sternum;

The connections between the scapula and the cervical and thoracic spine muscles. 

 

MUSCLE GROUP 

 

The superficial muscles responsible for shoulder movements are:

Pectoralis major, that pulls the arm forward;

Trapezius, that elevates the shoulder;

Deltoid, that raises the arm laterally;

  Latissimus dorsi that pulls the arm down. 

 

The deltoid, together with a set of smaller muscles, covers the humeral head, form the prominence of the shoulder joint and help prevent joint dislocations. 

 

The pectoralis major forms the anterior of the axilla while the posterior part is formed by the latissimus dorsi and the teres major muscle. The axillary vessels and the brachial plexus network of nerves go through this region. 

 

The glenoid labrum is a fibrocartilaginous structure, similar to a meniscus, which increases the contact with the humeral head, thus stabilizing the joint. 

 

 

The Rotator Cuff is a four-muscle set: 

 

supraspinatus;

infraspinatus; 

teres minor; 

subscapularis.

 

These muscles are smaller when compared to the pectoralis major and the deltoid muscles, but they are essential for shoulder and scapulothoracic joint movements. 

 

The Rotator Cuff is a convergence of tendons around the humeral head. The tendons of the four muscles join with the articular capsule of the glenohumeral joint. 

 

Their main functions are:

 • to centre and lower the humeral head;

 • to enhance the rotations of the glenohumeral joint ;

 • to stabilise the glenohumeral joint; 

• to provide a closed compartment, which is important to assure the nutritional needs of the joints.

A shoulder joint dislocation occurs when the humerus separates from the scapula, at the glenohumeral joint level. Considering that the shoulder has a great range of motion, this joint becomes quite vulnerable to this type of injuries. 

 

A shoulder joint dislocation is generally caused by a trauma that occurs with the arm in abduction and external rotation, which causes the anterior displacement of the humeral head, thus leading to ruptures in the articular capsule and the tearing of the glenoid labrum in the lower-anterior portion (Bankart's Lesion).

 

Depending on the position of the humeral head, joint dislocations may be:

• Anterior

• Posterior

• Superior

• Inferior 

 

 

When Bankart's lesion occurs, especially in young patients with some ligament laxity, it is likely to occur again, causing recurrent shoulder dislocations (a sign of chronic instability). 

Treatment 

Physiotherapy shows good results when joint dislocation episodes are not frequent and with patients older than 30-40 years old.

It aims at strengthening the periarticular musculature (especially on the internal and/or external rotators) and the proprioceptive training so as to stabilise the joint. 

 

When joint dislocation episodes occur frequently, open surgery or surgery by means of arthroscopy is needed to stabilise the articulation.

 

Bankart repair is an arthroscopy procedure that fixes the labrum zone to restore the articulation's original anatomy.

 

It is performed by placing small metallic implants or reabsorbable materials in the anterior-inferior edge of the glenoid, which will serve as anchor points to the highly resistant wires with which the injury will be fixed. 

 

In order to prevent a recurrence, Bankart repairs require a careful rehabilitation and a 4 to 6 months interval before returning to competition. 

 

This type of procedure is usually indicatedfor young patients (under 20 years old) or high-level contact sports athletes with multiple joint dislocation episodes (>5-6), with associated bone lesions and with ligamentous laxity.

 

Most cases require a surgical incision at the front of the shoulder from where a coracoid bone graft is transferred to the anterior-inferior edge of the glenoid, and fixed with a screw and washer. The Bristow-Latarjet Procedure consists in the creation of a bone block that prevents the humeral head from migrating out of the articulation. 

 

This procedure has a very low rate of recurrence; however, if it is not correctly performed it might result in a slight limitation of external rotation. 

 

We are currently performing this procedure, in some cases, via arthroscopy so as to take advantage of mini-invasive surgery.

 

 

The inflammation of the tendon of the biceps brachii muscle is one of the most frequent causes of shoulder pain. It can occur in isolation or derive from other pathologies of this joint.

 

Symptoms may be aroused by palpation of the biceps brachii in the groove along the humeral head, by flexing the elbow or by the resisted supination external rotation test, which practically confirm the diagnosis. 

In addition, magnetic resonance imaging (MRI) or ultrasound exams will show the tendon surrounded by an oedema, which is characteristic of inflamed tissue. 

 

 Treatment requires rest, non-steroidal anti-inflammatory drugs (NSAIDs) and physiotherapy. When dealing with refractory cases, the solution might be an infiltration of diluted corticosteroid with a local anaesthetic, e.g. lidocaine. 

 

 

 

This group of tendons may suffer an inflammatory process (tendinitis), causing pain, and a limited range of motion due to a conflict of space with the superior part of the glenohumeral joint, which is formed by the acromion. 

 

These injuries are common not only in athletes but also in people whose regular activities involve repetitive arm movements above the head level. 

 

These injuries can be caused by degenerative diseases or trauma, and there is some degree of correlation between their incidence and the convergent shape of the acromion. 

 

Physiotherapy associated with anti-inflammatory drugs allows the recovery in a high number of cases. 

 

Infiltration with corticosteroids in the subacromial area is especially suitable for this situation. Although often associated with deleterious effects, if correctly performed in the extra-articular area, in carefully selected patients, and when highly diluted with an anaesthetic, it may cause the symptoms to subside completely. 

 

• Surgery 

Subacromial decompression surgery is only indicated for cases in which other treatments, including physiotherapy or infiltrations, failed to succeed. 

 

Arthroscopic surgery allows a faster recovery than open surgery since muscle disinsertion (of the deltoid) is not needed. 

 

 

 

The clinical picture of a rotator cuff tear is generally characterised by acute onset of pain, not only when in rest but also while in movement.

 

During abduction of the arm some patients may also present a small clunk. Arm abduction usually becomes more limited when complete tears occur, considering that these types of movements depend on the deltoid muscle, which suffers with the upward migration of the humeral head. 

 

Magnetic Resonance Imaging (MRI) is important to study patients in these conditions, it is a means of confirming a diagnosis and obtaining prognostic information whilst it aids therapeutic decision making. Not only does it allow an accurate assessment of the tear, including the extent of the retraction, but it also assesses the degeneration of the torn tendon and its progressive substitution by fat tissue.

 

Elderly patients are often exclusively treated with physical therapy as most of the times the main objectives in this age group are related to pain management and functionality. 

 

In younger patients, who will eventually undergo surgery, physiotherapy has the function of reducing inflammatory processes, managing pain and restoring passive range of motion.

 

Physical therapy also helps the patient to fully recover after surgery. 

 

The strengthening of the deltoid and of the muscles that contribute to this function is expected to recentre the humeral head. 

 

Surgical treatment of rotator cuff tears is recommended for elderly patients who show no signs of pain relief through non-steroidal anti-inflammatory treatment or physiotherapy. Surgery is also recommended for younger patients who want to improve shoulder functionality and prevent the progress of the injury, by repairing the torn tendons. 

 

Surgeries are performed arthroscopically to treat intra-articular injuries and to allow a faster recovery. 

 

Its aesthetic advantages, in comparison with traditional open surgery, are also worth noting.

 

 

Glenohumeral joint arthritis is primarily caused by a progressive loss of the cartilage between the humerus and the scapula, or secondarily from the degeneration caused by other pathologies such as rheumatism. 

 

Shoulder osteoarthritis causes pain, rigidity and a loss of range of motion progressing into an incapacitating condition for the patient. 

 

Periodic physiotherapy associated with anti-inflammatory treatment may improve functional parameters and reduce the pain, but it can’t usually stop the progression of the osteoarthritis. 

 

Corticosteroid infiltrations or viscosupplementation with hyaluronic acid might relieve the symptoms to some extent. 

 

A partial or total replacement of the shoulder has positive results in terms of functionality, improving the symptoms significantly. 

 

There has been a remarkable evolution regarding shoulder implant procedures, which nowadays include, but it’s not limited to, the classic hemiarthroplasty (in which only a humeral component is used), total arthroplasty (in which the glenoid is also resurfaced) and "resurfacing" procedures (with minimal bone loss where only the humeral cartilage is removed and replaced by a metallic implant). 

 

Currently, even in shoulder osteoarthritis cases associated with a complete rotator cuff tear, it is possible to use special implants (reverse arthoplasties) with satisfactory functional results. In this procedure it is the glenoid component that has a convex surface in which a humeral concave component will be implemented. This will lower the rotation centre of the joint and improve the leverage of the deltoid muscle compensating the absence of the rotator cuff. 

 

 

Calcific tendinitis of the rotator cuff is a frequent cause of shoulder pain. This pain is so acute and incapacitating that it can disturb the patients' sleep for several days if left untreated. 

 

This disease generally affects the supraspinatus and is caused by the accumulation of hydroxyapatite deposits (a crystalline calcium phosphate) in the tendons. The hydroxyapatite deposits can be seen through X-rays and ultrasound exams. 

 

 

Treatment can be accomplished with non-invasive methods, which are usually our starting point, including: anti-inflammatory drugs (and eventually corticosteroids) as well as physiotherapy. 

 

We have a shockwave therapy system that allows us to perform a sort of extracorporeal lithotripsy, similar to the well-established and tested treatment for kidney stones. Although its mechanism of action is not yet fully known, this is a process that applies pressure variations inside the shoulder, shattering the hydroxyapatite deposits into smaller fragments. Three sessions, one-week apart, are usually effective in easing this clinical picture (see the images in the "Physiotherapy" tab). 

 

If this treatment is not fully effective, then it becomes necessary to remove the deposits. 

SHOULDER ARTHROSCOPY

 

Ultrasound-guided fine needle aspiration (FNA) is one of the possibilities, however when treating large calcifications, arthroscopic procedures are better suited to remove them in a minimally invasive way. 
 

The image on the left shows a voluminous calcification in the supraspinatus (indicated by the arrow), while the image on the right shows the same shoulder after an arthroscopic cleaning procedure.