What is it about ?
The shoulder is the most mobile joint in the body. This mobility is ensured by the joint work of 3 joints and a whole series of muscles, in particular the rotator cuff, a group of muscles which reinforce the stability of the shoulder joint and take charge of the movements of the shoulder. around 3 axes, namely outward (external rotation), sideward / upward (abduction) and inward (internal rotation).
The shoulder has 3 bones:
- A flat bone located at the back (shoulder blade or scapula)
- The arm bone (humerus)
- A small bone located at the front on the side (collarbone).
The scapula ends laterally in the acromion, a protrusion that overhangs the shoulder forming an arch over the largest of the 3 joints. This joint, between another part of the scapula, the glenoid cavity, and the head of the humerus, is called the glenohumeral joint.
Between the acromion and the head of the humerus is a small pocket filled with fluid called the bursa.
Many tendons are attached to these structures including the “rotator cuff” which is the meeting point of 4 tendons of different muscles located around the shoulder.
Sometimes the space between the acromion and the head of the humerus is too small to accommodate the tendons and bursa. This results in a pinch, especially when raising your arm sideways. The bursa and tendons may become inflamed and swell. This further increases the pinch. The phenomenon is known as the subacromial impingement syndrome. There may also be calcification of the tendon.
Following an accident or overwork, small or large cracks can form in the tendons. It is then question of a tear of the rotator cuff. This tear can be partial or complete.
Where do we meet them?
In people under the age of 30, a chronic shoulder problem is often the result of excessive laxity (instability) of the joint.
In middle-aged people, rotator cuff syndrome is often the cause of the problem. In this case, a tendon is often stuck under the acromion (subacromial impingement syndrome).
Pain after the age of 50-55 usually follows a tear in the rotator cuff. In people over 45, a shoulder dislocation is almost always associated with a cuff tear.
How to recognize them?
Subacromial impingement is characterized by pain that appears when you raise your arm to the side. Often a “painful arc” is present. This means that you can lift your arm painlessly up to a point, then pain appears as the arm continues to rise, before disappearing again when it reaches a certain height. The pain increases with exertion. You may also have difficulty lying on the affected shoulder, with the pain waking you up during the night.
A tear in the rotator cuff is accompanied by pain and loss of strength. If the tear is complete (a full thickness tear), you cannot make a certain movement. Most often, you are no longer able to raise your arm at a right angle to the side (abduction).
How is the diagnosis made?
The doctor will first perform a exam clinic of your shoulder. This procedure takes place in three stages: an active exam, a passive exam and a muscle strength test.
In the passive exam, the doctor performs the shoulder movements while you relax the arm completely. It therefore examines the maximum movement at zero force. You should not participate in the movements at all. By this examination, the doctor tries to determine if it is a disease of the joint itself and the bursa, and looks for signs of pinching.
When testing for muscle strength, the doctor will ask you to perform all movements using as much force as possible, while he or she retains these movements. It thus tests the muscles and tendons.
X-rays can be taken.
Ultrasound may be necessary if a tear is suspected. If all these examinations indicate the need for intervention, a CT scan of the shoulder with contrast medium (arthroscanner) may be considered.
What can you do ?
In the case of an onset of subacromial impingement syndrome, treatment consists of rest and possibly taking anti-inflammatory drugs. Rest doesn’t mean you can do nothing. It is best to avoid working above shoulder height for a short time and to avoid pain-inducing movements.
Continue to use your shoulder and arm regularly, even if it hurts a bit. The movement prevents your shoulder problems from worsening and your shoulder being completely blocked (adhesive capsulitis or “frozen shoulder”).
Can’t keep using your shoulder despite the painkillers? Physiotherapy sessions will be prescribed to you by your doctor. The physiotherapist will show you suitable exercises and help alleviate your pain, both in the shoulder and in the neck.
What can the doctor do?
If rest and medication do not help, the doctor may give an injection (infiltration) of cortisone, anesthetic, or a mixture of both in the bursa. This infiltration will deflate the bursa and reduce pain. It is also possible to make an infiltration where an inflamed tendon attaches to the bone. If the results are good, the injections can be repeated several times, until the symptoms disappear.
On the other hand, if the symptoms do not improve and persist for more than 6 months, the doctor will refer you to an orthopedist. The latter can perform a procedure in which he creates more space in the shoulder joint by removing some bone and tissue. This procedure is usually done by inserting a small tube called an endoscope and does not require a large incision in the skin (endoscopy).
A small muscle tear usually causes few complaints and heals on its own.
A larger, or even complete, tear does not heal on its own. Indeed, the muscles are elastic and the torn ends gradually move away. If you are in great pain and have a significant loss of strength, the doctor will refer you to a specialist who will eventually repair the tear. A shoulder operation is usually followed by a long period of rehabilitation under the supervision of a physiotherapist.
Want to know more?
- Radiography, here, Where to find on this page of Cliniques St Luc UCL
- Ultrasound here Where to find on this page of Cliniques St Luc UCL
- Arthrography (arthrography) – Hôpital Erasme ULB
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