Painful shoulder is characterized by pain in the shoulder area and by restricted movements. Under painful shoulder, doctors consider periartritis humeroscapularis (PHS). Periartritis humeroscapularis diagnosis is unavoidable in everyday practice and is used by everyone, from general practitioners to specialists in physical therapy and orthopaedic specialists. After being diagnosed with PHS, patients are subjected to different physical therapy procedures for months and are given injections to different parts of the shoulder.

Painful shoulder or PHS is a general diagnosis which only tells us that something is wrong with the shoulder, that the shoulder is painful and that movements are restricted. Before starting the treatment, it is necessary to establish the correct diagnosis so that we could help and not worsen the patient’s condition with the wrong treatment method. I will describe the most common shoulder injuries and illnesses, meant under the name painful shoulder or PHS.

1. Subacromail impingement syndrome

Pain in the shoulder primary comes from soft tissue. The most common cause of shoulder pain is injury of the rotator cuff tendons. Rotator cuff is a tendon-muscle envelope of the shoulder joint, it envelopes it from all sides except the bottom. It consists of four muscles:
subskapularis
supraspinatus
infraspinatus
teres minor
The primary function of the rotator cuff is dynamic stabilization of the head of the humerus in relation to the shoulder blade. When lifting the arm there occurs a compression of the rotator cuff tendons, between the head of the humerus on the one hand and on the other the upper part of the shoulder blade (acromion). This condition is called impingement syndrome (from English “impinge”, which means to hit against something). In Croatian, the best expression is “subakromijalni sindrom sraza” (subacromail impingement syndrome). Each narrowing of the subacromail space causes impingement syndrome. Narrowing of the subacromail space may arise because of the shape of acromion, bone spurs of acromion, and fractures of the greater tubercule of the humerus. Subacromail impingement syndrome is divided into three progressive stages.

Edema and haemorrhage occur in the first stage in case of too intensive overhead activities (arm lifted above head height). Since this is a matter of excessive straining, rest should spontaneously bring to recovery. When training sports where overhead activities are common, subacromail impingement syndrome appears secondary – as a consequence of anterior shoulder instability.

In the second stage, fibrosis and tendinitis appear as a result of repetitive micro-traumas with inflammation and thickening of the subacromail bursa and rotator cuff tendons. While the volume of tendons and bursa is increasing, the subacromail space is diminishing and there is an even larger compression of the rotator cuff tendons.

In the third stage, with further wearing away of the rotator cuff tendons, there occurs a partial or total tendon rupture.

In the first and second stage, conservative treatment is applied; based on simply avoiding to use the arm in overhead activities, stretching exercises and taking non-steroidal anti-inflammatory medications. If conservative treatment shows to be unsuccessful, arthroscopic surgery – subacromial decompression is performed as a routine surgery nowadays. Its purpose is to expand the subacromial space and prevent the humeral head and shoulder blade (acromion) from being in contact.

In the third stage, surgical treatment prevails; this is based on arthroscopic reconstruction of the rotator cuff tear.

2. Rotator cuff tear

The most common cause of the rotator cuff tear is wearing away i.e. degeneration of the rotator cuff tendons, and only at second place the cause is the subacromail impingement syndrome. Patients with rotator cuff tear are almost always more than 40 years old, they complain about shoulder pain and a feeling of weakness when lifting the arm. Rotator cuff can be repaired by a classic technique, open or arthroscopic technique (surgery where the doctor is working with a camera through small incisions). In Akromion Hospital, arthroscopic transosseous suture anchor technique for rotator cuff repairs is performed routinely (see chapter rotator cuff).

3. Calcific tendonitis of the shoulder

Calcific tendonitis of the shoulder or calcific tendinopathy (chalk in the shoulder) is a common condition of purely unknown etiology which is characterized by calcium deposits in rotator cuff tendons with spontaneous resorption of calcium deposits and consequently tendon healing. While calcium is depositing, the patient usually has no major difficulties. But, during resorption of calcium deposits, the shoulder is extremely painful because of the vascular proliferation and increase in intra-tendon tension. During the formation phase, the patient complains of uneasiness rather than pain. In the acute, resorption phase, the pain is so strong that the patient keeps the arm close to the body and does not tolerate any movements. X-ray imaging and shoulder ultrasound show calcium deposits within the rotator cuff tendons, supraspinatus tendon in most cases.

Chronic, formation phase requires conservative treatment with maintaining shoulder mobility, rarely does it call for corticosteroid injections. In the acute phase, because of the great pain, stipple and lavage are necessary in order to decrease the pressure in the tendon, plus, at the same time, administering corticosteroids with local anaesthetic. Patients who have had calcium deposits in the shoulder for months or years are recommended to have the deposits removed. This is performed by an arthroscopic technique (Fig. 1). The surgery is performed through two small incisions, 5-6 mm in size.

Fig. 1 Shoulder joint. Needle protruding through calcium deposits of the supraspinatus tendon, becomes filled with calcium deposits.
Fig. 2 Subacromial space. Incision on the tendon, calcium deposits are resected

4. Frozen shoulder

Frozen shoulder is a syndrome best described by the name PHS. This is a syndrome of unknown etiology characterized by pain and restricted movements in the shoulder, regardless of the direction. The cause of frozen shoulder can be found in other illnesses, including tumors. It affects patients between the ages of 40 to 60. More often, it is found in diabetics.

Frozen shoulder syndrome develops through 4 phases:

Phase 1. It usually lasts for 3-4 months, patients complain about shoulder pain. The pain restricts movements in the shoulder. Patients usually connect the beginning of this illness with a minor injury of the arm (Fig. 2).
Phase 2. This phase is known as the “Freezing stage”, it last from 4 to 6 months. Characteristic of this phase is strong pain and decrease in all motions in the shoulder. Loss of motion is the outcome of shortening and thickening of the joint capsule.
Phase 3. Third phase is really the frozen shoulder. Its duration is 3 to 6 months. Active and passive motions are restricted in all directions. The pain is lesser, but it appears when making sudden movements.
Phase 4. This phase is the recovery phase and lasts for 6-9 monhts. Shoulder movements are gradually returning, the pain is disappearing.
Changes are reversible and in most cases recovery sets in within 2 years. Stiff shoulder is a clinically clear entity with a predictable prognosis in most patients. Clinically, active and passive motions are equally restricted in all directions. In the initial phase, because of the pain, the patient keeps the arm in internal rotation, in a protected position and avoids any usage of the elbow or hand.

The goal of the treatment is to reduce the pain and prevent further shoulder stiffness. It is important to familiarize the patient with the nature of the illness. In very painful, hard-core cases, arthroscopic technique is used to relax the joint capsule which has become short and thick whereby relieving the pain and shortening time of recovery.

Fig. 3 Inflamation of the joint capsule around biceps tendon

5. Acromioclavicular joint arthrosis and humeroscapular joint arthrosis

(AC) Acromioclavicular joint arthrosis most commonly appears as consequence of injuries and AC joint instability. The pain occurs when lifting the arm over 120 degrees, in sudden horizontal adduction and when performing internal rotation of the hand behind the back. Radiologically, there is a narrowing of the joint cavity along the lateral bone spurs. Patients are recommended to avoid using the arm in overhead activities and take non-steroidal anti-inflammatory medications. In order to reduce pain, steroid injections are administered, intra-articular. In case of a joint altered by arthrosis, the external part of the collarbone is resected arthroscopically.

Shoulder joint arthrosis is, like any arthrosis, also characterized by the narrowing of the joint cavity, sclerosation of the subchondral bone and bone spurs. Patients complain about constant pain and decreased hand mobility. Bone spur (osteophyte) typically appears in the lower part of the humeral head. Conservative way of treatment includes administering non-steroidal anti-inflammatory medications, decrease in physical activity and physical therapy. In advanced cases, implant of shoulder endoprosthesis is indicated.

6. Posterior shoulder dislocation

Posterior shoulder dislocation occurs rarely, but very often it remains overlooked. Patients with chronic, unrecognized posterior shoulder dislocation go through different physical therapy threatments, without any improvement whatsoever.

Posterior shoulder dislocation happens in epileptic seizures, electro-shocks and when a person falls down and lands on the shoulder – severe trauma (for instance, when falling down off a motorcycle). Clinical features are characteristic. The arm is in internal rotation, external rotation is impossible. The main reason why acute posterior shoulder dislocation is not recognizing the clinical features and uncorresponding radiological treatment. In chronic posterior shoulder dislocation, the head of the humerus hits against the rear line of the shoulder blade (glenoid) whereby causing a fracture of the humeral head. Treatment method depends on the size of this defect (Fig. 3). In minor defects, transposition of a part of the humeral head into the defect in question is performed. In larger defect, shoulder endoprosthesis is implanted.

Fig. 4 Posterior shoulder luxation. Humeral head is pressed against the back line of the shoulder blade.
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