Bursitis – Calcified shoulder – Impingement
These three associated and often very painful clinical pictures of the shoulder joint are often the result of incorrect posture and incorrect loading of the joint. Muscular imbalances lead to dynamic constriction of the tendons of the rotator cuff, inflammatory reactions of the bursa (bursitis subacromialis) and calcium deposits in the tendons (tendinipathia calacarea).
Therapy initially includes various non-surgical approaches such as physiotherapy, anti-inflammatory drugs and also infiltrations. Here, therapy with autologous growth factors (platelet rich plasma therapy, ACP therapy) represents a modern treatment approach.
If symptoms persist, arthroscopic surgery may be indicated after non-operative measures have been exhausted.
Tendon ruptures and instabilities
Ruptures of the tendons of the rotator cuff can be caused by accidents or by degenerative processes. The tendon of the supraspinatus muscle is most frequently affected; in the case of extensive ruptures, the tendon of the infraspinatus muscle is also involved. Pathologies of the subscapularis tendon are often associated with instability or injury of the long biceps tendon. With greater trauma, all tendons may also avulse (hood avulsion) or the bony attachments (greater and lesser tuberosity) may avulse from the humeral head.
In the case of small tendon ruptures that do not affect the entire tendon cross-section (partial ruptures), physiotherapeutic treatment alone can sometimes be useful.
Larger tears and especially tears with displacement of the tendon components due to muscle pull have a poor spontaneous healing tendency and almost always require surgical therapy. In most cases, the tendons can be reattached to their insertion purely arthroscopically or via small accesses (mini open repair) with the aid of suture anchors.
In the case of pathologies of the long biceps tendon, depending on the injury pattern, it can be refixed at its attachment with anchors (SLAP lesion) or must be severed there (tenotomy) and can be reattached to the head of the humerus with suture anchors (biceps tendon tenodesis).
In contrast, avulsion fractures of the tuberosity must usually be fixed openly with screws or small plates.
Shoulder dislocation and chronic instability
Traumatic shoulder dislocations occur only in severe direct trauma and are extremely painful injuries in which the humeral head slips out of the socket of the scapula. In addition to bony injuries to the humeral head (Hill-Sachs lesion, reversed Hill-Sachs lesion), there are also extensive capsular ligament injuries as well as avulsions of the cartilaginous glenoid rim (capsule-labral complex) to bony avulsions (Bankart lesion, reversed Bankart lesion and subgroups) and glenoid fractures.
The deformity in the joint can also cause damage to sensory and motor nerves of the affected arm and vascular injuries. Emergency reduction of the joint with radiographic control should always be followed by further evaluation with MRI or, better yet, contrast MRI to assess the extent of associated injuries.
In some cases, nonoperative treatment with immobilization in a shoulder-arm bandage for several weeks may be sufficient. In young and active patients, however, a surgical procedure with arthroscopic refixation of the torn structures with small suture anchors is indicated in many cases due to an expected very high recurrence dislocation rate of up to 90% with conservative therapy. This can significantly reduce the recurrence rate and significantly improve the functional outcome.
Chronic instability can develop after inadequate or failed therapy following initial dislocation. In this case, the remaining instability can cause the humeral head to dislocate again even during minor trauma or everyday movements because there is insufficient stability due to the inadequately healed initial injury. In many cases, arthroscopic stabilization can still be performed after scarring of the scarred structures. In rare cases, after frequent subsequent dislocations, bone loss may occur at the glenoid rim. In these cases, arthroscopic stabilization can no longer be performed successfully and open reconstruction of the cup with pelvic bone (J-Span) or replacement surgery (Latarjet surgery) becomes necessary.
Acromioclavicular joint injuries
Acromioclavicular joint injuries often occur as a result of a fall on the shoulder and are a common sports injury. The acromioclavicular joint is the only bony connection between the trunk and the shoulder and is stabilized by a joint capsule with additional acromioclavicular and strong coracoclavicular ligaments. Within the joint, between the cartilage-covered surfaces, is the discus articularis, a meniscus-like structure that functions as a buffer.
AC joint injuries can range from tearing of the ligaments, to tears of individual ligaments with mild joint slackening, to complete rupture of all stabilizing ligaments with significant joint slackening and pseudo-extension of the outer end of the clavicle.
For lower grade injuries, a good result can often be achieved with non-surgical therapy involving immobilization in a shoulder-arm brace followed by physical therapy. Higher grade injuries with rupture of all ligaments and pronounced instability, on the other hand, are often an indication for surgery in younger and athletic patients or patients with occupations involving overhead work.
In surgical treatment, the AC joint is visualized via an open approach after arthroscopy of the glenohumeral joint to assess and treat associated injuries. Discus injuries can be treated and the stabilizing ligaments are stabilized with suture straps after exact alignment of the joint.
Fracture treatment of the shoulder girdle
Fractures of the shoulder girdle usually occur as a result of direct trauma in the context of falls and can affect the scapula, the clavicle or the upper amniotic bone.
A large proportion of scapula fractures can be treated conservatively because the fracture parts are largely held together in a stable manner by the adherent muscles. The exceptions are severely displaced fractures of the neck and joint fractures; these are usually set up open and stabilized with plates and screws.
Clavicle fractures can often be treated conservatively with a figure-of-eight sling bandage (satchel) or shoulder brace for a few weeks if there is only minor displacement of the fracture fragments. In cases of severe displacement of the fracture fragments with parts of the trapezius muscle trapped in between or significant shortening in the fracture area as well as additional scapula fracture (floating shoulder), surgical treatment is indicated. After exposure and setting of the fracture fragments, stabilization is performed with a stable-angle plate and screws or with a titanium intramedullary nail. This also allows early motion therapy.
Fractures of the head of the humerus or the third of the humerus close to the body can be treated conservatively with good success if there is only a slight displacement. After immobilization for 3 to 4 weeks, exercise therapy can be started if consolidation begins.
Articular fractures or multi-fragmentary fractures with more severe displacement should be treated surgically; if the blood supply to individual fracture parts is at risk, for example in the context of dislocation fractures, this must even be done on an emergency basis in order to be able to maintain the vitality of the humeral head. In many cases, the fracture fragments can be set up and stabilized with an angle-stable plate and screws or an intramedullary nail. This usually allows for immediate postoperative exercise treatment and can also prevent stiffening.
After the fracture has healed, an individual decision can subsequently be made together as to whether or not removal of the implants is advisable. In cases where movement is still restricted or there are residual complaints, this can also be combined with shoulder arthroscopy in order to improve the function of the shoulder.
Circumscribed cartilage damage (focal cartilage lesions) can be caused by trauma – after fractures, dislocations, chronic instabilities or tendon injuries, but also by incorrect or overloading of the shoulder joint during sports or heavy physical work.
Several treatment options are available, ranging from physiotherapy to improve muscle balance and joint centering, arthroscopic surgery with removal of the defective cartilage and bone marrow stimulation by drilling (microfracture, nanofracture) and defect coverage with cell-free membranes, to open surgery with autologous bone and cartilage transplantation (MACT) for large cartilage defects.
Shoulder joint arthrosis
Cartilage damage in the context of shoulder arthrosis (Omarthrosis) is treated with conservative or surgical measures in a stage-adapted manner. In the case of localized osteoarthritis in the early stages, a combination of physiotherapy, chondroprotective nutritional supplements and injections with autologous growth factors (PRP therapy, ACP therapy, autologous blood concentrates) can often achieve a significant improvement. Shoulder arthroscopy with cartilage smoothing and removal of local osteoarthritis follow such as bone spurs can also contribute to pain relief.
In advanced or generalized osteoarthritis, pain relief can often still be achieved with infiltrations and physical therapy. After conservative measures have been exhausted, the implantation of a total endoprosthesis of the shoulder joint can bring about a permanent improvement in shoulder function as well as pain relief. Several systems are available for this purpose, which are individually selected for each patient in order to achieve an optimal result.