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Common diagnoses for shoulder pain
There are hundreds of diagnoses inherent to shoulder pathologies. It is necessary to know how to eliminate differential diagnoses due to neurological or rheumatic causes. There are also diagnoses relating to certain sporting practices and certain professional activities. We describe in the section below the most frequent pathologies.
The rotator cuff is a muscle group that provides mobility and stability to the shoulder by centering the humeral head in front of the glenoid of the scapula. Muscles are linked to bones by tendons, and when these are torn due to trauma or wear and tear on your joint, your shoulder can no longer function properly.
The mobility and stability of your shoulder are ensured by the combined action of different muscles that make up the rotator cuff. It is so called because these muscles somehow "cap" the humeral head.
When the tendons, which attach the muscles to the bones in your joint, are damaged, the normal function of your shoulder is made difficult. The humeral head can no longer rotate correctly around its center of rotation, it may tend to rise and come into contact with the acromion, creating a subacromial impingement .
Some patients are more bothered by the functional limitation, others by the pain, but this is not related to the severity of your condition: some massive ruptures can be relatively painless while more superficial inflammations can be more painful .
There are different stages of severity in rotator cuff tears, a distinction is then made between partial or superficial tears, which do not pierce the tendon, and complete or full-thickness tears.
A tendon tear in the rotator cuff muscles impairs the functioning of the shoulder, resulting in loss of strength and often insomnia pain. These pains, relieved by rest, are exacerbated by all the work done above the plane of the shoulders.
Muscle strength is diminished due to pain and tendon tearing.
The doctor's clinical examination looks for signs of a subacromial impingement and specifically tests each rotator cuff tendon.
Faced with a suspicion of rotator cuff tear, a radiographic and ultrasound assessment is essential before consulting an orthopedic surgeon.
The radiographic assessment will be supplemented by an Arthro-scanner or an MRI to define the importance of the tendon rupture, and the prognostic elements.
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Anti-inflammatory drugs, infiltrations and rehabilitation represent the first-line therapeutic arsenal. However, these treatments do not allow repair. If pain persists, your surgeon may suggest shoulder surgery . This intervention has two purposes:
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Remove the subacromial impingement by flattening the acromion (making the parrot's beak disappear).
The intervention takes place under outpatient arthroscopy ,
The clinical picture may be identical to that of a full-thickness rupture. It is dominated by pain that is often insomnia, relieved by rest, exacerbated by all the work done above the level of the shoulders. Muscle strength is diminished due to pain.
The surgeon's clinical examination looks for signs of subacromial impingement and specifically tests each rotator cuff tendon.
Faced with a suspected lesion of a tendon of the rotator cuff, an X-ray and ultrasound assessment is essential before consulting an orthopedic surgeon.
In second intention, the MRI makes it possible to quantify the importance of the lesion, in percentage of thickness of injured tendon.
These tendinopathies are of various origins:
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Secondary to a subacromial impingement when the acromion is aggressive on the superficial part of the tendon of the supraspinatus muscle.
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Secondary to a postero-superior conflict . In the throwing athlete, the decentering of the humeral head can damage the deep surface of the tendon of the infraspinatus muscle.
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Primary, when the anomaly comes from the tendon itself. Two causes can be mentioned. A vascular cause: the terminal portion of the supraspinatus is a poorly vascularized and particularly fragile area. A degenerative cause: the normal aging of the tendons of this particularly strained joint.
The treatment of unruptured tendinopathies is above all medical and re-education .
It is based initially on resting the shoulder, taking non-steroidal anti-inflammatory drugs, and corticosteroid injections in the most painful forms.
On a supple and painless shoulder, muscle rebalancing work for the benefit of shoulder depressors is secondarily implemented.
Calcifying tendinopathy of the shoulder is manifested by inflammatory pain, often insomnia and which can be exacerbated when the calcification appears or disappears.
Radiological diagnosis is essential to characterize the situation and the type of calcification. The repetition of radiological images is useful over time to judge the evolution of a calcification, or even its spontaneous disappearance.
It is a benign and very common condition, affecting especially women whose age is between 30 and 50 years old.
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The first treatment to be offered is a drug treatment including analgesics and anti-inflammatories.
An infiltration is often proposed.
The treatment representing the best risk benefit is a washing puncture performed under local anesthesia, guided by ultrasound. The washing puncture eliminates the calcification. The painful symptom disappears in 3 to 4 weeks.
However, depending on the size of the calcification, arthroscopic surgery may be required to remove it. This intervention requires a very short, outpatient hospital stay.
The bony rim that is felt above the head of the humerus is a part of the shoulder blade called the acromion . This can become aggressive for the tendons of the cuff when a bony outgrowth in the shape of a parrot's beak (entesophyte) develops. The friction of the acromion on the tendons of the rotator cuff then causes a painful inflammation of the bursa which surrounds them ( impingement under acromial ).
The clinical examination finds a painful attachment when the trochiter of the humerus comes into contact with the acromion.
It can be sensitized by an infiltrative test (infiltration in the subacromial bursa).
X-rays are essential to characterize the shape of the acromion.
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Treatment of subacromial impingement is primarily medical.
it consists of infiltrations and rehabilitation.
lasting relief from shoulder pain.
Your surgeon may suggest you a procedure: an acromioplasty
This action has two goals:
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Remove the subacromial impingement by flattening the acromion (making the parrot's beak disappear).
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Check the condition of the rotator cuff tendons.
The intervention takes place under arthroscopy, by means of an optical fiber which penetrates into the shoulder. Two small openings (less than 1 cm) allow the passage of an optical cable and a motorized cutter to flatten the acromion.
The operated shoulder will be immobilized in a splint at the end of the operation for a few days. The post-operative rehabilitation is not desirable. Daily activities are resumed gradually.
Adhesive capsulitis is a stiff, "frozen" shoulder related to a retraction of the capsule. The clinical picture is characterized by pain and a passive limitation of articular amplitudes.
The duration of evolution can be particularly long, several months.
If no additional examination is necessary to confirm the diagnosis, the cause must however be sought.
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The causes of adhesive capsulitis are multiple:
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Shoulder pathologies: calcifying tendinopathy of the rotator cuff , rupture of the rotator cuff , surgery, trauma.
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General pathologies: myocardial infarction, diabetes, taking barbiturates, dysthyroidism.
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The treatment of adhesive capsulitis is medical.
the purpose of the treatment is twofold:
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reduce pain
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improve shoulder range of motion.
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Therapeutic means are:
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Analgesics can be combined with muscle relaxants to allow better muscle relaxation and facilitate rehabilitation.
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In some cases, intra-articular infiltration can be proposed.
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Rehabilitation : Decontracting massages, relaxation postures and stretching are essential and the recovery of amplitudes
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When the humeral head dislocates and comes out of the cavity of the glenoid, we say that the shoulder "dislocates". If the first shoulder dislocation generally occurs accidentally, the repetition of the phenomenon can lead to significant bone, cartilage and ligament damage.
In the shoulder joint , the contact surface between the humeral head and the glenoid of the scapula is quite small. It is not a fully interlocking joint, like the hip for example, and its stability is largely ensured by the joint capsule.
We speak of dislocation when the humeral head comes out completely , or of subluxation when it comes out partially. When these phenomena are repeated, we speak of shoulder instability .
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Anterior instability (95% of cases)
It is a pathology mainly affecting young adults. Two populations are particularly exposed to the risk of dislocation and instability of the shoulder : hypermobile patients (very flexible) and those who practice sports or activities at risk soliciting the shoulder in its extreme amplitudes ( rugby, handball, basketball, combat sports, climbing). The traumatic context is then frequent, but the clinical presentation is sometimes more frustrating, only marked by pain without any real episode of dislocation: we then speak of an unstable painful shoulder.
Complementary examinations include x-rays and arthroscanner, looking for bone passage lesions and ligament lesions. The injection of contrast product, during the realization of an arthro-scanner, makes it possible to appreciate the state of the inferior glenohumeral ligament (often broken on its glenoid insertion) and the state of the glenoid bead. It can also be used to look for a fracture of the antero-inferior edge of the glenoid.
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Posterior instability (5% of cases)
Apart from the traumatic nature, which is rare, posterior instability is very often part of the field of ligament hyperlaxity. This instability can sometimes be voluntary.
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Treatment of instability first requires specific rehabilitation, emphasizing muscle strengthening (particularly of the medial rotator muscles) and proprioceptive work (proprioception work is based on rehabilitation of postural adjustment, balance and movement of the body in space. It improves the ability to anticipate muscle contraction).
In case of failure: recurrence of instability or persistence of pain, your surgeon may be required to offer you surgery.
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Two techniques exist:
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The coracoid stop , which consists of positioning the coracoid process (part of the scapula) on the anterior edge of the glenoid. It is the most reliable intervention, the risk of recurrence is less than 2%.
After the operation, the shoulder will be immobilized in a splint for 15 days. the rehabilitation protocol post-operative period will begin after weaning from the splint.
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Arthroscopic Bankart : intervention performed under arthroscopy which tightens the injured ligament plane.
When throwing, the shoulder acts like a catapult. Armed with the arm, the humerus constitutes an axis of rotation around which the soft parts are wound, particularly the ligaments and the muscles. This area is the center of the lower part of the glenoid.
The shoulders considered to be at risk are those which present a deficit of internal rotation and/or a malposition of the scapula. What makes a shoulder pathology serious in a pitcher is the appearance of glenohumeral intra-articular lesions .
This combination is particularly dangerous for the postero-superior bead, the inferior and posterior part of the supraspinatus and the antero-inferior capsular complex. The clinical examination must be complete, focusing on any pathologies of the kinetic chain concerned during the sporting gesture. An examination of the spine (lumbar) and lower extremities will look for asymmetry of mobility.
The arthro-scan of the shoulder or the arthro-MRI look for lesions of the glenoid bulge and the rotator cuff.
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The vast majority of patients respond to rehabilitation treatment combining a postero-inferior capsular stretching program with specific scapula repositioning rehabilitation.
Here, it is essential to analyze the sporting gesture in an extremely precise way in order to look for a movement that is particularly damaging to the rotator cuff. The reprogramming of the throw is adapted in order to limit micro traumas and overuse lesions as much as possible.
Surgical treatment of the thrower's shoulder can only be done under arthroscopy. There is indeed no traditional surgical way to reach and repair the glenoid insertion of the biceps longus with implant-mounted wire suture.
Shoulder osteoarthritis is often well tolerated, manifesting itself in pain occurring when the upper limb is solicited. These mechanical pains are frequently associated with stiffness which can be the main reason for consultation.
It is necessary to know how to distinguish between two types of osteoarthritis in the shoulder depending on the condition of the rotator cuff.
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When the rotator cuff is intact, osteoarthritis is said to be centered , corresponding to the only degradation of the humeral and glenoid articular cartilage.
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On the other hand, when the rotator cuff is largely ruptured, the head of the humerus rises above the glenoid during the elevation of the arm through the ruptured rotator cuff. Osteoarthritis is then called eccentric ( eccentric omarthrosis , due to the eccentricity of the humeral head).
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Simple X-rays allow the diagnosis of osteoarthritis of the shoulder to be made on the narrowing of the glenohumeral joint space.
Faced with a centric osteoarthritis , the use of ultrasound of the rotator cuff is valuable to ensure the normality of the rotator cuff.
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The treatment of shoulder osteoarthritis is primarily medical since functional tolerance is often good. It includes analgesics and intra-articular injections.
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It is also necessary to know how to propose a rehabilitation adapted to a beginner eccentric osteoarthritis (rehabilitation of decoaptation under acomiale).
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Faced with the failure of medical treatment, your surgeon may have to offer you an intervention to relieve you of your pain: this intervention is the shoulder prosthesis.