Shoulder

The tendons of the rotator cuff run along a space (subacromial space), situated above the portion of the scapula called the “acromion” and below the head of the humerus. A serum bag is located between the bones and tendons and facilitates their sliding.

The rotator cuff is a common source of shoulder pain. The pain can be caused by:

• Tendinitis: the tendons of the rotator cuff can be irritated or damaged. The degenerative process of the tendons alters their resistance and elasticity to the point of tearing, which can be spontaneous or due to a trauma.  One specific type of tendinitis is caused by the formation of calcifications in the tendon area. It is a primitive disorder for which the causes are not known and is called Duplay’s disease; it most frequently affects young people (mostly women).
• Bursitis: The serum bag can become inflamed due to overuse and cause pain.
• Impingement syndrome: the sub-acromial space can be reduced for many reasons, causing irritation of the tendons during their movement and cause inflammation. Raising the hand and the arm naturally reduces this space and can cause pain even in a normal shoulder.

Pain originating in the rotator cuff is common both in young athletes that play sports where the arms are used in a raised position (swimming, baseball, tennis, volleyball, etc) and in middle-aged patients that work in professions where repetitive activities with raised arms are required (painters, artists, bricklayers, etc).

In elderly patients, on the other hand, the degenerative process is the main cause of the evolution of pain from rotator cuff disorders.

The tearing of the tendons of the rotator cuff can occur after more or less severe traumas; the more a tendon is inflamed and/or degenerated, the more it will be subject to ruptures.

The disorders of the cuff normally cause pain spread throughout the shoulder (especially in the front portion), loss of strength and major functional limitation up to rigidity. In the beginning the symptoms can be light; in the most acute phases the pain is present even while resting and night-time pain is common.  Simple movements such as brushing your hair, latching your bra or getting your wallet from your back pocket can become impossible.

The treatment of rotator cuff disorders is aimed at reducing pain and recovering functional use.In most cases, initial treatment is conservative. Even if this treatment can last several weeks or months, many patients note a gradual improvement and recovery of use.

In acute phases, a systemic and local anti-inflammatory therapy along with cryotherapy (ice) can help treat the symptoms. The doctor could suggest absolute rest or the modification of some activities. In more severe cases infiltrations with cortisone solutions could be indicated.

Physical-rehabilitative therapies for recovering mobility and shoulder strength are the second and most important step in the path to resolving symptoms. A particularly effective physical therapy used for shoulder disorders consists in focal shock waves, high-pressure acoustic waves that through pressurized impulses stimulate the activation of natural biological tissue repair processes, in particular tendons.

The physical therapy will initially concentrate on regaining normal shoulder movement. Stretching exercises are very useful for improving the range of movement. If there is difficulty with intra-rotation (bringing the hand behind the back), there could be a retraction of the posterior capsule. In these cases, a specific lengthening of the posterior capsule through exercises and kinesiotherapy maneuvers can be very helpful in limiting pain.

As the symptoms improve, a program to strengthen the muscles of the rotator cuff will be introduced.

Surgical treatment is reserved for cases that do not show improvement from conservative treatment and whose symptoms cause a substantial limitation in the practice of normal daily activities.

The objective of the surgery is to increase the sub-acromial space in order to decompress the tendons of the cuff. The so-called acromioplasty foresees both the removal of the inflamed bag (bursectomy) and a partial removal of the acromion. These procedures can be done with either an arthroscopic or open procedure.  The arthroscopic techniques allow for the minimally invasive treatment of most rotator cuff disorders and a quicker recovery period.

In the case of tearing of the cuff, tendon sutures can be added to the abovementioned surgery. There are multiple techniques for suturing injured tendons and each has different indications based on the type of injury.

Of critical importance for recovery after the surgical treatment is an intense and targeted rehabilitation program that includes mobilization, stretching and muscle strengthening exercises to allow for the complete re-education of the shoulder.

Shoulder instability is a condition in which the capsular ligament structures are no longer able to maintain the head of the humerus perfectly attached to the glenoid portion of the shoulder blade. The patients that suffer from this disorder, therefore, feel a sensation of anomalous movement in their shoulder, especially during certain movements in space (generally extra-rotation-abduction).

If the shoulder partially exits the glenoidal cavity it is known as a subluxation, if it completely comes out and a relocation maneuver is required it is a dislocation.

Patients with shoulder instability frequently complain of a feeling of discomfort and instability.

Shoulder instability mainly affects three types of patients:

1. Patients who have previously had traumatic dislocations – the patients who, due to a trauma, have already suffered an episode of shoulder dislocation can develop a chronic instability due to the tearing of the capsule, ligaments and glenoidal lip at the time of the trauma. If the instability is particularly strong, numerous episodes of habitual dislocation can occur even after simple movements.
   
2. Young athletes – athletes that play sports in which the upper body is used with movements above the shoulder itself (volleyball, swimming, tennis, etc), put the capsule and ligaments under repeated and violent stress which can lead to this type of instability, defined as multidirectional.
3. Hyperlaxity – these are patients with a generalized laxity of the connective tissues due to a disorder (Ehlers-Danlos syndrome, Marfan syndrome, rheumatoid arthritis, imperfect osteogenesis, lupus erythematosus, polio, Down’s syndrome, Morquio’s syndrome, clediocranic disintegration or congenital myotonia) or to a para-physiological condition that prevalently affects young women.

The treatment of shoulder instability depends on the type and the severity of symptoms.

The majority of patients with multi-directional instability or hyperlaxity respond well to the physical-rehabilitative therapies aimed at joint stabilization through targeted reinforcement of the shoulder girdle.

Surgical treatment is reserved for patients with the so-called Bankart injury (disengagement of the glenoid labrum) following a dislocation and who show a marked instability with recurring episodes of dislocation.

The suture of the labrum arthroscopically (anterior capsuloplasty) has reached high qualitative standards in recent years, with very low recurrence rates.

In any case a specific rehabilitative program under the guidance of expert physical therapists will allow for full recovery of the joint and muscular tone.

Frozen shoulder, also known as adhesive capsulitis, is a primitive disorder of the shoulder that affects approximately 2% of the population (most frequently women between the ages of 40 and 60), which causes pain and shoulder rigidity. The cause of this disorder is not yet fully understood; it is believed to be an autoimmune process in which the capsule is inflamed, thickens and tightens, developing adherences that reduce active and passive mobility.

Predisposing factors are believed to be diabetes, hypo- and hyper-thyroidism, Parkinson’s disease, and cardiac disease.  Even the immobilization of the shoulder following surgical interventions or traumas (fractures or other injuries) can trigger the freezing process. It is, therefore, fundamental to reduce immobilization to a minimum and start the process of joint re-education early in order to prevent it.

As the disorder progresses, the shoulder will become increasingly rigid and immobile.

It develops in three phases:

1. Freezing phase: in this phase the shoulder pain progressively increases and the shoulder loses mobility. The freezing normally lasts anywhere from 6 weeks to 9 months.
2. Frozen phase: the painful symptoms can improve in this phase, but the rigidity remains. The frozen phase can last from 4 to 6 months, and it can be difficult to perform even common daily tasks.
3. Thawing stage: shoulder movement slowly improves (lasts between 6 months and 2 years) until near total recovery of movement and strength.

The objective of the treatment for frozen shoulder is to control the pain and recover movement and strength through physical therapy. More than 90% of patients improve with physical-rehabilitative treatment.

Anti-inflammatory drugs and infiltration therapies with cortisone solutions can reduce inflammation and thus pain, but joint mobility remains of fundamental importance: rehabilitative protocols call for both autonomous and assisted stretching exercises.

In rare cases a surgical approach is necessary, which foresees manipulation and mobilization under anesthesia as well as arthroscopic lysis treatments on adherences and capsulotomies to increase the volume of the joint and make the motion of the head of the humerus more fluid.

Another cause of shoulder pain comes from arthrosis, a chronic-degenerative disorder that gradually leads to constant pain and functional limitation. Even if the shoulder is not a load-bearing joint, factors influencing the evolution of the disorder include sports and strenuous work on that joint, previous tendinopathies or tears in the rotator cuff.  Generally symptoms start around the age of 55-60 years and the disorder develops slowly, worsening with time.

The physical therapies, (instrumental and/or rehabilitative) are effective remedies for improving symptoms, however when these treatments don’t work, prosthetic surgery can become the only alternative.

Even if the prosthetic substitution of the shoulder is less common than that of the hip or the knee, it is just as effective at alleviating joint pain.

There are different types of prostheses for different situations; the surgeon will carefully evaluate the clinical and pathological conditions and choose the type of prosthesis on the basis of various factors.

Total prosthesis: indicated in degenerative pathologies (arthrosis, arthritis, etc) and are made up of a humeral component with a stem to anchor into the humeral canal, and a glenoidal component (implanted into the scapular glenoid) in direct contact with the head of the prosthesis and made up of plastic material. The prosthetic components can be press-fit or cemented with acrylic bone cement.

Endoprosthesis: in the case of complex fractures of the humerus head or when it goes into necrosis due to a vascular crisis, only the humeral component is substituted, while the scapular portion is not. The choice for using this type of implant depends on factors linked to the quality of the joint or bone cartilage as well.

Resurfacing prosthesis: this consists in the substitution of only the surface of the joint of the humeral head with a prosthesis with no stem. The major advantage of this type of prosthesis is that of conserving bone and it is a valid alternative to conventional shoulder prostheses. Resurfacing prostheses are recommended for young and active patients, in that they reduce wear and tear and thus the risk of prosthetic mobilization. Thanks to its more conservative nature, the resurfacing prosthesis can be easily converted later on, if necessary, into a total prosthesis.

Reverse prosthesis: in this type of prosthesis the joint components are inverted. The hemisphere is implanted in the glenoid while the concave portion with which it articulates is inserted into the humerus. This very particular prosthesis is recommended for patients with a total tear in the tendons of the rotator cuff that would not have great results from the implant of a conventional prosthesis. The concept of the resurfacing prosthesis is the use of the deltoid as the engine of the shoulder as an alternative to the cuff muscles which are no longer functional.

After the prosthetic intervention on the shoulder, with whichever implant was chosen, early mobilization and an intense and specific rehabilitative program are very important for recovery. Active and passive mobilization exercises will be started immediately and later a muscle strengthening program, able to obtain the best results from this type of intervention, will be set up.