Causes of pain in the right shoulder joint

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Traumatologist-orthopedist > Treatment > Treatment of the shoulder joint

Rotator cuff injuries Habitual shoulder dislocation Latarge surgery SLAP injury Pathology of the long head of the biceps tendon Problems of recovery after shoulder dislocations

The shoulder is a complex joint made up of four anatomical structures, the movements of which together provide its extensive mobility. During development, stability was sacrificed in favor of mobility.

There are three possible directions of movement in the shoulder joint: flexion and extension in the sagittal plane, abduction and adduction in the frontal plane, as well as external and internal rotation.

The clavicle, scapula, and humerus provide the bony base of the shoulder joint. They are involved in the formation of three double joints: the sternoclavicular joint, the acromioclavicular joint, and the glenohumeral joint. The scapulothoracic joint is the fourth anatomical formation of the shoulder; it is formed by a scapula sliding on a layer of muscle and bursa along the posterior surface of the upper chest. These three bones are fixed to the axial skeleton and controlled by 19 muscles. The muscles are divided into an internal group, which moves the humerus relative to the scapula, and an external group, which moves the shoulder girdle and humerus relative to the axial skeleton.

Rotator cuff injuries

Rotator cuff tendon damage can occur for several reasons:

• degenerative changes;
• narrowing of the space between the acromion and the head of the humerus;
• injury;
• chronic traumatization.

Degenerative changes are associated with poor circulation of the rotator cuff tendons, the aging process and tissue wear, as well as qualitative changes in the collagen fibers in the tendons.

Narrowing of the space between the acromion and the head of the humerus (impingement syndrome) occurs due to the special structure of the acromion process or after injury. The tendon of the supraspinatus muscle, passing through this space, falls into a vice, as it were, and is gradually compressed.

Typical injuries are a fall on the shoulder joint or on an outstretched arm, a sudden lifting of a heavy object, or a sudden movement of the arm to the side.

Frequent microtraumas of the shoulder joint area occur in people with heavy physical labor and throwing athletes. Typical professions include those whose work involves prolonged hand position at level 900 and above. These are, for example, hairdressers, dentists, electricians, carpenters, painters.

Symptoms of a rotator cuff tear.

Small tears or partial damage may be asymptomatic. But most often the leading symptom is pain. When an injury occurs, pain occurs sharply, and with repeated stress it intensifies gradually and increases over time. The greatest intensity of pain is determined when the arm is abducted in an arc from 600 to 1200. Periodically, the pain intensifies at night and leads to sleep disturbance.

During the examination, a decrease in muscle strength of the injured limb can be detected. Painful sensations limit the range of motion in the shoulder joint and lead to the development of contracture (stiffness).

Conservative treatment

Partial injuries to the rotator cuff tendons can occur on the articular surface, on the acromion side, or within the tendon. It is advisable to start treatment with conservative methods. The main task is to eliminate the cause of the pathological process and stop inflammation. The patient needs to reduce his physical activity. The doctor prescribes anti-inflammatory drugs, physiotherapy, and exercise therapy. In the absence of confirmation of a full-thickness tear, it is possible to administer subacromial corticosteroid drugs to relieve pain and reduce inflammation.

Recently, much attention has been paid to the possibility of tissue regeneration. As a modern alternative method of non-surgical strengthening of the soft tissue structures of the shoulder, intra-articular injection of platelet-rich plasma (PRP) in combination with shock wave therapy (SWT) is used. Conservative treatment is also considered as a preparatory stage before surgery.

Operation

A full-thickness tear can affect one tendon or several. Massive injuries of the rotator cuff in some cases are characterized as irreparable and require open surgery to plastically replace tendon defects or move other muscles to the rupture zone.

Bioabsorbable implants Titanium implants

For the majority of ruptures, modern arthroscopic suture technologies are used. Arthroscopy is performed under endotracheal anesthesia, which can be combined with conduction anesthesia of the brachial plexus nerves. On the operating table, already under anesthesia, the patient is placed in the “beach chair” position. Arthroscopic intervention involves making 4-5 5mm punctures around the perimeter of the shoulder joint, into which a camera and microsurgical instruments are inserted. With their help, the tendon is decompressed, the subaromial space is cleaned and expanded. The tendon suture is performed after installing special screws (anchors) with non-absorbable threads attached to them into the head of the humerus. Using threads, the tendons are stitched and fixed in the head of the humerus.

The best results of surgical treatment of a rotator cuff tear are observed within up to 3 months from the moment of injury.

Blood supply

In addition to the main source of blood flow - the axillary artery, there are two auxiliary vascular anastomoses (circles) around the shoulder joint. The scapular and acromial-deltoid arterial circles are necessary for additional blood supply to the upper limb. This may be necessary if the axillary artery is damaged or blocked by atherosclerotic plaque.

Their essence lies in the formation of dense vascular networks in the thickness of the deltoid and subscapularis muscles. The vessels feeding these formations depart slightly earlier than the axillary artery. Therefore, if the blood flow through it is disrupted, then these plexuses will allow blood supply directly to the artery of the shoulder.

Since the vessels of these plexuses are small in size, they can provide normal blood flow only if the axillary artery is gradually damaged. Consequently, they will work effectively only with atherosclerosis of this vessel.

Habitual shoulder dislocation

One of the erroneous statements is that a dislocation is better than a fracture. The consequences of a primary dislocation can be quite serious and lead to recurrence of the injury.

Habitual dislocation is a pathological condition in which the head of the humerus is displaced relative to the glenoid cavity of the scapula (instability of the shoulder joint). The cause of dislocation in 90% of cases is trauma, for example: a fall on an outstretched arm, a blow to the shoulder joint, lifting a heavy object, too much swinging of the arms, muscle spasm due to epilepsy.

A predisposition to dislocation is dysplasia - a congenital disorder of the development of connective tissue, in which the joints have increased mobility (hypermobility).

During a dislocation, there is a sudden movement of the head of the humerus, as if it is coming out of the joint. As a result, the supporting elements are damaged: the fibrous lip and ligaments. As the number of dislocations increases, displacement occurs with less resistance. The soft tissue structures do not provide adequate support to the joint and the contacting bones gradually begin to be damaged, which are then erased. Instability of the shoulder joint progresses over time and dislocations can occur even during sleep.

Treatment

The main method of restoring the stability of the shoulder joint is surgical treatment. The most gentle technique is arthroscopy (Bankart operation). If the bone tissue is intact and a good quality fibrous lip is present, refixation of the fibrous lip is performed using special anchored absorbable implants. The entire operation is performed through 3-4 skin punctures of 5-6 mm. Through the first puncture, a camera is inserted into the joint cavity and the image is transmitted to the monitor. The joint is examined from the inside; a tear in the fibrous lip is found. Through other punctures, it is mobilized with special mini-instruments, and the surface of the scapula is cleared of scars. Channels are drilled into the scapula and anchors are inserted into them and secured into the bone. Using threads from these implants, the fibrous lip is stitched and pulled to the cleaned surface of the scapula. Stabilization of soft tissue structures thus restores the anatomy lost during dislocation. It takes time for the fibrous lip to heal, so after the operation the arm is placed in a soft support bandage for a period of 4 weeks.

Movements in the glenohumeral joint

Planes in anatomy

• Abduction (abduction) - raising the shoulder in the frontal plane.
• Flexion (flexion) - raising the shoulder anteriorly in the sagittal plane.
• Extension (extension) - raising the shoulder posteriorly in the sagittal plane.
• Internal rotation (internal rotation) - rotation of the shoulder inward (in the medial direction).
• External rotation (external rotation) - rotation of the shoulder outward (in the lateral direction).
• Abduction in the plane of the scapula is the elevation of the shoulder in the plane of the scapula, which is between the frontal and sagittal planes.
• Horizontal adduction is the inward movement of the shoulder in the horizontal plane (usually accompanied by some degree of shoulder flexion).

Operation Latarget

If the shoulder joint is unstable due to a deficiency of scapular bone tissue, transposition of the coracoid process of the scapula is recommended - the Latarget operation.

The operation is also used in cases of poor condition of the ligamentous apparatus of the shoulder joint, recurrence of dislocation after the Bankart operation, and the absence of a fibrous lip. During the operation, a fragment of the coracoid process (2x1 cm) is cut off. With the muscles attached to it, it is carried through the subscapularis muscle to the anterior surface of the glenoid cavity of the scapula (glenoid). After preparation and correct positioning, it is fixed with 2 screws.

The operation provides restoration of the bone defect of the glenoid due to the transfer of the coracoid process and a supporting effect due to the relocated muscles closer to the head of the humerus.

Recovery and return to previous loads is possible within 3 months after surgery.

Bursae of the shoulder joint

Bursae of the shoulder joint
The shoulder complex has many bursae, the largest being the subacromial bursa. It also includes the subdeltoid bursa as they are often continuous. The subdeltoid bursa allows the rotator cuff to slide easily under the deltoid muscle.

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SLAP damage

Until recently, establishing a diagnosis of SLAP injury was very difficult. With the development of MRI diagnostics and improvement of arthroscopic technologies, this pathology has become mandatory in the practice of shoulder surgery.

SLAP (superior labrum anterior posterior) is characterized by separation of the fibrous lip from the glenoid in its upper segment with anterior and posterior distribution. In this localization, the tendon of the long head of the biceps begins from the fibrous lip, which is the main vector of traction during injury.

The cause of damage is most often trauma: a fall with support on the abducted arm, a blow to the shoulder area, often found in “throwing” athletes (handball, baseball, water polo), boxers.

Conservative treatment rarely leads to full recovery, because a return to specific loads provokes a recurrence of pain and progression of the rupture.

However, in patients without heavy physical and sports activities, complex therapy provides long-term relief from pain. First of all, rest is ensured for the shoulder joint by fixing the arm on a support bandage. Anti-inflammatory non-steroidal drugs are prescribed. To reduce the inflammatory reaction and reduce pain, physiotherapeutic procedures are necessarily used, such as phonophoresis with drugs, high-intensity laser (HILT), shock wave therapy (SWT), massage, and taping. Stimulation of regeneration is achieved by taking chondroprotectors and intra-articular administration of platelet-rich plasma (PRP). After inflammation has been relieved and the resting stage has been completed, proper rehabilitation under the supervision of a physical therapist will be an important factor in restoring function.

Arthroscopic fixation of the fibrous labrum, by analogy with the usual dislocation of the shoulder, is the most rational method of treatment, because ensures precise restoration of anatomical structures. Low-traumatic surgery reduces rehabilitation time. Under camera control, anchors are installed into the glenoid cavity of the scapula and the fibrous lip is returned to its place using non-absorbable sutures.

Diagnostics

Traumatic injuries are managed by traumatologists; for pain of non-traumatic origin, patients turn to rheumatologists or orthopedists. Specialists collect complaints, conduct an external examination, establish the time and circumstances of occurrence, the dynamics of the development of symptoms, and their dependence on external circumstances. The examination may include the following techniques:

• Radiography.
  Performed in one or two projections. The presence of disorders is indicated by changes in the contours of the humeral head and glenoid cavity, a decrease in the size of the joint space, areas of rarefaction in the thickness of the bone tissue, marginal defects, and osteophytes.
• Ultrasonography.
  When assessing the condition of periarticular soft tissues, it detects hemorrhages, signs of inflammation, degeneration, and foci of calcification. Sonography visualizes loose intra-articular bodies, fluid in the joint, and often allows one to determine the cause of pain.
• and MRI.
  Prescribed at the final stage of the diagnostic search when the data from other methods are unclear, to clarify treatment tactics. They allow you to accurately determine the localization, prevalence and nature of pathological changes of traumatic, inflammatory, tumor origin.
• Joint puncture.
  It is performed if there are signs of synovitis. The resulting liquid is sent for microbiological or cytological examination and studied using immunological methods.
• Biopsy of the synovium.
  It is carried out for rheumatological diseases, specific arthritis, tumor processes for subsequent histological examination.
• Arthroscopy.
  It is carried out for a visual inspection of the elements of the joint and collection of a biopsy sample. When determining pathology, diagnostic measures are complemented by therapeutic measures (for example, removal of loose bodies).
• Lab tests.
  In rheumatic pathology, specific markers of various diseases are identified. In inflammatory processes, an increase in ESR and leukocytosis with a shift to the left are confirmed. In case of oncological lesions, the severity of anemia, the degree of dysfunction of organs and metabolic disorders are assessed.

Pathology of the tendon of the long head of the biceps

Pathology of the long head of the biceps tendon often accompanies other conditions, such as: SLAP injury, impingement syndrome, ruptures of the supraspinatus and subscapularis tendons. However, even an isolated violation of the integrity of the biceps tendon can lead to dysfunction of the upper limb and requires surgical treatment.

The human biceps muscle consists of a long head, which is attached to the upper segment of the articular surface of the scapula, and a short head, which is attached to the coracoid process of the scapula. The short head bears the main load, while the long head gives the characteristic contour to the arm. When the tendon of the long head of the biceps is completely ruptured, a characteristic clinical picture occurs. The long head falls down, as a result the contour of the shoulder is deformed. This symptom is named after the famous cartoon character Popeye due to its resemblance to the hands of a sailor.

Persistent pain syndrome is supported by partial damage to the integrity of the tendon, the development of chronic tendonitis, and tendon instability in the intertubercular groove. It is difficult for the patient to perform rotational movements in the shoulder joint, push-ups and pull-ups. Pain localized in the anterior part of the joint is often accompanied by clicking sounds.

Treatment begins with conservative methods similar to SLAP injuries. To quickly relieve inflammation, a therapeutic blockade is often used. To the tendon area

An anesthetic solution with Diprospan is injected under ultrasound control. The effect is achieved quite quickly, however, in order to prevent relapse, compliance with the treatment regimen and physiotherapeutic treatment is necessary.

If conservative treatment is ineffective, the question of surgical intervention is raised. The development of technology has left no room for open surgery in this matter - all manipulations are performed under the control of an arthroscope through punctures.

The techniques used are varied and combined during the operation: debridement of the tendon (i.e., grinding of it and surrounding tissues), correction of concomitant pathology, subacromial decompression. Tenodesis of the long head of the biceps tendon is recommended for young active patients and athletes. This manipulation is performed at different levels of the intertubercular groove using arthroscopic implants. After fixation to the head of the humerus, the intra-articular part of the tendon is excised. For elderly patients, the method of choice is tenotomy - cutting off the tendon from its attachment to the scapula. This is a simpler method, but no less effective. However, in the postoperative period, Popeye's symptom may develop, about which the patient must be warned in advance.

If there is a complete rupture in a young patient, the first thing to think about is surgical treatment. The essence of the operation is to isolate the torn tendon and fix it to the anterior surface of the head of the humerus (tenodesis) in the intertubercular groove. The operation can be performed either arthroscopically or through an incision.

Muscles of the glenohumeral joint

Muscles of the shoulder complex

Flexors

• anterior portion of the deltoid muscle.

Extensors

• triceps brachii;
• teres major;
• posterior portion of the deltoid muscle;
• latissimus dorsi muscle.

Rotator cuff muscles

• supraspinatus muscle;
• infraspinatus muscle;
• teres minor;
• subscapularis muscle.

Internal rotators

• subscapularis muscle;
• teres major;
• latissimus dorsi muscle;
• pectoralis major muscle.

External rotators

• teres minor;
• infraspinatus muscle.

Abductors

• deltoid;
• supraspinatus muscle.

Adductors

• pectoralis major muscle.

Approach to treating the disease in our clinic

Specialists at the Paramita clinic have developed their own approach to the treatment of shoulder arthrosis. First of all, each patient is carefully examined using the most modern diagnostic equipment (including MRI). Then he is completely relieved of pain using medicinal and non-medicinal methods. At the same time, individual complex therapy is selected for him, including:

• the most modern medications and non-drug techniques, including plasma lifting;
• traditional oriental methods of treating and restoring the function of joints and the whole body; these are acupuncture, moxotherapy, auriculotherapy, taping, etc.

This approach quickly relieves a person of pain and suppresses the progression of the disease. And regular preventive courses allow our patients to forget about the disease and lead a normal life. Numerous reviews from our patients indicate how effective this treatment is.

We combine proven techniques of the East and innovative methods of Western medicine.
Read more about our unique method of treating arthrosis

Causes of shoulder arthrosis

The main causes of shoulder arthrosis:

• consequences of acute injuries - dislocations, subluxations, intra-articular fractures, bruises;
• constant long-term microtrauma associated with profession or sports activities;
• suffered acute and chronic infectious-inflammatory and autoimmune processes in the shoulder joint - acute purulent arthritis, chronic rheumatoid, psoriatic and other arthritis;
• against the background of a chronic inflammatory process in the periarticular tissues - glenohumeral periarthritis, leading to impaired blood circulation and nutrition of cartilage tissue;
• metabolic (metabolic) joint disorders – gouty arthritis;
• hormonal disorders;
• congenital developmental anomalies (dysplasia) - for example, the articular surfaces of the shoulder joints.

Under the influence of any of these reasons (sometimes several at once), the composition and volume of the joint fluid that nourishes the cartilage tissue of the joint is disrupted. The cartilage gradually decreases in volume, cracks, and loses its shock-absorbing properties. This leads to bone injury, its growth along the edges of the articular surfaces, joint deformation and decreased function. In the articular cavity, inflammation of the synovial membrane periodically occurs - synovitis. Because of synovitis, arthrosis is called osteoarthrosis or osteoarthritis, depending on which process predominates (inflammatory or metabolic-dystrophic). As a result of inflammation and necrosis of the bone, small pieces of tissue are separated from it - sequestra or articular mice.

At risk:

• for microtrauma - blacksmiths, miners, tennis players, weightlifters, discus throwers;
• for acute injuries - gymnasts, track and field athletes, circus performers;
• persons with a family history;
• persons suffering from any chronic joint diseases.