Shoulder Pathologies

Anatomy
The tendons of the rotator cuff are:

The supraspinatus tendon: which contributes to shoulder elevation.
The infraspinatus and teres minor tendons: which allow external rotation and, therefore, positioning and maintaining the hand in space (for activities like combing hair, drinking, or using a computer mouse, for example).
The subscapularis tendon: which enables internal rotation (such as reaching the hand to the back).
There is also an “accessory” tendon, the long head of the biceps, with a limited role.

The biceps muscle has a main tendon, the short head of the biceps, which attaches to the coracoid, another area of the shoulder blade. This short head of the biceps provides strength when flexing the elbow. The long head of the biceps is a finer tendon that does not significantly contribute to strength. When it ruptures, it causes an asymmetry in the shape of the biceps (known as the Popeye sign). The rupture may cause pain, similar to cramps, for a few weeks, without causing long-term deficits. The only long-term consequence is aesthetic (Popeye sign). For this reason, although it is located at the shoulder joint, it is not part of the rotator cuff.

Causes
A tendon rupture can be caused by trauma or progressive wear and tear (degenerative origin). The degeneration of tendons and muscles of the rotator cuff naturally occurs over time. The origin can also be mixed, where a degenerative lesion may worsen and enlarge during trauma. During a shoulder dislocation, individuals over 40 years old have an increased risk of associated rotator cuff injury. The risk is extremely low in individuals under 40 years old.

Symptoms
A rotator cuff tendon rupture can cause pain, loss of mobility, and/or a sensation of weakness. The pain is typically localized on the lateral side of the arm and may radiate to the elbow. Nocturnal pain is also common. It is important to note that some patients with rotator cuff tendon tears may be asymptomatic.

Clinical Examination
Clinical examination helps identify potential loss of mobility, loss of strength, and assess which tests trigger the pain described by the patient.

Diagnostic Tests Standard X-rays, although they do not visualize tendons, are necessary. They reveal possible associated lesions: calcification, arthritis. They also indirectly reveal chronic and irreparable rotator cuff lesions. Shoulders with irreparable cuff lesions will show a deformation of the shoulder joint. In such cases, an MRI is not necessary.

An ultrasound is not always necessary. It is an examination that can only be interpreted by the performing physician, and the analysis quality depends on the specialist’s expertise. Moreover, an ultrasound cannot assess if a lesion is surgically repairable because muscle quality is not visible. Therefore, an additional assessment, such as an MRI, is imperative before considering repair surgery. Ultrasound can be useful for targeted injections. Four different areas can be targeted for injections, and performing it with ultrasound increases the precision of the procedure.

MRI is the gold standard examination for quantifying tendon lesions and assessing their reparability (by evaluating muscle quality). In some cases, an arthrogram MRI may be prescribed for better analysis in small or partial tendon lesions.

Treatment
There are two types of treatment for transfixing rotator cuff lesions (involving the entire thickness of the tendon): surgical treatment and conservative treatment.

Conservative treatment is initiated as the first option for partial lesions of the rotator cuff tendons (involving only a portion of the tendon thickness) or for transfixing lesions in older individuals who are primarily bothered by pain associated with the cuff injury. The patient undergoes physiotherapy to strengthen other muscles of the scapular belt and enable the shoulder to “compensate” for the torn tendon. Infiltration may also be considered at the beginning of treatment, depending on the intensity of the pain.

Surgical treatment is intended for:

Young patients (up to 60 years or more, depending on the patient’s activity level)
Patients primarily bothered by the lack of strength due to the cuff lesion
Patients for whom conservative treatment has been ineffective

It involves repairing the torn tendon(s). The surgery is performed arthroscopically through small incisions. Postoperatively, the upper limb is immobilized for 6 weeks. It’s worth noting that the type of brace during the immobilization period depends on the affected tendon(s). The patient undergoes physiotherapy the day after the intervention and is allowed to move the hand, wrist, and elbow based on pain.

After surgery, the shoulder temporarily stiffens, so it is necessary to regain shoulder flexibility before considering muscle strengthening, which comes later. Any stiffness can cause residual pain, so it is crucial to restore all shoulder ranges of motion.

The biological healing of the tendon takes 6 months (at 6 months, the tendon’s strength is 80% compared to a healthy tendon). Therefore, it is normal for shoulder rehabilitation to take several months. It is essential to undergo gradual rehabilitation and avoid carrying heavy loads or making significant efforts at the beginning of rehabilitation. Premature efforts in rehabilitation can lead to re-rupture or non-healing of the repaired tendons. Risk factors for non-healing include diabetes, smoking, muscle quality, tendon retraction during repair, and poor compliance.

In case of irreparable rotator cuff tendon lesions, surgical options mostly include a total shoulder prosthesis, typically of the reverse type. In rare cases, tendon transfers may be considered (latissimus dorsi, lower trapezius, or major pectoral, depending on the affected tendons).

Causes
Subacromial impingement is a mechanical problem that causes irritation and inflammation of the rotator cuff tendons. It can be caused by insufficient scapular muscle strength, intratendinous calcification reducing the subacromial space, or changes in the acromion (calcification of the coracoacromial ligament, which can cause mechanical impingement during certain movements). In severe cases, it may lead to a rotator cuff injury.

Symptoms
Subacromial impingement primarily causes pain, initially during certain movements. Over time, the pain may worsen and become constant. In the context of this inflammation, pain may also be present at night. With time, a loss of mobility (especially due to pain) may occur. It is important to note that the intensity of pain is not necessarily proportional to the severity of tendon involvement.

Diagnosis
The diagnosis of subacromial impingement is a clinical one. It is a dynamic pathology that appears during movement. Complementary examinations (X-rays, ultrasound, or MRI – tailored to the clinical examination) help exclude other pathologies (such as arthritis), identify certain causes of impingement (large intratendinous calcification, calcification of the coracoacromial ligament), and look for complications related to impingement (rotator cuff lesions). Complementary examinations alone cannot diagnose subacromial impingement. Pain can be significant without the presence of a rotator cuff tear.

Treatment
The treatment of subacromial impingement is mainly conservative. Physiotherapy is necessary, and in some cases, depending on the intensity of pain and previous treatments, an injection may be indicated.

Based on the cause of subacromial impingement, specific treatment is initiated. Additionally, in cases of associated rotator cuff injury, surgical treatment may be considered (depending on the type of injury; see article on rotator cuff injuries).

In some people, one or more calcifications (deposits of calcium) can form in a rotator cuff tendon. These calcifications are located inside the tendon and “push” against the tendon fibers.

This condition typically affects individuals between the ages of 30 and 60, more often women. The most common anatomical location is the tendon of the supraspinatus. The origin of this condition is not known.

These calcifications can be asymptomatic for months or even years. However, they can become painful in two ways:

When a calcification resolves (self-destruction of the calcification): this causes significant inflammation in the shoulder, leading to pain and stiffness.
When a calcification is large (e.g., 1 cm): it can cause mechanical impingement and inflammation during shoulder movement, especially when raising the arm forward (flexion) and to the side (abduction).

Standard X-rays are the best examination to diagnose and monitor these calcifications. They also help identify the density and stage of calcification (stable calcification versus resorption).

The decision to perform an MRI is not systematic and should be evaluated case by case, based on the patient’s clinical examination and the radiographic appearance of the calcification. An MRI is not routinely necessary for this condition. It is indicated only when an associated tendon tear is suspected.

Treatment is then adapted based on the size and evolution of the calcification. Treatment is mostly conservative and includes pain management along with tailored physiotherapy. For large calcifications without signs of resorption, a needling procedure under radiological control, known as “trituration,” may be performed. This involves fragmenting the calcification and aspirating its contents with a needle. Radiologists perform this procedure under local anesthesia.

Rarely, calcifications do not respond to conservative treatment, and surgical intervention is necessary. In the case of a large calcification causing subacromial impingement, the calcification may be surgically resected to eliminate the painful mechanical impingement.

Regardless of the treatment, the recovery time can vary and may last for several months.

A frozen shoulder, also known as “adhesive capsulitis,” is a stiffening of the shoulder. It involves the thickening and tightening of the capsule surrounding the joint, known as the joint capsule, due to significant inflammatory processes. This condition is twice as common in women and most often affects individuals between the ages of 40 and 60, although it can occur at any age.

Stiffness can develop following trauma or surgery. However, more often than not, the cause of this stiffness is not identified, a condition referred to as “idiopathic” origin.

Known risk factors include diabetes, hypo- and hyperthyroidism, and hormonal changes (such as during menopause).

Frozen shoulder evolves in three phases:

Stage 1:

Insidious onset with the appearance of diffuse pain at rest and during movement, associated with nocturnal pain. The intensity of pain varies greatly. In a second phase, shoulder movements decrease.

Stage 2:

Significant limitation of movements sets in, affecting activities of daily living. At this stage, pain gradually diminishes.

Stage 3:

Disappearance of pain and progressive recovery of shoulder mobility.

The progression of this condition is slow and gradual and can last up to 1.5-2 years for complete recovery.

Clinical examination is crucial for making the diagnosis.

Complementary tests (X-rays, ultrasound, MRI) are tailored to each patient’s medical history and clinical examination. They are performed to search for associated lesions (for example, after trauma) but are not necessary to confirm the diagnosis of frozen shoulder.

Depending on symptoms, a cortisone injection may be administered. However, it is not systematically performed (and necessary). While it can reduce the intensity of pain when standard analgesics are ineffective, it does not accelerate the recovery of ranges of motion.

Treatment mainly involves managing pain and gradually recovering mobility. The Liotard protocol (a series of self-stretching exercises performed within the pain threshold) has proven effective in this regard. Treatment may be complemented by physiotherapy, such as in a pool, depending on the degree of stiffness.

The main joint of the shoulder is the glenohumeral joint, located between the head of the humerus and the scapula (glenoid). In cases of trauma or in hypermobile patients, the shoulder can dislocate.

During this dislocation phenomenon, two injuries commonly occur:

Bankart lesion: detachment of the anteroinferior labrum (present in >90% of cases).

Hill-Sachs lesion: a notch in the posterosuperior part of the humeral head that impacts against the glenoid of the scapula during the dislocation (present in >80% of cases, of variable size).

In a first episode, the dislocation often needs to be reduced in the emergency room. X-rays are essential before the reduction to exclude any associated fractures, which can affect the method of reducing the dislocation (light sedation versus general anesthesia).

Surgical intervention is usually not required after the first episode (except in cases of associated fractures, depending on their displacement). Immobilization with an orthopedic brace is necessary for 3 weeks (depending on the patient’s age; the risk of recurrence decreases with age, so immobilization is not required for as long after the age of 35). Subsequently, physical therapy is prescribed to recover shoulder movement and strengthen the muscles of the scapular girdle.

In cases of recurrence, even without trauma, immobilization is no longer necessary (except in cases of fracture), and surgical intervention is considered.

The risk of recurrence is correlated with the age at which the first dislocation occurred. Patients under 20 at the time of the first dislocation have a 90% risk of recurrence. Other risk factors for new dislocations include contact sports, hypermobility, and bone loss in the glenoid (>20-25% of its articular surface).

Complementary exams play a crucial role in evaluating instability. Standard X-rays assess bone lesions caused by dislocation episodes and look for signs of early arthritis. An arthro-MRI evaluates labral and ligamentous injuries.

Following a dislocation, physical therapy is prescribed to regain shoulder mobility and strengthen the dynamic stabilizers of the shoulder and scapula.

Historically, there have been two types of surgeries:

Bankart Repair: This surgery involves repairing the ligaments and labrum. It requires a longer postoperative immobilization. This surgery can only be performed in isolated cases (among other things, when the Hill-Sachs lesion is small, when the labrum is repairable, and when constitutional hyperlaxity is excluded).

Latarjet Procedure: This surgery currently yields the best results in the literature. It involves taking the coracoid (another part of the scapula) onto which two tendons (short head of the biceps and coracobrachial) are attached. The coracoid is fixed against the glenoid to increase the articular surface of the glenoid, thereby increasing the contact area between the humeral head and the scapula during shoulder movement. Additionally, this new configuration allows the two tendons (biceps and coracobrachial) to act as a “hammock” and prevent the humeral head from dislocating during movements that could cause dislocation (e.g., arm movement or throwing).

In the postoperative period, the upper limb is immobilized with an orthopedic brace for pain relief, and physiotherapy is initiated the day after surgery. The coracoid fixation takes approximately three months to consolidate (heal).

Contact sports such as rugby and ice hockey can be resumed around four months postoperatively. For patients participating in these sports, a specific test (isokinetic test) can be performed at three to four months postoperatively to assess the remaining muscle strength needed for complete recovery.

After this type of surgery, the risk of redislocation is less than 5%.

Other risks associated with this surgery include hardware discomfort (two screws used to fix the coracoid; the need to remove these screws in <5% of cases), neurological injury (traction injury to the musculocutaneous nerve, which can result in weakness in the biceps; rare, usually transient), and infection.

In cases of revision surgery or in rare cases where the coracoid cannot be used, bone transfer via autograft or allograft from the iliac crest may be considered.

Lesions of the acromioclavicular joint are common, especially in contact or collision sports (football, hockey, rugby, judo) and other sports where the risk of falling is higher (cycling, skiing). It is an injury affecting the ligaments of the joint between the clavicle and the scapula. It is caused by a direct impact on the lateral part of the shoulder, leading to significant stress on the acromioclavicular joint, ultimately causing a tear in the ligaments. This results in a deformation of the upper part of the shoulder, known as a “piano key sign.” Several ligaments maintain the distal clavicle in place, and the degree of displacement depends on the number of affected ligaments.

Pain is felt in the area of the acromioclavicular joint deformation and may radiate along the trapezius muscle and the neck.

Clinical examination and X-rays help quantify the number of torn ligaments. X-rays of the shoulder and clavicle are essential to exclude an associated fracture.

In cases of minor clavicle displacement (and thus minor deformation), conservative treatment is initiated with a brief period of immobilization followed by physiotherapy to regain shoulder mobility and strengthen the muscles. The return to normal activities takes an average of 3 months.

In cases of more significant displacement, surgical treatment is indicated.

The type of surgery depends on the time between the trauma and surgery. Ligaments can heal if surgery is performed within 2-3 weeks of the trauma. The goal is to allow ligament healing by repositioning the clavicle anatomically using a “cable” system that fixes the clavicle to the scapula (at the coracoid and acromion). Postoperatively, the upper limb is immobilized in an orthopedic brace for 6 weeks. Physiotherapy rehabilitation begins in the third postoperative week. The hand, wrist, and elbow can be mobilized freely. However, lifting heavy objects is prohibited for 3 months.

In cases where the injury is older, ligament reconstruction (with grafting) is necessary to rebuild the torn ligaments, which no longer have the ability to heal. The type and duration of immobilization and rehabilitation are similar to ligament repair. However, this type of surgery has a lower satisfaction rate. The graft used to reconstruct the ligaments tends to “stretch” slightly in the first few months, causing a mild deformation of the acromioclavicular joint. Additionally, as this is a chronic situation, mild pain may persist.

It is important to note that the acromioclavicular joint is a biomechanically complex joint. Therefore, it is impossible with surgery to achieve the level of stability equivalent to the “native” state, i.e., before any injury.

Osteoarthritis corresponds to a gradual wear of the cartilage covering the bony surfaces of the shoulder joint (glenohumeral joint). When wear is severe and the cartilage is depleted, it causes:

A progressive reduction in the range of motion.

Pain during movement, even at rest. In the most symptomatic cases, the pain can be disruptive to sleep.

Pain is not proportional to the severity of osteoarthritis. Some individuals may experience little pain despite significant joint wear, while others with minimal wear may have more significant pain.

Diagnosis is based on X-rays.

In cases of early osteoarthritis, conservative treatment may include physiotherapy and pain management (pain-relieving medications or injections, depending on the situation).

Treatment is tailored to the degree of osteoarthritis. For instance, injections may not be effective in cases of severe osteoarthritis.

In cases of severe or treatment-resistant osteoarthritis, surgical intervention may be recommended.

There are two types of shoulder prostheses. The type of prosthesis depends on the type of osteoarthritis.

Anatomic prosthesis:
As the name suggests, it replicates the anatomy of the shoulder with a convex (rounded) part on the humerus side and a concave (curved) part on the glenoid side (scapula).

This type of prosthesis yields excellent results but requires intact rotator cuff tendons (muscles that enable joint mobility).

Reverse prosthesis:
It reverses the natural anatomy of the shoulder with a rounded part on the glenoid side and a curved part on the humerus side.

In cases where the rotator cuff is damaged, the shoulder can no longer function “normally.” Therefore, the anatomy is altered to allow another muscle, the deltoid, to take over and replace the role of a portion of the rotator cuff.

This prosthesis also shows excellent results, but studies indicate that internal rotation (the ability to reach behind the back) may be limited, depending on the patient’s anatomy.

This type of prosthesis is also indicated when joint wear is extremely severe.

The labrum is a ring of fibrocartilage (a structure similar to the meniscus in the knee) that enhances the stability of the glenohumeral joint (shoulder joint). This structure can be injured during trauma or repeated micro-traumas, as seen in certain sports.

A labral injury can cause pain during specific movements, limited range of motion, and a lack of strength. This type of injury is more common in younger patients.

Clinical examination helps in suspecting or ruling out such an injury and guides the choice of additional diagnostic tests.

The treatment depends on the extent of the injury but may involve surgical intervention, especially when the injury is extensive. The type and duration of immobilization depend on the location of the lesion (anterior versus posterior part of the labrum).

Fractures of the proximal humerus are very common. It is the 3rd most frequent fracture in patients ≥ 65 years old. This type of fracture is more common in women, as they are more prone to osteoporosis.

The fracture can be associated with a dislocation of the glenohumeral joint and, more rarely, with neurological damage to the axillary nerve (traction injury related to dislocation).

The diagnosis is made based on X-rays. In cases where it is difficult to accurately assess the degree of displacement of the different fragments of the fracture, a CT scan may be necessary. However, it is not always recommended.

In most cases, conservative treatment with 4-6 weeks of an orthopedic brace (depending on the type of fracture) and progressive physiotherapy is the preferred approach. Initially, physiotherapy facilitates the recovery of mobility. Only in a second phase is muscle strengthening introduced.

Bone consolidation (healing of the fracture) takes 3 months. It is therefore recommended not to carry heavy loads during this period.

In cases of significant displacement, surgical treatment is indicated. The type of surgery depends on the type of fracture, the patient’s age, and bone quality. When bone quality is sufficient, fixation of the fracture (called osteosynthesis) with a centromedullary nail or plate is indicated (the implant being chosen according to the type of fracture). In cases of advanced osteoporosis, a total reverse shoulder prosthesis may be recommended.

Complications, whether the treatment is conservative or surgical, include joint stiffness (which is usually transient at the beginning of treatment. However, shoulder mobility cannot always be fully restored, and slight loss of mobility may persist), malunion (meaning that the fracture is consolidated but with a deformation compared to the normal anatomy of the shoulder), and non-union of the fracture (also called pseudarthrosis).

In case of surgery, additional risks include infection, and in the case of osteosynthesis surgeries, hardware discomfort (which can be removed 1.5 years after surgery, but only in case of significant discomfort) and avascular necrosis of the humeral head (in cases of very significant displacement of the fracture, blood vessels in the bone can be damaged and cause complications despite fracture fixation). In cases of avascular necrosis, radiological monitoring is necessary for 2 years postoperatively and may require removal of the osteosynthesis material. In severe cases, a prosthesis may be necessary as a second step.

The shoulder is a complex joint