Shoulder Impingement Syndrome

Transcription

1 Shoulder Impingement Syndrome Causes The shoulder joint is stabilized and moved mainly by the four tendons of the socalled rotator cuff. These tendons are situated in a narrow bony canal between the ball and the socket (acromion) which directly surrounds the shoulder joint. During the course of life, possible signs of wear can cause increasing narrowing of this canal what in turn may lead to painful inflammations of tendons and bursae. In advanced stages permanent damages of the rotator cuff may occur which lead to lasting painful movement restrictions of the shoulder joint. Signs and Symptoms Patients mostly complain of pain at night when lying on the shoulder or pain which occurs with spreading movements from a certain angle. This pain is due to compression of the rotator cuff and the bursae lying above between ball and socket. Mobility of the arm is in most cases painfully limited; sometimes occurs also loss of power. Diagnostics Examination and questioning of the patient give in most cases decisive indications to impingement. Besides this, bony changes which result in narrowing of the sliding canal of the supraspinatus tendon can be visualized by special x-ray images. In order to confirm this diagnose of tendon damage, sonography of the shoulder or a MRI are needed. Treatment In early stages freedom or at least reduction of pain can be achieved by simple measures such as: temporary rest (avoiding working overhead within the painful area, no carrying of weights with outstretched arms), medication with analgesic and decongestant effect, local ice- or heat treatment as well as special physiotherapy. However, if the painful condition continues even after several months of consequent treatment, or the diagnosed tendon damage is confirmed, surgical repair of the tendon and removal of the bony narrowing is recommended. In case that the tendon has only minor damages, enlargement of the bony narrowing is sufficient. Rastatter Str Pforzheim Germany Phone info@sportklinik.de 55

2 Shoulder Impingement Syndrome Surgical Treatment The first operation step is thorough assessment of the damage by arthroscopy. Further steps depend on the injuries detected during arthroscopy. Injured tendons can be treated through a small incision. In case that there is no obvious damage at the tendons, the only thing to do is grinding the bone edges at the acromion (socket) to reduce narrowing of the tendon gliding canal. Grinding the acromion is called acromioplasty and can be performed arthroscopically through two small incisions. After surgery, an in-patient stay of 1-2 days is necessary. If no operation of the tendon has been necessary, special rest of the operated shoulder is not needed. However, the shoulder joint should be treated with care for about 4-6 weeks. Informations about a special aftercare program you will receive from your ward physician. Pain limits always have to be respected, but supportive therapies such as decongestant medication and local ice-treatment are possible. Results and Risks With about 90% of the patients, complaints resolve within 3-6 months. In rare cases painful movement restriction of the arm remains. Operation-related risks such as infects, injuries to nerves and vessels occur rather infrequent. 56 Rastatter Str Pforzheim Germany Phone info@sportklinik.de

3 Calcified Tendinitis of the Shoulder (tendinosis calcarea) Causes The shoulder joint is stabilized and moved mainly by the four tendons of the socalled rotator cuff. These tendons are situated in a narrow bony canal between the ball and the socket which directly surrounds the shoulder joint. During the course of life and often unnoticed at first may occur signs of wear, particularly with the supraspinatus tendon. This in turn can result in calcifications which also occur mostly with the supraspinatus tendon. These calcifications may lead to the so-called shoulder impingement syndrome (p. 55). Signs and Symptoms Patients mostly complain of pain at night when lying on the shoulder or pain which occurs with spreading movements from a certain angle. In most cases mobility of the arm is painfully limited. Acute pain may also be an indirect indication for break-up of a calcium deposit. Diagnosis Examination and questioning of the patient offers in most cases the essential hint that leads to a disorder in the area of the rotator cuff. Diagnosed calcium deposits can then be confirmed by x-ray images and sonography. These measures also help to differentiate between a chronic stage or an acute stage with break-up of the calcium deposit. Treatment Generally speaking, calcium deposits can resolve spontaneously. Unfortunately, this involves in most cases considerable discomfort. Being in this stage the motto is first wait and see. By temporary rest, analgesic- and decongestant medication, and local treatment with ice or heat, pain can be eased and calcium resorption supported. However, if the pain continues unchanged over a longer period of time, and the calcium deposit remains on the x-ray images without any changes operative removal of the deposit is recommended. Alternatively, the calcium deposit can also be destroyed by shockwave therapy, but effectiveness of this method is not definitely proven so far. Rastatter Str Pforzheim Germany Phone info@sportklinik.de 57

4 Calcified Tendinitis of the Shoulder (tendinosis calcarea) Operation of Calcium Deposits within the Rotator Cuff First step of this operation is localizing the calcium deposit by means of arthoscopy. After longitudinal incision of the affected tendon, the calcium is removed with a spoon as completely as possible. Possible occurring bone edges which lead to compression of the affected tendon are grinded arthroscopically. In rare cases, when the deposit cannot be found during arthroscopy, a small incision is needed for calcium removal. Very often, complete removal is not possible, but a large part of the remaining calcium residues resolves little by little by itself. Aftercare After surgery, an in-patient stay of 1-2 days is necessary. Discomfort will not disappear immediately after surgery but slowly during the following weeks. Therefore, rest for 4-6 weeks is recommended. Mobilization of the shoulder should be started carefully with the painfree area, and pain limits should strictly be respected. Aftercare can be supported by decongestant medication and local ice treatment. Convalescence of about 3-6 months should be expected until recovery of painfree functioning of the shoulder joint. In order to achieve good operation results, aftercare should be performed according to a previously defined schedule which is given to you by your ward physician. Results and Risks With about 90% of the patients, the surgery brings back a painfree situation. With incomplete removal of the calcium deposit, some discomfort may remain. Operationrelated risks such as infects or injuries to nerves and vessels occur rather infrequent. 58 Rastatter Str Pforzheim Germany Phone info@sportklinik.de

5 Shoulder Luxation Causes The shoulder joint consists of a ball and a socket. Stabilization of the joint is ensured by the joint capsule, tendons and muscles as well as a cartilaginous ring (the socalled Labrum) which encloses the socket. Causes for shoulder dislocations can be of generic kind (e.g. too large capsule, loose ligament apparatus) or may be the result of injuries. Injuries of the shoulder may lead to tear of the labrum or the capsule or even to break-off of parts of the socket. This in turn can impair the stability of the shoulder joint in a way that repeated luxations occur, or that a painful movement restriction remains. Fig. 1: Fixation of torn labrum (source: Arthrex GmbH) Fig. 2: Complete fixation of labrum (source: Arthrex GmbH) Diagnosis Examination and questioning of the patient in most cases give the decisive hint whether the shoulder joint is instable and therefore endangered by possible further luxations. Bony injuries have to be excluded by x-ray examination. With younger patients under 40, the most common diagnose is a torn labrum. This can be confirmed by sonographic or MRI examination. With patients over 40, most common injuries are injuries of the tendons surrounding the shoulder joint. These diagnoses can also be confirmed by sonography or MRI. Treatment Luxations which are due to generic disorders are at first treated conservatively with muscle training to stabilize the joint. Operative treatment is only recommendable if this muscle training does not show any reduction of the luxation risk after at least one year of consequent therapy. With young, physically and professionally active patients where the luxation occurred after injury of the shoulder joint, operative treatment of the torn labrum or bony injury is preferred; of course after respective diagnostic and confirmation. With elderly patients it is often possible to wait and see what can be achieved by temporary rest and stabilizing muscle training, at least Rastatter Str Pforzheim Germany Phone info@sportklinik.de 59

6 Shoulder Luxation if an injury of the tendons could be excluded. Generally it can be said that therapy has to be planned individually for every patient. Surgical Stabilization of the Shoulder The first operation step is thorough assessment of the damage by arthroscopy. Further steps depend on the injuries detected during arthroscopy. In case that no severe capsule injuries are diagnosed, stabilization can be performed arthroscopically. However, should severe damages to the labrum and the capsule ligament apparatus be confirmed, open stabilization through an approx. 6 cm long incision at the front side of the shoulder joint is inevitable. Primary aim of the operation is to re-attach the torn labrum to the rim of the socket. Here, small metal dowels are used. If there are furthermore bony injuries at the rim of the socket, an additional piece of bone retracted from the iliac crest has to be screwed to the socket. Aftercare After surgery, an in-patient stay of about 2 days is necessary. In order to avoid repeated luxations of the shoulder joint, special aftercare is recommended. It includes conservative measures such as limitation of movement and consequent wearing of a shoulder sling for 6 weeks. Detailed information material is given to you by your ward physician. Furthermore, special muscle training as well as avoidance of overhead- and contact sports is necessary for about 4-6 months. Results and Risks With 90-95% of the patients stabilization can be regained. In rare cases, limitations to outward movements of the arm due to shortening of the joint capsule remain. Operation-related complications such as infects and injuries of nerves and vessels occur rather infrequent. 60 Rastatter Str Pforzheim Germany Phone info@sportklinik.de

7 Rotator Cuff Damages Causes The shoulder joint is stabilized and moved mainly by the four tendons of the socalled rotator cuff. These tendons are situated in a narrow bony canal between the ball and the socket which directly surrounds the shoulder joint. During the course of life and often unnoticed at first may occur signs of wear, particularly with the supraspinatus tendon. In extreme cases a complete hole can develop in a tendon; and here, the supraspinatus tendon is the very often affected too. In many cases there already has been a damage to the tendon which first is detected after a fall or physical overload. Acute tendon ruptures occur rather infrequent. Fig. 3: Supraspinatus tendon defect (source: Zimmer Germany GmbH) Fig. 4: Supraspinatus tendon suture (source: Zimmer Germany GmbH) Signs and Symptoms Patients mostly complain of pain at night when lying on the shoulder or pain which occurs with spreading movements from a certain angle. This pain can radiate up to the hand and in most cases mobility of the arm is painfully limited. Sometimes there also is loss of power. Diagnosis Examination and questioning of the patient in most cases give the decisive hint to a damage of the rotator cuff. Bony changes which lead to narrowing of the sliding canal of the rotator cuff can be detected by special x-ray images. Normally, a sonographic examination is enough to securely confirm the tendon damage; only in rare cases MRI is needed. Rastatter Str Pforzheim Germany Phone info@sportklinik.de 61

8 Rotator Cuff Damages Treatment With younger patients and with the rare acute injuries, surgery is recommended in order to re-attach the tendon to the bone and with this regain power and functionality. With elderly patients of more than 70 years, simple measures such as temporary rest, decongestant- and analgesic medication, local ice- or heat treatment as well as special physiotherapy can bring a painfree situation again. However, if an inacceptable and painful movement restriction remains even after several months of consequent therapy, repair of the tendon and removal of the bony entrapment should be done by surgical treatment. Surgical Treatment of Rotator Cuff Damages The first operation step is thorough assessment of the damage by arthroscopy. Further steps depend on the injuries detected during arthroscopy. The bony entrapment can be removed in arthroscopic or open surgery by grinding the narrowing bony edges. In most cases the tendon can be reattached to the bone through an about 4 cm long incision. Aftercare After surgery, an in-patient stay of about 2-3 days is necessary. For optimal healing of the tendon in the bone, an abduction pillow has to be worn for 6 weeks. In order to achieve the best possible operation result, some long term aftercare instructions given to you by your ward physician should be objected. Physiotherapeutic treatment for example is necessary for about 6 months. For a good overall result the exercises learned during physiotherapy should be performed at home for further 3-6 months whereby the pain limit always has to be respected. Aftercare can be supported by decongestant medication and local ice treatment. Results and Risks With 80-90% of the patients, an almost painfree situation can be regained. Experiences show however, that functions and power are not essentially improved and that early stress or non-wearing of the abduction pillow can result in the sutured tendon tearing a second time. After surgery, movement restrictions or loss of power in the arm may remain. Operation-related risks such as infects or injuries to nerves and vessels occur rather infrequent. 62 Rastatter Str Pforzheim Germany Phone info@sportklinik.de

9 Injuries and Arthrosis of the Acromioclavicular Joint (AC-joint) Causes The joint lying between the socket and the collarbone is called AC-joint. Falling onto the shoulder is often accompanied by ruptures of the joint ligaments. This can result in an upward dislocation of the collarbone. But the AC-joint can also be damaged in association with degenerative signs (arthrosis) which may occur when physically working hard. Signs and Symptoms After ligament ruptures arises painful movement restriction of the shoulder joint, which fortunately recedes with 80% of the patients. Very often, patients also complain of pain at night when lying on the shoulder or pain which occurs with spreading movements from a certain angle. When palpating the joint, pain arises on pressure. In some cases after ligament ruptures, one can even see that the outer end of the collarbone points upwards. Fig. 5: Stabilization of AC-joint (source: Arthrex GmbH) Fig. 6: Stabilization of AC-joint (source: Arthrex GmbH) Diagnosis Examination and questioning of the patient in most cases give the decisive indication of an AC-joint damage. With ligament ruptures, the outer end of the collarbone may visible and palpable point upwards and cause heavy pain. Bony changes can be visualized by focused x-ray images. With arthrosis, cause of discomfort respectively localization of the AC-joint as definite cause can be achieved by injecting an analgesic into the joint space. Treatment Treatment of ligament ruptures of the AC-joint can be performed either conservatively or surgically. If surgical treatment is necessary depends on severity of the ligament rupture. Up to a grade III rupture we in most cases recommend conservative therapy first. That means resting the shoulder and avoiding weight stress and Rastatter Str Pforzheim Germany Phone info@sportklinik.de 63

10 Injuries and Arthrosis of the Acromioclavicular Joint (AC-joint) spreading movements over the horizontal level for about 6-8 weeks. Only in few cases there is absolute need for immediate operation. When having treated the ligament rupture conservatively and a painful movement restriction develops there are several operation methods to regain painfree mobility and correct position of the collarbone even after years. Pain which results from degenerative wear of the AC-joint can be eliminated by chiseling off the outer end of the collarbone. Operative Treatment In case of an isolated arthrosis of the AC-joint, the outer end of the collarbone is removed (approx mm). This can be done by arthroscopic surgery or open surgery through two small incisions. If the arthrosis results from a former injury with rupture of the joint ligaments, the outer end of the collarbone is removed (like with AC-arthroscopy) and the collarbone reattached in correct position with a body-own ligament which passes to the socket (there additionally may also be need for wires, screws or an artificial ligament). When operating ligament ruptures directly after the accident we mostly make use of temporary fixation of the collarbone by wires. They are removed in a second small operation 6-8 weeks later after healing of the ligament suture. Aftercare After surgery, an in-patient stay of about 2-3 days is necessary. Aftercare of AC-joint operations depends on the surgical method used. Removal of the outer end of the collarbone alone does not require special rest. When having stabilized the joint with ligaments, wire slings or screws, limitation to movement has to be objected for about 6-8 weeks to avoid avulsion of the ligaments or breakage of the metal implant. You will receive a special aftercare program from your ward physician. The pain limit always has to be respected. Aftercare can be supported by decongestant medication and local ice treatment. Results and Risks About 80% of the patients regain painfree mobility of the shoulder joint within 3-6 months. After joint stabilization with metal implants, there is the danger of 20% of breakage or loosening of the metal as well as repeated upward dislocation of the outer end of the collarbone. Further operation-related risks which occur more often are wound healing disorders and infects. Injuries to nerves and vessels occur rather infrequent. 64 Rastatter Str Pforzheim Germany Phone info@sportklinik.de

11 Collarbone Fracture (clavicle fracture) Collarbone fractures are often the result of a fall onto the shoulder. Especially affected are sportsmen who practice sports with higher risk of falling (cycling, skiing, playing football). Signs and Symptoms Directly after falling heavy pain occurs in the area around the fracture. The shoulder joint can hardly be moved due to the severe pain. The mere weight of the arm hanging down triggers strong discomfort. Therefore patients use the healthy arm to hold the affected arm to the body. Diagnosis Most collarbone fractures are visible at first sight as the mostly extremely dislocated fragments of the collarbone lye directly under the skin. Palpation of the fracture is very painful; the bone ends grinding against each other can often be felt. For assessment of the fracture and further treatment planning, a special x-ray is necessary. Fig. 1: Collarbone fracture without dislocation that can heal without surgical treatment Fig. 2: Heavily dislocated collarbone fracture Fig. 3: that has been stabilized by means of a metal plate Treatment Fractures without or with slight dislocations can be treated by strictly resting the arm for 3-4 weeks. With strong professional or sportive shoulder strain as well as fractures with heavy dislocation or bone fragments which are lying on top of each other we definitely recommend operative treatment. This shortens duration of aftercare and normally offers better results. We prefer stabilization by means of a plate which is performed through an about 10 cm long incision directly over the affected area. During surgery, the bone fragments are moved back into the correct position and both fracture ends are stabilized with a metal- or titanium plate and at least 6 screws. Rastatter Str Pforzheim Germany Phone info@sportklinik.de 65

12 Collarbone Fracture (clavicle fracture) Fig. 4: Fracture at the external end of the collarbone Fig. 5: A special clavicle hook plate is needed for stabilization Aftercare After surgery the arm should be relieved by wearing a shoulder sling until removal of the stitches after 2 weeks. This eases the pain and supports healing of the wound. From the first day on you can move your arm in the shoulder sling. You will learn respective exercises from your physiotherapist. After about 2 days you can leave the hospital. From the third week after surgery you can take off the sling and move the arm without additional weights. Most fractures are stably healed after 12 weeks but the plate should not be removed before one year after surgery what is done in a short out-patient surgery. Complications such as infects, healing disorders of the fracture or a repeated fracture after plate removal occur rather rare. 66 Rastatter Str Pforzheim Germany Phone info@sportklinik.de

13 Humeral head fracture A humeral head fracture is often a result of a fall onto the shoulder. Especially affected are elderly women with osteoporosis as well as sportsmen who practice sports with higher risk of falling (cycling, skiing, motorcycling). Signs and Symptoms Directly after falling heavy pain occurs in the area around the fracture. The shoulder joint can hardly be moved due to the severe pain. In many cases the patient can feel the bone ends grinding against each other. The healthy arm should hold the affected arm to the body. Fig. 1: Slightly dislocated fracture, healing by immobilization and physiotherapy Fig. 2: Completely dislocated fracture Fig. 3: Stabilization with plate Diagnosis In order to assess whether it is only a heavy contusion or a real humeral head fracture, x-ray images are needed. With them also type and severity of the fracture can be defined. A distinction is made between fractures with 2, 3 and 4 bigger bone fragments as well as difficult comminuted fractures. By means of the x-ray images taken further treatment can be planned. Rastatter Str Pforzheim Germany Phone info@sportklinik.de 67

14 Humeral head fracture Treatment By means of the x-ray images is decided whether an operation is necessary. Heavily dislocated fractures are operated. Fractures without or with slight dislocation can normally be treated conservatively by temporarily resting the affected arm and practicing physiotherapeutic exercises afterwards. However, with heavy professional or sportive strain we nevertheless recommend surgery also for slightly dislocated fractures as it shortens the period of aftercare and supports better results. The surgery method used depends on the type of fracture. Fractures with only one fragment can often be stabilized with screws. Complicated fractures with 3 or 4 bone fragments require stabilization by nails or plates. And with comminuted fractures is sometimes even makes sense to use a prosthesis. We prefer stabilization with a plate even with complicated fractures. During surgery all bone fragments are moved back into the correct position by opening the skin directly over the fracture for approx. 15 cm. Then all those fragments are affixed to one plate (of metal or titanium). Aftercare After surgery the arm should be relieved by wearing a shoulder sling until removal of the stitches after 2 weeks. This eases the pain and supports healing of the wound. From the first day after surgery on you can move your arm in the shoulder sling. You will learn respective exercises from your physiotherapist. After about 4-5 days you can leave the hospital. From the third week after surgery you can take off the sling and move the arm without additional weights. Most fractures are stably healed after 12 weeks but the plate should not be removed before one year after surgery. Complications such as infects, healing disorders of the fracture or a repeated fracture after plate removal occur rather rare. Typical for humeral head fractures is that with about a third of all patients, discomfort when lying on the shoulder, as well as discomfort or movement restrictions when spreading the arm or moving it outwards can remain despite correct stabilization. 68 Rastatter Str Pforzheim Germany Phone info@sportklinik.de

15 Shoulder Endoprosthetics Shoulder prosthesis with arthrosis and after bone fractures Causes Within the frame of age-related wearing processes, or after circulatory disorders or fractures of the ball, there might occur loss of joint cartilage and damage of the shoulder joint with painful limitation to its functions. In later stages then the musculature recedes what results in increasing stiffening of the joint. Fig. 1: Shoulder ball replacement without socket (source: Zimmer Germany GmbH) Fig. 2: Total shoulder joint endoprosthesis (source: Zimmer Germany GmbH) Signs and Symptoms At the beginning, increasing pain occurs with rotational movements and spreading of the arm to the side. Later, every movement is accompanied by pain and the shoulder joint shows progressing movement restrictions; the patient suffers from pain at night and rest pain. Diagnosis Examination and questioning of the patient in most cases offers the decisive indication of shoulder joint arthrosis. This assumption can then be confirmed by x-ray. For operation planning and assessment of the tendons surrounding the shoulder joint, further examination by sonography is necessary. In some cases even CT or MRI are needed. Rastatter Str Pforzheim Germany Phone info@sportklinik.de 69

16 Shoulder Endoprosthetics Treatment In early stages it is often possible to regain a painfree situation with simple measures such as: temporary rest, decongestant- and analgesic medication, local ice- or heat treatment and special physiotherapy. It is important to keep the shoulder mobile even if only within the painfree area and train the muscles. In some cases injections with anti-inflammatory substances into the joint may be necessary. However, if this heavily painful movement restriction remains, a progressing movement restriction and muscular athrophy develop and respective damage can clearly be seen on the x-ray image, usage of prosthesis should be considered. With younger patients under implanting a prosthesis should be delayed as long as possible to avoid future problems such as for example loosening of the prosthesis. Fig. 3: Inverse shoulder prosthesis (source: Zimmer Germany GmbH) Fig. 4: Shoulder ball replacement without shaft Implantation of shoulder prosthesis or humeral head prosthesis Access is made through an approx. 15 cm long incision at the front side of the shoulder joint. The damaged fragment of the humeral head is removed, and as long as the cartilage of the socket is intact, it may be enough to only replace the ball. The prosthesis consists of a steel ball with attached shaft which is cemented to the upper arm. Otherwise also the socket has to be provided with a new surface which is mostly made of special synthetics. 70 Rastatter Str Pforzheim Germany Phone info@sportklinik.de

17 Shoulder Endoprosthetics Aftercare After surgery, an in-patient stay of about one week is necessary. In order to achieve the optimal operation result, aftercare should be carried out according to a previously defined scheme which is given to you by your ward physician. It depends on the type of prosthesis used and on the tendons sutured during operation. During the first weeks, limitation to outward rotations has to be objected in order to prevent sutured tendons from tearing again. Physiotherapy is necessary for about 3-6 months but to achieve the best possible result, exercises should be practiced independently at home for further 3-6 months. Results and Risks With 80-90% of the patients, shoulder prosthesis helps regaining painfree functioning of the shoulder joint. The achievable level of movability depends on condition of the joint prior to operation and your contribution. Operation-related risks such as: A humerus fracture during attachment of the prosthesis, sprains of the artificial joint, infects or injuries to nerves and vessels occur rather rare. As with any artificial joint, the shoulder prosthesis may loosen some day and need to be replaced. According to the experiences made so far, an average lifespan of 10 years is expected, whereby loosening mostly occurs with the artificial socket. Rastatter Str Pforzheim Germany Phone info@sportklinik.de 71