Chronic shoulder pain: Rotator cuff syndrome

Calcified shoulders and tendon tears result from various disorders in the shoulder joint, particularly focusing on rotator cuff syndrome.

Anatomy of the Shoulder

The tendons of the shoulder torsion muscles (rotators) encompass the shoulder joint like a cuff. The tendon of the upper torso slides between the roof of the shoulder and the head of the humerus. That works as long as nothing disturbs the process.

Over time, however, incorrect loads or injury stimuli leave their mark on the shoulder. Remodeling processes begin on heavily stressed tendons. Doctors generally call this degeneration, in the case of tendon tendinosis. It is unclear what proportion of inflammatory processes and circulatory disorders have, which is often assumed. If pain occurs, rotator cuff syndrome should be considered: tendon tears, calcifications, and adhesions. Bone edges can cause problems on the shoulder roof.

The risk factors include overhead activities in sports (throwing and ball sports, backstroke, dolphin and crawling) and in certain occupations (e.g. painting), also muscle imbalances and instability of the shoulder, obesity, diseases such as diabetes, lipid metabolism disorders, rheumatism. After all, age also plays a role, as rotator cuff syndrome usually occurs over the age of 50.

The calcareous shoulder, on the other hand, is a tendon disease that usually heals by itself. It is sometimes classified as a special form of rotator cuff syndrome because it actually mostly affects one of the associated tendons.

Rotator cuff syndrome

Tendon sliding is disrupted during activities involving the arm raised above the head and/or the shoulder turned outwards, resulting in further narrowing of the already confined space between the shoulder joint and the shoulder roof. This constriction primarily affects the tendon of the upper bone muscle (also known as supraspinatus), the bursa under the shoulder roof, the head of the humerus, and possibly the long biceps tendon. The wedged bursa, in particular, is prone to inflammation, causing pain depending on movement and position (impingement syndrome).

Symptoms

Symptoms typically develop gradually. Initially, other parts of the shoulder compensate for slight mobility loss, making the problem less noticeable. However, symptoms range from mild to severely disabling, especially during activities such as lifting the arm above shoulder height or lifting and rotating the arm outwards. Nocturnal pain when lying on the affected side is also common. Depending on severity, the pain may radiate into the entire arm or neck. A minor movement can sometimes lead to a tear in the damaged shoulder tendon. Those with a torn rotator cuff often complain of weak shoulder and anterior shoulder pain, though some may be asymptomatic.

Diagnosis

The medical history, along with a detailed examination of the shoulder and the musculoskeletal system as a whole, often guides the doctor in the right direction. Movement tests yield a positive sign of impingement if they elicit pain by narrowing the space under the shoulder roof during movement. For example, actively lifting the arm forward against resistance, with the shoulder “held” by the doctor, or in the end position raised just above shoulder height, turning the arm inwards and pointing it to the opposite side (Neer test). In the Hawkins test, the examiner stabilizes the patient’s shoulder and bends the elbow of the raised arm to shoulder height. Then, the still bent arm is rotated forward to the opposite side, with the elbow bent in front of the patient’s upper body and pointing forward, while the forearm tilts downward. The drop arm sign may indicate tendon rupture or impingement: the patient slowly lowers the arm, raised to about 150 degrees, but struggles to hold it, or experiences pain.

Injecting a local anesthetic into the bursa under the roof of the shoulder reveals structural problems such as tendon tears, early-stage frozen shoulder, or joint damage. While the shoulder pain temporarily dissipates, it remains difficult for the affected person to actively lift the arm if the tendon is already torn.

X-rays can detect calcifications and are essential for diagnosing acute shoulder injuries. However, ultrasound examination is typically prioritized for shoulder pain, as it optimally visualizes conditions like bursitis, calcification, tendon tears, and impaired gliding processes. Magnetic resonance tomography (MRT) of the shoulder joint, possibly with contrast medium administration (MRT arthrography), offers more detailed information. Nevertheless, many asymptomatic individuals have incidental findings such as partial tendon tears and calcifications, emphasizing the importance of correlating symptoms with clinical findings by an experienced examiner.

Therapy

Treatment initially involves conservative measures, especially for partial tears and younger patients. Surgery may be considered based on tear severity, muscle condition, age, and desired functionality. Decompression and defect repair procedures can alleviate pain and improve shoulder mobility, though success rates vary.

Shoulder “crime thriller”

Calcified shoulder: Unclear cause +++ Affects patients aged between 35 and 50 +++ Often involves several phases with a dramatic climax: the most intense shoulder pain that ultimately resolves itself through self-healing +++ Sometimes manifests as only a few painful attacks or nearly painless processes, all encompassed under the term “calcified shoulder.”

In addition to a wide range of chronic stresses, local circulatory disorders could temporarily lead to the formation of cartilage and calcification in the tendon tissue, which then subsides after the cessation of these “false stimuli.”

Symptoms

Initially, there are hardly any symptoms. This preliminary phase occurs at the cellular level in one of the shoulder tendons, often affecting the upper bone muscle. As the process continues, the resulting calcification can lead to entrapment symptoms with repeated irritation. Symptoms primarily occur when lifting the arm and lying on the affected side. Under certain circumstances, the arm can only be moved apart when the shoulder is turned inward or outward, allowing the calcified tendon piece to slip more easily under the shoulder roof. Patients often rely on the mobility of the shoulder blade to move the arm with less pain, which may result in unusual movement sequences causing tension and further pain. If the calcium breaks into the shoulder joint or bursa, it triggers an acute, extremely painful inflammation (bursitis). This may lead to complete immobility of the arm (pseudoparalysis). Fortunately, calcifications usually resolve spontaneously as the process progresses.

Diagnosis and Therapy

For examination options, refer to the section above on rotator cuff syndrome. In addition to clinical examination, sonography (ultrasound examination) is the primary diagnostic method. Treatment typically involves conservative measures (as discussed above). Another well-documented treatment option, especially for pain that is difficult to manage, is extracorporeal shock wave therapy. Possible side effects include pain, bleeding, and injury to surrounding tissues. Surgeons generally avoid surgery in these cases.

A newer treatment are PRP injections into the joint. These seem to be successful for various joint injuries and are performed by a variety of doctors.

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