The shoulder joint is highly mobile and relies on coordination between various muscles, tendons and ligaments – yet these traits also make it vulnerable to injury. Shoulder injuries typically involve the rotator cuff. However, osteoarthritis, dislocations, impingement or a broken collarbone can also cause shoulder pain and limit the mobility of the joint. Here is an overview of the structure and problems associated with this complex joint.
Due to its complex anatomy the shoulder is prone to injuries and to degenerative wear and tear such as:
- Osteoarthritis of the shoulder
- Frozen shoulder / Painful shoulder syndrome
- Collarbone fracture
- Rotator cuff rupture
Shoulder problems
Osteoarthritis of the shoulder
Osteoarthritis of the shoulder is chronic wear and tear in the shoulder joint. Cartilage and bones between the scapular and the collarbone rub against each other, which can be painful and limit your range of movement. If this causes inflammation, swelling and a build-up of heat in the joint, it may be a sign of osteoarthritis of the shoulder.
Treatment
Osteoarthritis cannot be cured. However, if it is detected early and treatment is started in good time (physiotherapy and anti-inflammatory drugs), the symptoms can be alleviated and further wear and tear prevented.
TIP
Do not favour the shoulder too much. When you move, the joint receives nutrients which limit cartilage degeneration.
Shoulder tendon tear / rotator cuff rupture
The rotator cuff is a group of four muscles which link the upper arm with the shoulder blade. It centres the humerus in the flat socket of the scapula and stabilises the joint, which enables movement of the upper arm. An accident or wear on the tendon can cause a rotator cuff tear. When this occurs, there is usually a tear in the cap where all four muscles come together and sit on the upper arm. Contact with the bone is lost, which means the muscles can no longer perform their role correctly. The shoulder and the arm can no longer be moved, or only with pain.
Treatment
The treatment method is extremely patient-specific. Depending on the profession, age or type of sport, small tears can be treated with physiotherapy and pain-relieving medication.
TIP
Move yes, strain no. Lifting, carrying, supporting your weight and driving are taboo in the first few weeks.
Calcific shoulder tendonitis
Calcific shoulder tendonitis is caused by a build-up of calcium salts under the scapular on the tendon of the rotator cuff. The cause is unknown; however, such calcification usually occurs in people between the ages of 30 and 50. The pain increases when the body triggers an inflammatory reaction in the bursa against the fibro cartilage tissue on which the calcium salts collect and harden.
Treatment
Temporary immobilisation of the shoulder with cooling can alleviate pain in the event of inflammation. Shockwave therapy selectively triggers biological healing processes which can disintegrate the calcium deposits. Physiotherapy prevents tension caused by poor posture as a result of pain.
TIP
A stiff shoulder due to a relieving posture can be counteracted with stretches and circular movements.
Frozen shoulder
Frozen shoulder and shoulder stiffness cause the joint lining and capsule to become inflamed. In the process, the capsule initially thickens and then shrinks back later. If the patient has no other issues with their shoulder, the cause of this stiffness usually remains unclear. It begins with pain and difficulty lifting and rotating the arm outwards. It can take up to several years for the patient to progress through the inflammatory, stiffening and thawing phases.
Treatment
In the first phase, the inflammation in the joint must be treated with anti-inflammatory medication (cortisone, if necessary). In the second phase, the stiffening phase, the movement should be improved with special exercises so that the stiffness can release in the third phase – the thawing phase.
TIP
Patience and positive thinking are required: The healing process takes between 1.5 years and 3 years; those affected are spared any long-term damage. A frozen shoulder usually heals completely.
Dislocated shoulder and shoulder instability
When a dislocated shoulder occurs, the humerus pops out of the socket. This injury usually occurs as a result of an accident or weakness in the capsule ligament apparatus. It is one of the most common types of dislocations as the shoulder joint is very mobile. If a patient suffers frequent (close) dislocations, this can cause shoulder instability with resulting soft tissue injuries, overstretching of the joint capsule or a tear in the labrum.
Treatment
As long as there is no fracture in one the neighbouring bones, the joint should be immediately reset so that ligaments and tendons do not suffer any long-term damage. After immobilising the joint for several days, follow-up treatment to stabilise the joint can be started. This will also treat any painful dysfunction caused by the injury. If a ligament tear occurs at the same time as the dislocation, surgery may prevent chronic instability.
TIP
Gentle mobilisation exercises at home can release painful muscle blockages in the shoulder and promote healing in the injured ligaments.
Impingement syndrome
Impingement syndrome reduces the distance between the humerus and the scapular. Soft tissue such as the tendons and the bursa in between is so incarcerated that this can trigger inflammation of the bursa or even tears in the ligaments. Impingement syndrome causes pain to radiate out as far as the elbows when you lift your arm over your head.
Treatment
Depending on the severity of the pain, a cortisone injection can provide relief. In the acute phase, the arm is immobilised and rested so that the Impingement syndrome can then be treated afterwards in intensive physiotherapy with targeted exercises. Depending on how widely impinged the joint is, surgery may be required.
TIP
Do not underestimate pain: Please seek medical advice right from the time that you first experience pain in the shoulder. This can counteract any further constriction and prevent the shoulder issue from becoming chronic.
Injury to the acromioclavicular joint
The scapular and the collarbone make up the acromioclavicular joint, which is surrounded by a stabilising network of ligaments that can tear in the event of a fall. The collarbone is then no longer correctly fixed in the scapular, which causes the joint to become unstable and can restrict the function of the arm.
Treatment
The affected shoulder should initially be immobilised so that swelling and internal bleeding can subside. Only then can the severity of the injury be determined and a decision made as to whether the ligaments must be surgically joined together or left to grow back together naturally with a bandage.
TIP
If a visible “hump” forms in the middle of the shoulder, this is an indication of injury to the acromioclavicular joint.
Broken collarbone
The collarbone is a long, thin bone which breaks quickly due to its structure and location – particularly in the event of a fall. A collarbone fracture usually causes clear elevation in the shoulder as the muscles pull the broken pieces up and forwards. Extensive bruising and pain when moving are further indicators of a broken collarbone.
Treatment
Immobilisation with a bandage heals the break in around four weeks. Depending on the position and the state of the fragments, surgery with a stabilising metal plate or nails is required so that the individual connective bones between the shoulder and trunk grow back together correctly and the patient does not suffer any permanent complaints.
TIP
After six weeks, daily exercise can be managed again with the affected arm. The arm should be rested for a period of approx.12 weeks before undertaking intensive exercise such as mountain biking.
Tension and strains
Tension or strains in the shoulder usually affect the muscles of the rotator cuff and the trapezoid. Tension often occurs due to stress or poor posture in which the muscle is maintained in a state of permanent tension and is not correctly supplied with blood as a result; this means it is no longer adequately supplied with oxygen, which causes painful hardening. On the other hand, strains are inflammatory reactions in the muscle which occur as a result of extremely intense or sudden strain.
Treatment
Tension can be effectively treated with massage as well as with mobilisation exercises and those which promote blood flow. It is also important that the causes of the tension are found and avoided. A strain heals in one or two weeks by itself. Anti-inflammatory ointments can be applied to combat the pain; a break from training is also a good idea for the shoulder.
TIP
To heat or cool? If there is tension in the shoulder, warmth can improve the blood supply to the muscles, which will then help them to relax. On the other hand, a strain should be cooled as this will help to alleviate any inflammation.
Osteoarthritis of the shoulder
Osteoarthritis of the shoulder is chronic wear and tear in the shoulder joint. Cartilage and bones between the scapular and the collarbone rub against each other, which can be painful and limit your range of movement. If this causes inflammation, swelling and a build-up of heat in the joint, it may be a sign of osteoarthritis of the shoulder.
Treatment
Osteoarthritis cannot be cured. However, if it is detected early and treatment is started in good time (physiotherapy and anti-inflammatory drugs), the symptoms can be alleviated and further wear and tear prevented.
TIP
Do not favour the shoulder too much. When you move, the joint receives nutrients which limit cartilage degeneration.
Shoulder tendon tear / rotator cuff rupture
The rotator cuff is a group of four muscles which link the upper arm with the shoulder blade. It centres the humerus in the flat socket of the scapula and stabilises the joint, which enables movement of the upper arm. An accident or wear on the tendon can cause a rotator cuff tear. When this occurs, there is usually a tear in the cap where all four muscles come together and sit on the upper arm. Contact with the bone is lost, which means the muscles can no longer perform their role correctly. The shoulder and the arm can no longer be moved, or only with pain.
Treatment
The treatment method is extremely patient-specific. Depending on the profession, age or type of sport, small tears can be treated with physiotherapy and pain-relieving medication.
TIP
Move yes, strain no. Lifting, carrying, supporting your weight and driving are taboo in the first few weeks.
Calcific shoulder tendonitis
Calcific shoulder tendonitis is caused by a build-up of calcium salts under the scapular on the tendon of the rotator cuff. The cause is unknown; however, such calcification usually occurs in people between the ages of 30 and 50. The pain increases when the body triggers an inflammatory reaction in the bursa against the fibro cartilage tissue on which the calcium salts collect and harden.
Treatment
Temporary immobilisation of the shoulder with cooling can alleviate pain in the event of inflammation. Shockwave therapy selectively triggers biological healing processes which can disintegrate the calcium deposits. Physiotherapy prevents tension caused by poor posture as a result of pain.
TIP
A stiff shoulder due to a relieving posture can be counteracted with stretches and circular movements.
Frozen shoulder
Frozen shoulder and shoulder stiffness cause the joint lining and capsule to become inflamed. In the process, the capsule initially thickens and then shrinks back later. If the patient has no other issues with their shoulder, the cause of this stiffness usually remains unclear. It begins with pain and difficulty lifting and rotating the arm outwards. It can take up to several years for the patient to progress through the inflammatory, stiffening and thawing phases.
Treatment
In the first phase, the inflammation in the joint must be treated with anti-inflammatory medication (cortisone, if necessary). In the second phase, the stiffening phase, the movement should be improved with special exercises so that the stiffness can release in the third phase – the thawing phase.
TIP
Patience and positive thinking are required: The healing process takes between 1.5 years and 3 years; those affected are spared any long-term damage. A frozen shoulder usually heals completely.
Dislocated shoulder and shoulder instability
When a dislocated shoulder occurs, the humerus pops out of the socket. This injury usually occurs as a result of an accident or weakness in the capsule ligament apparatus. It is one of the most common types of dislocations as the shoulder joint is very mobile. If a patient suffers frequent (close) dislocations, this can cause shoulder instability with resulting soft tissue injuries, overstretching of the joint capsule or a tear in the labrum.
Treatment
As long as there is no fracture in one the neighbouring bones, the joint should be immediately reset so that ligaments and tendons do not suffer any long-term damage. After immobilising the joint for several days, follow-up treatment to stabilise the joint can be started. This will also treat any painful dysfunction caused by the injury. If a ligament tear occurs at the same time as the dislocation, surgery may prevent chronic instability.
TIP
Gentle mobilisation exercises at home can release painful muscle blockages in the shoulder and promote healing in the injured ligaments.
Impingement syndrome
Impingement syndrome reduces the distance between the humerus and the scapular. Soft tissue such as the tendons and the bursa in between is so incarcerated that this can trigger inflammation of the bursa or even tears in the ligaments. Impingement syndrome causes pain to radiate out as far as the elbows when you lift your arm over your head.
Treatment
Depending on the severity of the pain, a cortisone injection can provide relief. In the acute phase, the arm is immobilised and rested so that the Impingement syndrome can then be treated afterwards in intensive physiotherapy with targeted exercises. Depending on how widely impinged the joint is, surgery may be required.
TIP
Do not underestimate pain: Please seek medical advice right from the time that you first experience pain in the shoulder. This can counteract any further constriction and prevent the shoulder issue from becoming chronic.
Injury to the acromioclavicular joint
The scapular and the collarbone make up the acromioclavicular joint, which is surrounded by a stabilising network of ligaments that can tear in the event of a fall. The collarbone is then no longer correctly fixed in the scapular, which causes the joint to become unstable and can restrict the function of the arm.
Treatment
The affected shoulder should initially be immobilised so that swelling and internal bleeding can subside. Only then can the severity of the injury be determined and a decision made as to whether the ligaments must be surgically joined together or left to grow back together naturally with a bandage.
TIP
If a visible “hump” forms in the middle of the shoulder, this is an indication of injury to the acromioclavicular joint.
Broken collarbone
The collarbone is a long, thin bone which breaks quickly due to its structure and location – particularly in the event of a fall. A collarbone fracture usually causes clear elevation in the shoulder as the muscles pull the broken pieces up and forwards. Extensive bruising and pain when moving are further indicators of a broken collarbone.
Treatment
Immobilisation with a bandage heals the break in around four weeks. Depending on the position and the state of the fragments, surgery with a stabilising metal plate or nails is required so that the individual connective bones between the shoulder and trunk grow back together correctly and the patient does not suffer any permanent complaints.
TIP
After six weeks, daily exercise can be managed again with the affected arm. The arm should be rested for a period of approx.12 weeks before undertaking intensive exercise such as mountain biking.
Tension and strains
Tension or strains in the shoulder usually affect the muscles of the rotator cuff and the trapezoid. Tension often occurs due to stress or poor posture in which the muscle is maintained in a state of permanent tension and is not correctly supplied with blood as a result; this means it is no longer adequately supplied with oxygen, which causes painful hardening. On the other hand, strains are inflammatory reactions in the muscle which occur as a result of extremely intense or sudden strain.
Treatment
Tension can be effectively treated with massage as well as with mobilisation exercises and those which promote blood flow. It is also important that the causes of the tension are found and avoided. A strain heals in one or two weeks by itself. Anti-inflammatory ointments can be applied to combat the pain; a break from training is also a good idea for the shoulder.
TIP
To heat or cool? If there is tension in the shoulder, warmth can improve the blood supply to the muscles, which will then help them to relax. On the other hand, a strain should be cooled as this will help to alleviate any inflammation.
Treatments
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Patient Q&A
Our medical specialists regularly answer readers’ questions in newspapers, magazines and online. We have put together a few of these questions and answers for you here. Please note that the Q&A is purely informative. The advice provided is not comprehensive and does not substitute a consultation with a medical professional.
Shoulder pain
«I would like to ask a question on behalf of my colleague: three months ago she was playing with her nephew and during the rough and tumble he accidentally hit her, and something went click in her shoulder. Then she also started having pain in her shoulder and couldn’t lie on it any more. The pain still hasn’t gone away and she keeps waking up during the night whenever she rolls onto her left shoulder. For the last three or four days she has been in pain virtually all day and she can’t extend her arm that well either. Is that just bruising or something more serious?»
Unfortunately the information you have provided is not specific enough for us to come up with a tentative diagnosis. An acute injury, like the one your colleague suffered when playing with her nephew, should generally be checked out immediately by a doctor. It’s important to establish whether the shoulder has been dislocated or not (shoulder luxation). The examination should also check whether any tendons have been torn. In these kind of situations, I recommend getting checked out by a medical specialist relatively soon after the injury has occurred.
Dr. med. Walter Seelig, Hirslanden Klinik Birshof, Münchenstein Basel
Torn ligament in the shoulder
«My father’s partner (78) had a fall 10 weeks ago. They both live abroad. She tore the ligaments in her shoulder and needs an operation. The earliest appointment she could get for the operation is in 7 months. She has very severe pain, particularly at night. She’s currently doing physiotherapy and taking pain killers that have various side effects. She has already had an ultrasound, so would it be possible to have the images evaluated by a specialist in advance?»
Based on your description, I assume that your father’s partner has a torn rotator cuff (tear in the inner tendon). It is treated using a routine operation that is frequently carried out these days. An arthro-MRI examination is usually required to assess the possibility of reconstructing the cuff and the expected outcome. Sonographic (ultrasound) images can only be interpreted by the person performing the examination. An external assessment of the sonographic images is not possible. If an operation is indicated (is necessary and has a good chance of success), in Switzerland, the procedure can usually be scheduled and performed relatively quickly. However, the patient must have sufficient insurance coverage.
Dr. med. Walter Seelig, Hirslanden Klinik Birshof, Münchenstein Basel
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