Muscle Problems around the Shoulder

Surrounding the shoulder is a dome of muscles commonly referred to as the rotator cuff, composed of four muscles. The risk of tears in these muscles increases with age. In fact, rotator cuff tears that do not cause symptoms have been detected in half of individuals over the age of 80. In patients under 40, these tears usually result from significant trauma, whereas trauma is rarely present in patients over 60.

Patients typically report night pain and have difficulty lifting their arms overhead or reaching behind their backs. If the symptoms begin due to a known cause within the last three months, they are defined as acute. The same symptoms persisting for more than three months are considered chronic, and can be associated with increased pain, limited motion, and progressive tear size.

Rotator cuff tears are classified by their size and depth (full-thickness or partial-thickness). Partial-thickness tears are described based on their location and depth. The decision between surgical and non-surgical treatment takes into account the tear type, timing, size, patient age, expectations, muscle condition (e.g., fatty degeneration), presence of arthritis, nerve injury, or chronic infection.

Non-surgical treatment:

Preferred mainly for older patients. Methods include avoiding painful movements, ice application, pain-relieving medications, physical therapy, subacromial steroid injections, and the recently popular PRP injections. Rehabilitation should include exercises aligned with shoulder kinematics, especially in cases where muscle imbalance exists due to the tear.

Surgical treatment:

Recommended for full or partial-thickness tears unresponsive to non-surgical methods, all acute traumatic tears in patients under 60, or tears causing acute weakness and motion loss regardless of age, provided there are no contraindications for surgery. Repairs can be performed via arthroscopic, mini-open, or open techniques.

Ligamentous Problems in the Shoulder Joint

Instability refers to abnormal motion in the joint. This can cause pain or even result in full dislocation. Shoulder stability is maintained by both active (muscular) and passive (capsule-labral) components.

The labrum is a passive stabilizer that deepens the glenoid socket and helps the capsuloligamentous structures adhere to the bone. The rotator cuff muscles are the primary dynamic stabilizers.

a) Anterior Instability

The most common form of shoulder instability, typically caused by the shoulder abducting and externally rotating.

There is damage to the anteroinferior labrum and inferior glenohumeral ligament complex. Associated injuries may include ligament avulsion, rotator cuff tears, fractures, axillary nerve injuries, or cartilage damage.

In early stages, conservative treatment such as immobilization with a sling followed by physiotherapy should be tried in patients without additional complications.

However, young patients under 25, athletes, or those with significant bone or muscle damage should be treated surgically without delay.

b) Posterior Instability

Accounts for 2–5% of all shoulder instability cases. Half result from trauma, and may also be caused by electrical shock or epileptic seizures. Typically occurs when the arm is extended forward, internally rotated, and close to the body, with a force applied from behind.

Conservative treatment should always be attempted first. If it fails or in athletes, surgical intervention is required.

c) Multidirectional Instability:

Usually due to generalized ligament laxity. Most commonly seen in patients in their 20s or 30s. Symptoms include pain, clicking or catching in the shoulder, a feeling of instability during sleep, and difficulty throwing or lifting objects.

Non-surgical treatment focuses on strengthening the rotator cuff, scapular kinematics, and proprioceptive training. If these fail and the patient experiences pain or instability during daily or athletic activities, surgery may be considered.

d) Chronic Dislocations:

Often associated with fractures involving the joint. Half of posterior dislocations can be missed. In elderly patients with no major functional loss and high surgical risk, surgery may not be indicated.

Closed reduction can be attempted within 3 weeks of dislocation in appropriate cases. Surgical options include open reduction, bone grafting, arthroplasty, or arthrodesis, depending on the case.

e) SLAP Lesions:

Refers to damage to the superior portion of the labrum. Often caused by traction or throwing injuries.

There are four types:

Type 1: Some authors recommend non-surgical treatment, while others support surgery.

Types 2, 3, and 4: Treated surgically.

Return to work for desk jobs usually occurs in 3–6 weeks, while for elite athletes, it may take up to 6–7 months.

Shoulder Arthritis (Glenohumeral Osteoarthritis)

Shoulder arthritis may be primary (unknown cause) or secondary (due to trauma, instability, or prior surgery). Patients commonly report pain at rest and with movement, restricted motion, and difficulty performing daily tasks.

Non-surgical treatment includes pain medications, intra-articular steroid injections, and physical therapy. Patients with advanced symptoms or significant functional impairment may require surgical intervention.

In selected cases without severe arthritis or motion restriction, arthroscopic debridement may be considered, although its benefits remain controversial.

Surgical options include:

• Hemiarthroplasty
• Resection-interposition arthroplasty
• Total shoulder arthroplasty
• Arthrodesis (joint fusion)

The choice depends on the patient’s condition and needs.