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An algorithmic approach to shoulder pathology

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Shoulder pain is a common presentation in both hospitals and the community. Shoulder pain can result from a number of different pathologies and to manage the shoulder pain, an accurate diagnosis is needed.An accurate diagnosis can often be made following…

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Continuing Education Activity

Shoulder pathology is very common. A comprehensive history should be acquired by clinicians evaluating patients with acute or chronic shoulder dysfunction. Indications for comprehensive shoulder evaluation include shoulder, periscapular, neck, or nonspecific upper extremity signs or symptoms. This activity reviews the comprehensive shoulder evaluation examination and highlights the interprofessional team's role in caring for patients with shoulder dysfunction.

Objectives:

Access free multiple choice questions on this topic.

Introduction

Shoulder pathology and dysfunction represent some of the most commonly diagnosed and treated conditions by primary care, sports medicine, and orthopedic providers.[1] This comprehensive review article discusses the clinical pearls and tips and tricks for delineating complex shoulder pathologies.

Anatomy and Physiology

The shoulder girdle consists of the scapula and clavicle, which articulate with the chest wall, and the proximal humerus, which articulates with the scapula (the glenoid). The humeral head and the glenoid vault of the scapula form the osseous components of the glenohumeral joint of the shoulder.

The glenohumeral joint is a complex, mobile, multiaxial, ball-and-socket articulation that allows coordinated motion in the frontal, transverse, and sagittal planes. The latter allows for 360 degrees of circumduction. The relatively shallow glenoid fossa articulates with the much larger humeral head to allow for a wide range of physiologic motion. Also, the joint capsule is relatively lax. Shoulder movements occur secondary to the dynamic and coordinated articulations at four distinct joints:

Static and Dynamic Stabilizers

The static stabilizers include the glenohumeral articulation, the labrum, the glenohumeral ligaments, rotator cuff interval structures, and the negative intraarticular pressure. The dynamic stabilizers consist of the rotator cuff muscles, the deltoid, and the scapular and periscapular stabilizers.

Supraspinatus

Arises from the medial two-thirds of supraspinatus fossa of the scapula, passes across the superior aspect of the glenohumeral joint, and inserts into the superior and middle facet of the greater tuberosity of the humerus.

Primarily initiates shoulder abduction.

Important for the initial 0 to 15 degrees of shoulder abduction motion when the arm is adducted against the side of the trunk

Beyond 15 degrees of abduction, the deltoid moment arm acts synergistically to assist in shoulder/arm abduction.

Along with the other rotator cuff muscles and provides dynamic stabilization of the shoulder.

Innervation: Suprascapular nerve (C4,C5,C6)

Blood supply: Suprascapular artery

Infraspinatus

Subscapularis

Teres Minor

The long head of the biceps brachii tendon (LHBT) originates at the supraglenoid tubercle and superior glenoid labrum. The labral origin is predominantly posterior in more than half of cases. Inside the joint, the tendon is extrasynovial, passing obliquely heading toward the bicipital groove. The long head tendon distally joins the short head of the biceps tendon (SHBT) as both transition to their respective muscle bellies in the central third of the brachium, and after crossing the volar aspect of the elbow, forms a common tendon and inserts on the radial tuberosity and medial forearm fascia. The latter occurs via the bicipital aponeurosis.

The short head of the biceps originates from the coracoid process, and the long head originates from the supraglenoid tubercle, passing through the intertubercular groove of the proximal humerus. The biceps brachii is not a shoulder muscle but does originate from the shoulder.

The bicipital groove is an anatomic landmark located between the greater and lesser tuberosities of the humerus and serves as a critical location for proximal biceps stability. The soft tissue components of the groove create a tendoligamentous sling to support the LHB tendon and include portions of the rotator cuff muscles (subscapularis and supraspinatus) coracohumeral ligament (CHL), and the superior glenohumeral ligament (SGHL).

Biomechanically, the LHBT has a controversial role in the dynamic stability of the shoulder joint. It has been demonstrated, mostly in biomechanical cadaveric-based studies and animal models, that the tendon at least plays a passive stabilizing role in the shoulder. Neer proposed in the 1970s that the LHBTs stabilizing role varied depending on the position of the elbow.[3] Several subsequent studies refuted the theory that the LHBT played any active shoulder stabilizing effect. Jobe and Perry evaluated the activation of the biceps during the throwing motion in athletes. The authors reported the peak muscle stimulation occurred in relation to elbow flexion and forearm deceleration, with very little proximal biceps activity during the earlier phases of throwing.

Thus, in most healthy patient populations, the LHBT plays a negligible role in the dynamic stability of the shoulder. The main function of the biceps muscle is forearm supination and elbow flexion. The biceps also contribute 10% of the total power in shoulder abduction when the arm is in external rotation.

Bicipital Groove Soft Tissue Pulley

The bicipital groove is an anatomic landmark that sits between the greater and lesser tuberosities, and its osseous and soft tissue components contribute to the inherent stability of the LHBT. The depth, width, and medial wall angle have been studied in relation to overall bicipital groove stability, with significant variability recognized in its components. Many authors attribute these parameters as predisposing factors to pain and instability in both primary and secondary LHBT pathologies.

The LHBT takes a 30-degree turn as it heads toward the supraglenoid tubercle, relying on the integrity of the enveloping soft tissue sling/pulley system. The most important elements in maintaining stability at this critical turn angle are the most medial structures at the proximal-most aspect of the groove's exit point. The soft tissue components of the biceps pulley system include the following:

The subscapularis has superficial and deep fibers that envelope the groove, creating the "roof" and "floor," respectively. These fibers also coalesce with those from the supraspinatus and SGHL/CHL complex. These structures attach intimately at the lesser tuberosity to create the proximal and medial aspect of the pulley system, with soft tissue extensions serving to further envelope the LHBT in the bicipital groove.

The CHL is a dense fibrous structure connecting the base of the coracoid process to the greater and lesser tuberosities. At its origin, the ligament is thin and broad, measuring about 2 cm in diameter at the base of the coracoid. Laterally, the CHL separates into 2 distinct bands that envelop the LHBT at the bicipital groove's proximal extent. Once the LHBT exits the groove, it takes a 30- to 40-degree turn as it heads toward the supraglenoid tubercle and glenoid labrum. Thus, the proximal soft tissue elements of the groove are especially critical for the overall stability of the entire complex. In addition to the CHL, the SGHL reinforces the complex at this proximal exit point. The SGHL travels from the superior labrum to the lesser tuberosity, becoming confluent with the soft tissue pulley as it takes on a U-shaped configuration. Warner and colleagues previously demonstrated that the cross-sectional area of the CHL is, on average, 5 times larger than that of the SGHL.

Historically, the transverse humeral ligament (THL) was thought to play a primary role in bicipital groove stability. However, more recently, its role in providing stability has been refuted, with many authors questioning its existence as a distinct anatomic structure. The latter remains fairly controversial, with most studies now reporting the THL is, at most, a continuation of fibers from the subscapularis, supraspinatus, and CHL. A histologic study in 2013 identified a distinct fibrous fascial covering in the "roof" of the groove. Neurohistology staining showed the presence of free nerve endings but no mechanoreceptors. Despite the controversial evidence concerning its definitive existence as an anatomic structure, its location at the distal extent of the bicipital groove inherently refutes the previous dogma of its potential role in LHBT stability. Furthermore, the presence of free nerve endings in recent histological studies suggests its possible role as a potential pain generator in the anterior shoulder.

Periscapular Stabilizers[10]

The scapula provides attachment for several groups of muscles. The intrinsic muscles of the scapula include the rotator cuff muscles and teres major. These muscles attach to the scapular surface and assist with the abduction and external and internal rotation of the glenohumeral joint.

The extrinsic muscles include the triceps, biceps, and deltoid. The third group of muscles includes the periscapular stabilizers. These muscles play a pivotal role in a wide range of scapular-based pathologies, including shoulder instability, scapular dyskinesia, and scapulothoracic pathology. These muscles include the rhomboids, trapezius, levator scapulae, and serratus anterior.

Rhomboid Minor

The rhomboid minor originates from the nuchal ligament and spinous processes of C7-T1. The rhomboid major originates from the spinous processes of T2-T5. The rhomboid muscles insert on the medial border of the scapula and work in combination with the levator scapulae muscles to elevate the medial border of the scapula. The only muscle which acts to depress the shoulder is the lower trapezius, which is assisted by gravity in the upright position.

Trapezius

The trapezius is a large triangular-shaped muscle that overlies the shoulder posteriorly. The trapezius originates from the superior aspect of the nuchal line in the occipital, cervical, and upper thoracic region and inserts at the lateral aspect of the clavicle, the acromion, and spine of the scapula. The function of the trapezius muscle is both elevation and depression of the shoulder, depending on whether the upper or lower muscle fibers are activated. When the entire trapezius muscle contracts, the fibers are geometrically opposed, and the forces are balanced, resulting in no movement of the shoulder.

Deltoid

The deltoid muscle overlies the shoulder superficially and functions to abduct the humerus. The deltoid muscle has three origins; the body of the clavicle, the spine of the scapula, and the acromion. The deltoid muscle has its insertion on the deltoid tuberosity of the humerus. The function of the deltoid muscle is variable depending on which muscle fibers are activated. The anterior deltoid flexes and medially rotations the humerus, the middle deltoid abducts the humerus, and the posterior deltoid performs the actions of extension and external rotation of the humerus.

Serratus

Originates on the superolateral surfaces of the upper 8 ribs at the side of the thoracic cavity. The serratus anterior inserts on the vertebral border of the scapula and acts to draw the scapula forward and upward. The serratus abducts and rotates the scapula while also dynamically stabilizing its vertebral border.

Levator Scapulae

The levator muscle originates from the posterior tubercles of transverse processes C1 through C4 in the cervical spine. The muscle inserts on the superior and medial border of the scapula, and it acts to elevate the scapula and thereby to tilt the glenoid vault inferiorly.

Indications

In general, the indications for a comprehensive evaluation of the shoulder include any patient presenting with any degree of the shoulder, periscapular, neck, and nonspecific upper extremity pathology.[11]

Technique or Treatment

A comprehensive history should be acquired by clinicians evaluating patients presenting with acute or chronic shoulder dysfunction. Even in the acute traumatic setting, patients may present with an ipsilateral upper extremity injury or fracture. This should not preclude an examination of the shoulder in order to mitigate the risk of a missed diagnosis. Furthermore, one should be aware that there are many "spooks" in the shoulder, and this phrase can aid the provider in painting a relatable picture to the patient regarding the multitude of potential pain generators and sources of pain in and around the shoulder.

When assessing patients presenting with history/symptoms concerning LHBT instability, it is important to clinically evaluate co-existing shoulder injuries or pathology. A thorough history of the mechanism of injury can often aid the clinician in the preliminary differentiation between various shoulder pathologies. For example, AC joint pathology often presents secondary to acute trauma, with the patient reporting either trauma directly to the shoulder during a contact sport, or the patient may report a history of a fall directly onto the shoulder.

The following is a summary of some of the most high-yield patient history elements that can help identify some common underlying shoulder pathologies.

LHBT Tendinopathy

LHBT Instability:

Patients often report painful "clicking" or audible "popping" noted with shoulder abduction, extension, and rotational movement of the shoulder. The patient can often reproduce this during the actual office visit.

LHBT instability (or tendinopathy) often manifests as pain at the anterior aspect of the shoulder, with or without radiation down the anterior arm over the biceps brachii muscle belly

Rotator Cuff Syndrome

Rotator cuff syndrome (RCS) can encompass any number of shoulder impingement etiologies. Typical history elements include:

Characteristics of a history of potential rotator cuff (RC) injury include:

Superior Labrum Anterior-posterior (SLAP) Lesions

SLAP tears may present in a relatively nonspecific fashion and in association with other shoulder pathologies. Clinicians should inquire regarding certain elements in history taking that may help differentiate SLAP tears from other shoulder injuries.

Pertinent elements in history taking to best elucidate the nature of a potential SLAP tear (or other associated shoulder injuries) include:

Acute onset of "deep" shoulder pain

Mechanical symptoms: popping, locking, catching with various movements and activity

History of any sudden, jerking force to the shoulder with associated onset of pain

History of or current episodes of shoulder instability

History or current sport-specific participation

Including the level of competition (e.g., professional, collegiate, recreational)

Common SLAP-provoking sports include but are not limited to:

Overhead sports (volleyball, baseball pitchers, javelin, swimming)

History or current manual/physical laborer occupations

Shoulder Instability

Clinicians evaluating patients with acute or chronic shoulder instability should obtain a comprehensive history. Providers should document any detailed elements regarding the index injury for both first-time versus chronic presentation dislocators. Also, other elements often include the following:

Patients presenting after a single acute event typically report a recent history of high-energy trauma or collision impact causing the dislocation.

Clinicians should inquire regarding:

Degree of trauma (high- or low-energy impact mechanisms)

Sport activity and position(s)

Discern a true dislocation from a subluxation event

Elicit the requirement for on-field or on-site manual reduction; presentation to the emergency department +/- sedation requirements

Patients typically present in a delayed fashion once the range of motion limitations begin to significantly impact daily activities.

Clinicians should gather a detailed history for any inciting instability events.

The initial injury may be overlooked, and the patient subsequently develops chronic instability/recurrence.

Heightened clinical suspicion is warranted in the setting of:

History of seizures or electrical shocks

Polytraumas in which the shoulder instability was overlooked or missed

Low-energy, recurrent subluxation cases

Shoulder instability episodes during sleep may be indicative of more complex instability that may involve significant bone loss.

Clinicians should elicit for any medical comorbidities or family history of underlying connective tissue disorders or generalized hyperlaxity on the exam.

A thorough history also includes sports participation and position(s) (if applicable occupational history and current status of employment, hand dominance, any history of injury/trauma to the shoulder(s) and/or neck, and any relevant surgical history.

Physical Examination

Cervical Spine/Neck

Co-existing cervical pathology, especially radiculopathy, should be ruled out in any situation where shoulder pathology is possible. Observation of neck posturing, muscular symmetry, palpable tenderness, and active/passive ROM should be evaluated. Special tests that are helpful in this regard include Spurling's maneuver, myelopathic testing, reflex testing, and a comprehensive neurovascular exam.[13][14][15][16]

A detailed sensory examination should be performed in all patients presenting with possible underlying shoulder or neck pathologies. A bilateral exam is imperative in many of these cases to obtain an accurate working differential diagnosis.

The clinician should assess the motor function of the elbow, wrist to rule out the possibility of brachial plexus injuries, and distal pulses also require assessment at the wrist.[17][18][19][20]

Shoulder

Clinicians should observe the overall shoulder girdle to assess symmetry, shoulder posturing, and overall muscle bulk and symmetry. Scapular winging should also be ruled out. The skin should be checked for the presence of any previous surgical incisions, lacerations, scars, erythema, or induration. In the setting of proximal biceps pathology, especially in traumatic or spontaneous LHBT ruptures, patients will typically exhibit significant ecchymosis in the upper arm over the area of the biceps brachii muscle itself and an associated "Popeye" deformity is characteristic for a complete rupture. The latter is more readily appreciated in fit or thin patients and can be a rather subtle finding in patients with large body habitus. Comparison to the contralateral extremity is helpful.

After the observations mentioned above, the active and passive ROM is documented. In the setting of both primary and secondary proximal biceps tendinitis cases, full ROM should be observed. In the absence of advanced glenohumeral arthritic changes affecting, limited passive ROM is considered diagnostic for adhesive capsulitis.

Proximal Biceps

There are many different focused physical examination maneuvers reported in the literature. Specific testing targets either LHBT pathology localized to the bicipital groove or more proximally near its origin at the supraglenoid tubercle.

Bicipital groove palpation: Direct palpation over the patient's bicipital groove elicits a painful response in the setting of pathology.

Speed's test: A positive test consists of pain elicited in the bicipital groove when the patient attempts to forward elevate the shoulder against examiner resistance; the elbow is slightly flexed, and the forearm is supinated.

Uppercut test: The involved shoulder is positioned at neutral, the elbow is flexed to 90 degrees, the forearm is supinated, and the patient makes a fist. The examiner instructs the patient to perform a boxing "uppercut" punch while placing their hand over the patient's fist to resist the upward motion. A positive test is a pain or a painful pop over the anterior shoulder near the bicipital groove region.

Yergason's test: The arm is stabilized against the patient's trunk, and the elbow is flexed to 90 degrees with the forearm pronated. The examiner manually resists supination while the patient also externally rotated the arm against resistance. A positive test is noted if the patient reports pain over the bicipital groove and/or subluxation of the LHB tendon.

Bicipital Groove

The examiner brings the patient's shoulder to 90 degrees of abduction and 90 degrees of external rotation. The examiner passively rotates the shoulder at this position in an attempt to elicit the patient-reported audible "popping" or "clicking" sensations. Sometimes passively maneuvering the shoulder from the extension to cross-body plan helps elicit instability symptoms.

At the 90/90 shoulder abduction/external rotation position, the patient is asked to "throw forward" while the examiner resists this forward motion. A positive test for groove pain must be localized to the anterior aspect of the shoulder to enhance diagnostic sensitivity and specificity.

Proximal biceps pathology is often associated with concomitant shoulder pathologies. Thus, it is important to differentiate the primary sources of patient-reported pain and symptoms clinically. Other important, provocative testing categories include the AC joint, the glenohumeral labrum, and rotator cuff muscles. The latter includes special consideration for subscapularis given the common pathological associations.

AC Joint

Observation and direct palpation: Patients presenting with chronic AC joint pain and/or arthritic pathology often will have clinically obvious AC joint hypertrophy that can be appreciated solely with observation and/or direct palpation over the joint.

Cross-body adduction: The examiner may find it helpful to directly localize the AC joint with direct palpation before initiating any shoulder movement. Subsequently, the examiner brings the shoulder into about 90 degrees of flexion in front of the plane of the scapula, and a positive test includes patient-reported symptom reproduction as the arm is brought into cross-body adduction positions. The physician should be able to discern the exact location of pain reproduction with the cross-body adduction maneuvers.

Superior Labrum Anterior-Posterior (SLAP) Lesions

O'Brien's test/Active compression test: The patient is standing, and the arm of interest is positioned at 90 degrees of forward flexion, 10 degrees of adduction, and internally rotated so the thumb points toward the floor. The examiner places his or her hand over the patient's elbow while instructing the patient to resist the examiner's downward force applied to the arm. This maneuver is repeated with the patient's arm now rotated, so the palm faces the ceiling. A positive test is denoted by pain located at the joint line during the initial maneuver (thumb down/internal rotation) in conjunction with reported improvement or elimination of the pain during the subsequent maneuver (palm up/external rotation).

Anterior slide test: The patient stands with his or her hand of the involved arm placed on the ipsilateral hip with the thumb pointing posteriorly. The examiner places one hand on the joint line of the shoulder and the other hand on the elbow. The examiner then applies an axial load in an anterosuperior direction from the elbow to the shoulder. A positive test includes pain or a painful click on the anterior or posterior joint line.

Modified O'Driscoll test/Modified dynamic labral shear test: The patient stands with his or her involved arm flexed 90 degrees at the elbow, and the shoulder is abducted in the scapular plane to above 120 degrees. The examiner then applies terminal external rotation until resistance is appreciated. Next, the examiner applies a shear force through the shoulder joint by maintaining external rotation and horizontal abduction and lowering the arm from 120 to 60 degrees abduction. A positive test includes a reproduction of the pain and/or a painful click or catch in the joint line along the posterior joint line between 120 and 90 degrees of abduction.

Rotator Cuff

Supraspinatus (SS)

Jobe's test: Positive test is pain/weakness with resisted downward pressure while the patient's shoulder is at 90 degrees of forward flexion and abduction in the scapular plane with the thumb pointing toward the floor.

Drop arm test: The patient's shoulder is brought into a position of 90 degrees of shoulder abduction in the scapular plane. The examiner initially supports the limb and then instructs the patient to adduct the arm to the side of the body slowly. A positive test includes the patient's inability to maintain the abducted position of the shoulder and/or an inability to adduct the arm to the side of the trunk in a controlled manner.

Infraspinatus (IS)

Strength testing is performed while the shoulder is positioned against the side of the trunk, the elbow is flexed to 90 degrees, and the patient is asked to externally rotate the arm while the examiner resists this movement.

External rotation lag sign: The examiner positions the patient's shoulder in the same position, and while holding the wrist, the arm is brought into maximum external rotation (ER). The test is positive if the patient's shoulder drifts into internal rotation (IR) once the examiner removes the supportive ER force at the wrist.

Teres Minor

Strength testing is performed with the shoulder positioned at 90 degrees of abduction and the elbow is also flexed to 90 degrees. Teres minor (TM) is best isolated for strength testing in this position while the examiner resists ER.

Hornblower's sign: The examiner positions the shoulder in the same position and maximally ERs the shoulder under support. A positive test occurs when the patient cannot hold this position, and the arm drifts into IR once the examiner removes the supportive ER force.

Subscapularis

The high rate of associated pathologies with the LHBT and the subscapularis (SubSc) makes the subscapularis evaluation component significantly important in this clinical setting. The diagnosis of injuries to the subscapularis remains a challenge in any setting of shoulder pathology. Multiple provocative maneuvers and special exams exist in the literature, with the bear-hug test being the most sensitive exam modality, although it only boasts a 60% sensitivity rate:

External Impingement/SIS

Neer impingement sign: Positive if the patient reports pain with passive shoulder forward flexion beyond 90 degrees.

Neer impingement test: Positive test occurs after the examiner gives a subacromial injection and the patient reports improved symptoms upon repeating the forced passive forward flexion beyond 90 degrees.

Hawkins test: Positive test occurs with the examiner passively positioning the shoulder and elbow at 90 degrees of flexion in front of the body; the patient will report pain when the examiner passively internally rotates the shoulder.

Internal Impingement

Internal impingement test: The patient is placed in a supine position, and the shoulder is brought into terminal abduction and external rotation; a positive test consists of a reproduction of the patient's pain.

Shoulder Instability Considerations

Global tissue laxity should be assessed by examining glenohumeral translation and hypermobility at the shoulder joints and other joints in the body if applicable. Hyperlaxity at other joints (e.g., elbow and knee hyperextension) may aid in the clinical diagnosis of underlying MDI-related diagnoses or connective tissue disorders.

Anterior Apprehension Test

The anterior apprehension test is performed by lying the patient supine on the examination table. The examiner positions the shoulder to 90 degrees of abduction and 90 degrees of external rotation. While an anteriorly directed force is applied to the proximal humerus. The test is positive if symptoms of anterior instability are reproduced.

Apprehension at lower degrees of abduction may suggest glenoid bone loss. Patients may be guarded during the examination, but in most circumstances, the provider is able to elicit if the apprehensive position is reproducible the patient's feelings of anterior shoulder instability.

Jobe Relocation

The Jobe relocation test is utilized with the previous apprehensive testing maneuver. Once the patient reports a subjective feeling of reproducing the shoulder instability symptoms, the examiner applies a posteriorly directed force while keeping the shoulder in the same apprehensive position. Resolution or improvement of symptoms indicates a positive test result.

Load-and-Shift

The examiner uses one hand to apply an axial load through the elbow to center the humeral head within the glenoid. An anterior and posterior directed force is then applied at 0-, 45-, and 90-degrees of shoulder abduction. Increased translation at increasing degrees of shoulder abduction implies a compromise of the IGHL.

The magnitude of humeral head translation is graded:

The load-and-shift test has been found to be up to 98% specific, but it has poor sensitivity for the detection of unidirectional and multidirectional instability.

IMAGING

Radiographs

Clinicians should obtain a true anteroposterior image of the glenohumeral joint, also known as the "Grashey" view. The true anteroposterior image is taken with the patient rotated between 30 and 45 degrees offset the cassette in the coronal plane. The beam can otherwise be rotated while the patient is neutral in the coronal plane. The distance between the acromion and the humeral head to compute the acromiohumeral interval. A normal interval is between 7 and 14 mm. This interval decreases in cases of advanced degenerative arthritis and RCA. Other standard views include the lateral, or "scapular Y," view and an axillary view.

Ultrasound (US)

Ultrasound (US) is highly operator-dependent but is touted as a fast, cost-effective tool for diagnosing LHBT pathology. Characteristic findings include tendon thickening, tenosynovitis, synovial sheath hypertrophy, and fluid surrounding the tendon in the bicipital groove. The ability to perform a dynamic examination increases the sensitivity and specificity for detecting subtle instability. The diagnostic accuracy of US in detecting LHB pathology ranges from 50% to 96% (sensitivity) and 98% to 100% (specificity) when compared to Magnetic resonance arthrography (MRA).

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is useful in evaluating the LHBT, bicipital groove, and any fluid or edema that may be indicative of pathology. MRI helps define other associated shoulder pathologies, and in the setting of LHBT instability, particular attention should be given to evaluating for concomitant subscapularis injury. Most of the previous studies that have investigated the accuracy of preoperative MRI scans have used open surgical approaches to correlate MRI with surgical findings.

Over 90% of subscapularis tendon injuries begin on the articular side. Therefore, it is important to correlate suspected MRI pathology with direct visualization during shoulder arthroscopy. A 2010 study demonstrated that preoperative MRI interpretations (by radiologists) did not correlate with arthroscopic findings in the setting of suspected injury.

MRI is useful in identifying the LHBTs position with respect to the bicipital groove. The absence of the tendon within the groove would suggest subluxation and/or dislocation. Given the relatively poor reliability of MRI capabilities in diagnosing subscapularis injuries, the presence of LHBT subluxation/dislocation has been advocated for diagnostic capability improved accuracy by association. A 2015 study by Warner and colleagues investigated 100 patients with shoulder pathologies, of which 26 were diagnosed with LHBT subluxation based on preoperative MRI. Results indicated that the presence of LHBT subluxation was a predictor for full-thickness subscapularis tears, with a sensitivity of 82%, a specificity of 80%, a positive predictive value of 35%, and a negative predictive value of 97%. LHBT subluxation was directly correlated with the severity of the subscapularis tendon tear.

Other associated shoulder pathologies and rotator cuff integrity can also undergo an evaluation with MRI. Other common sources of acute or chronic shoulder pain can be evaluated on MRI, including subdeltoid and/or subacromial bursitis, acromioclavicular (AC) joint pathology, and morphology. A systematic approach to review shoulder MRIs is essential, especially when tying the MRI findings with patient-reported symptoms and clinical examination.

MR Arthrography

Many studies have suggested MR arthrography (MRA) as the best imaging modality for detecting biceps soft tissue pulley lesions. Walch previously described the "pulley sign" on MRA, suggesting a lesion to the soft tissue pulley structures. The "pulley sign" is an extra-articular collection of contrast material anterior to the upper subscapularis muscle. A 2012 study established MRA criteria for diagnosing biceps pulley lesions. The findings on MRA included:

Other pertinent MRA findings include contrast material extending to the coracoid, indicating a potential lesion of the rotator interval. Recent studies have highlighted the importance of advanced imaging as well as diagnostic arthroscopy for evaluating for the presence and extent of biceps soft tissue pulley injuries. Advancements in imaging and arthroscopic techniques have become increasingly important as the clinical examination is prone to equivocal results.

Clinical Significance

Rotator Cuff Syndrome

Rotator cuff syndrome (RCS) describes a spectrum of clinical pathology ranging from minor injuries such as acute rotator cuff tendinitis, to advanced/chronic rotator cuff tendinopathy and degenerative conditions.

Rotator cuff injuries represent a common cause of shoulder pain. The rotator cuff tendons, particularly the supraspinatus tendon, are uniquely susceptible to the compressive forces of subacromial impingement. Improper athletic technique, poor posture, poor conditioning, and failure of the subacromial bursa to protect the supporting tendons results in a progressive injury from acute inflammation, to calcification, to degenerative thinning, and finally to a tendon tear.

Rotator cuff (RC) Tendonitis/Tendinosis

Acute or chronic tendinopathic conditions resulting from a vulnerable environment for the RC secondary to repetitive eccentric forces and predisposing anatomical/mechanical risk factors.

Shoulder impingement

A clinical term often used nonspecifically to describe patients experiencing pain/symptoms with overhead activities. Shoulder impingement is best subdivided into internal and external conditions:

Internal impingement: common in overhead-throwing athletes such as baseball pitchers and javelin throwers. Impingement occurs at the posterior/lateral articular side of the cuff as it abuts the posterior/superior glenoid rim and labrum when the shoulder is in maximum abduction and external rotation (i.e., the "late cocking" phase of throwing)

The term "thrower's shoulder" refers to a common set of anatomic adaptive changes that occur over time in this subset of athletes.

These adaptive changes include but are not limited to increased humeral retroversion and posterior capsular tightness.

Glenohumeral internal rotation deficit (GIRD) is a condition resulting from these anatomic adaptations, and GIRD is known to predispose the thrower's shoulder to internal impingement.

External impingement: a term used synonymously with SIS. External impingement (EI) encompasses etiologies of external compressive sources (i.e., the acromion) leading to subacromial bursitis and bursal-sided injuries to the RC.

Swimmers Shoulder

Swimmers have a significant potential for shoulder injuries due to the unique nature of the different strokes involved in swimming, as well as the high volume of repetitions needed during training. Swimmer's shoulder is a term that can represent numerous shoulder pathologies. These include impingement syndrome, rotator cuff tendinitis, labral injuries, instability secondary to ligamentous laxity or muscle imbalance/dysfunction, neuropathy from nerve entrapment, and anatomic variants. In order for the athlete to return to the sport in an appropriate and timely manner, the clinician must be able to differentiate between these different etiologies.

Inflammatory Conditions/Tendinitis/Tendinopathy

Biceps tendonitis describes a clinical condition of inflammatory tenosynovitis most commonly affecting the LHBT as it travels within the bicipital groove in the proximal humerus. Chronic pathology results in tendinosis and, eventually, severe tendinopathy.

Inflammatory pathologies are often secondary in nature due to the high prevalence of associated or preceding shoulder pathologies. In the 1970s, Neer demonstrated that the proximal biceps tendon is subjected to the same mechanical compressive forces under the coracoacromial arch as the rotator cuff. Thus, he noted their high degree of pathological association. In 1982, Neviaser demonstrated the relationship between increasing LHBT inflammatory changes with the severity of rotator cuff (RC) injury and tendinopathy. Other associated shoulder pathologies include shoulder impingement (external or internal) and glenohumeral arthritis.

Primary bicipital tendinitis is much less common compared to secondary cases. The etiologies for primary bicipital tendinitis are not well understood compared to the more common secondary presentations. A particular subset of patients with primary, isolated biceps tendinitis is recognized in the younger, athletic population. Provocative sports include baseball, softball, and volleyball. Various medical conditions can cause intrinsic degeneration of the tendon, potentially leading to spontaneous rupture. End-stage degenerative LHB tendinopathy can result in spontaneous rupture and resulting "Popeye" deformity in the upper arm.

Traumatic Pathologies and Tendon Ruptures

Traumatic pathologies can overlap with the instability spectrum. Conditions include superior labrum anterior to posterior (SLAP) lesions, partial versus complete ruptures, and injury secondary to direct or indirect trauma. The latter injuries would include partial or complete lacerations from a penetrating object or weapon, and indirect damage can occur to the tendon in various fracture patterns at the proximal humerus.

Rupture of the tendon usually occurs at either the musculotendinous junction or the LHBT origin near the supraglenoid tubercle. Just as in cases of LHB tendinitis, most ruptures occur in association with other shoulder pathologies. The most common cause of secondary LHBT rupture is rotator cuff injuries. The pathophysiology of secondary rupture is appreciated due to the loss of the protective role of the rotator cuff in protecting the LHBT from the coracoacromial arch. Primary LHBT rupture occurs at a similar rate to its primary LHB tendinitis counterpart pathology, about 5% of all total cases in each group.

Biceps Instability

Medial subluxation/dislocation of the LHBT can occur with repetitive mechanical wear, overuse, or acute trauma. While the osseous dimensions of the bicipital groove contribute to the stability of the LHBT, the most important stabilizers are the SGHL, CHL, and the interwoven fibers of the subscapularis and supraspinatus. The SGHL/CHL complex and the subscapularis fibers are intimately coalesced at the lesser tuberosity, serving an integral role as the medial and proximal portion of the soft tissue sling as part of the bicipital groove pulley system. Injury to one, a combination, or all of these components can lead to LHBT instability. Frequently, these structures can avulse from the tuberosity and remain attached to one another in the setting of varying degrees of instability.

Shoulder Instability

Glenohumeral instability encompasses both dislocation and subluxation events, and instability events commonly affect the general population. Approximately 1% to 2% of the general population will experience a glenohumeral dislocation in their lifetime. The young, active, athletic population is particularly susceptible to shoulder instability events. Over 95% of shoulder instability events occur in the anterior direction.

Enhancing Healthcare Team Outcomes

A comprehensive evaluation of the shoulder and neck is imperative in patients presenting with upper limb, nonspecific symptomatic presentations. Shoulder pathology and dysfunction represent some of the most commonly diagnosed and treated conditions by primary care, sports medicine, and orthopedic providers. Everyone on the healthcare team must work in a coordinated fashion to help delineate an appropriate clinical diagnosis and coordinate treatment as a team to ensure all patients are managed with optimal medical and/or surgical care. The orthopedic specialty nurses play a crucial role in managing to follow up and assisting with patient and family education. They should report any concerns if the patient is experiencing worse symptoms. Physical therapists will playa crucial role in helping the patient avoid surgery or in post-surgical rehabilitation. Working in an interprofessional manner will lead to the best outcomes. [Level 5]

References

Disclosure: Matthew Varacallo declares no relevant financial relationships with ineligible companies.

Disclosure: Youssef El Bitar declares no relevant financial relationships with ineligible companies.

Disclosure: Scott Mair declares no relevant financial relationships with ineligible companies.

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Shoulder pathology and dysfunction represent some of the most commonly diagnosed and treated conditions by primary care, sports medicine, and orthopedic providers.[1] This comprehensive review article discusses the clinical pearls and tips and tricks for delineating complex shoulder pathologies.

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What Is Shoulder Instability?

The shoulder is a ball and socket joint, it is made up of 3 bones that move together as one; the scapula (socket of the shoulder blade) and the head of the arm bone (ball section) and the collar bone.

The joint is designed to give a large amount of movement. This also means that it has the potential to be too loose. There are various structures that help to keep the joint in position. The most important ones are:

Ligaments, which hold the bones together

Labrum (A rim of cartilage, which deepens the socket)

Muscles, which keep the shoulder blade and ball in the correct position when moving or using the arm.

Joint capsule (lining that covers the joint)

Shoulder instability is when the ball is not suitably controlled within the socket. It can develop in two different ways; Traumatic and Atraumatic.

Traumatic caused by a sudden injury of dislocation (joint moving fully out of place), or subluxation (joint partially moving out of place).

Atraumatic when shoulder instability can occur without an injury, in people who naturally have greater laxity (looseness) in their joint and surrounding tissues. Additionally, in a very small minority of people shoulder instability can occur due to muscle imbalances i.e some muscles pulling too strongly or not coordinating well enough.

What Are The Symptoms Of Shoulder Instability?

Patients commonly complain of pain, weakness and poor movement and may feel apprehensive about moving their arm in certain ways. They may feel that their shoulder is slipping, giving way, catching or coming out of joint, which can cause patients to feel less confident about using their arm for general tasks of daily living, at work and during sporting activities.

If the problem develops following a sudden injury, patients may report that their shoulder repeatedly dislocates (comes out of joint) and need to visit the hospital to have it relocated (put back in), whilst other patients may feel as if their shoulder is partly coming out and then moving back in again (subluxing).

How Common Is Shoulder Instability?

The shoulder is a very mobile joint, and therefore dislocation (the joint coming out of place) is more common than in some other joints.

Traumatic shoulder instability accounts for approximately 96% of shoulder dislocations.

The first time of dislocation is an important factor:

If you first dislocate your shoulder before you are 30, there is a 70% chance of recurrent instability (the shoulder dislocating again in the future).

If you are over 40 years old when the first dislocation happens, there is less than a 10% chance of reoccurrence.

Atraumatic (without injury) The true prevalence is unknown but thought to be approximately 4% of shoulder instabilities. Predominately in the younger age of under 25 years.

What Causes Shoulder Instability?

Shoulder instability develops in two different ways:

Traumatic cause: Due to a specific injury or trauma. This can damage other structures in the shoulder such as ligaments, tendons, labrum (the rim of cartilage) or the bone in the upper arm (humerus). This can increase the chance of the shoulder coming back out again or inhibit how the shoulder works.

Atraumatic cause: the shoulder problem may not be linked to any injury. The person is either born with, develops laxity of their shoulder joint tissues

Shoulder joint laxity can also develop as a result of repetitive minor injuries, such as overhead throwing sports, that cause the shoulder structures to stretch out over time. Patients in this category can lose normal muscle control, causing the shoulder to become unstable whilst doing simple daily tasks and sporting activities.

What Can Help With Shoulder Instability?

Following a first-time dislocation/injury, your arm may be put in a sling. Your doctor or physiotherapist will advise you on when to remove it to exercise.

Making changes to the activities you do does not mean that you have to stop moving or stop using your shoulder altogether. Try to avoid activities that involve lifting your arm over your head, or contact sports for the first three months after the dislocation.

Your physiotherapist will guide you with an exercise programme to help regain shoulder function.

If you need any help with activities of daily living please follow the links below:

Atraumatic shoulder instability is a complex problem to treat. The shoulder is naturally too mobile, and you can't control or move it correctly.

Resting the shoulder does not help, keeping your shoulder moving and the muscles strong is beneficial. Learning to recognise the triggers and learning how best to prevent or deal with it is necessary.

In most cases, specialist Physiotherapy input and hard work from you, is the best treatment option to help shoulder instability, whether due to an injury or not.

Physiotherapy helps patients regain their shoulder mobility and targets specific strengthening for the muscles that surround the shoulder to increase the stability. It also helps to retrain the brain, to coordinate and control shoulder movement and restore more normal movement patterns.

Please speak to a healthcare professional for guidance on how to improve your shoulder stability.

Timescales/ Prognosis

Recovery timescales vary depending on the cause of the problem, and whether or not this is your first dislocation.

First-time dislocations with no structural damage can improve within 3-6 months.

Patients will be advised to avoid heavy lifting and sports involving shoulder movements for between 6 weeks and 3 months.

You'll probably be off work for 2 to 4 weeks, or longer, if you have a physical job. Discuss this with your physiotherapist or care team.

Surgery

There are procedures that can help and these usually work best in people who have had a specific injury and have clear damage to the structures in the shoulder - usually the labrum (the thickened tissue around the socket), or a specific ligament, or a certain type of damage to the bone in the shoulder. Further imaging of your shoulder in this case would then be done to tell us what exact damage is there to repair.

Surgery can consist of key hole surgery or open surgery depending on the damage in your shoulder.

Surgery for instability isn't perfect and carries risks. There is a chance your shoulder will dislocate again or continue to cause problems, including weakness, stiffness, giving way and pain. Infection, nerve and blood vessel injury are possible with a surgery, amongst other general risks.

If however after an extended period (minimum of 6 months) of specialist Physiotherapy input there is no improvement, surgery can be discussed to tighten up the joint. You may require specialist Physiotherapy input post - operatively too.

When to speak to a health professional

Following a first time dislocation you will need to attend ED to have your arm assessed. Do not try to pop your arm back in yourself - you could damage the tissues, nerves and blood vessels around the shoulder joint. Following this your Orthopaedic doctor may refer you onto Physiotherapy for rehabilitation and guidance.

In atraumatic cases Physiotherapy is the most effective way to help improve your shoulder pain, movement and function.

Your GP can refer you to Physiotherapy.

Help And Support

If after following the above advice, your symptoms have not improved within 6 to 12 weeks, a referral to a physiotherapist may be beneficial.

You can access physiotherapy by any of the following:

Acute Injury Management

POLICE is an acronym (Protection, Optimal Loading, Ice, Compression and Elevation) that is used as a management strategy for many injuries and conditions for the first 24 to 72 hours.

Protection and relative rest are advised immediately after injury for the first 24 to 72 hours.

Optimal Loading refers to having a balanced rehabilitation program which encourages early and gradual activity to improve recovery. How you progress will vary from person to person depending on the injury. It is about finding the injured areas happy place and increasing slowly and gradually.

Ice may be used for reducing pain and swelling. There are safety points to follow when you use ice:

Don't ice over a numb area or open wound. If the skin is numb you won't notice if you're developing an ice burn and ice on an open wound can increase the risk of infection.

Be wary of ice burns - don't apply ice directly to the skin, wrap an ice pack in a clean, damp tea towel before applying. Avoid prolonged exposure to ice, 10-20 minutes is usually adequate.

Apply crushed ice/frozen peas wrapped in a damp towel for 10-20 minutes, 2-3 times per day for the first 5-7 days post injury/ flare up of pain.

Stop applying ice if there are any negative effects such as increase in pain or swelling or skin soreness.

Compression and Elevation are helpful for reducing inflammation. This can be done by keeping your joint raised on a pillow and compressed by wrapping a bandage around it.
Do not make the bandage too tight and do not wear tubi-grip or any compression bandage in bed at night.

Heat: After 2-3 days, you may find that heat is more relaxing.

You could use a heat pad or a hot water bottle with an insulated cover on it. Make sure this is not too hot and is not directly touching your skin.

You should do this for 10 to 15 minutes, 3 to 4 times a day.

What do I do if my symptoms flare up?

Flare ups of pain are common. Some people have recurrent flare ups of pain so it is important to know how best to manage these flare ups. In most cases a pain flare-up will settle within 6 weeks.
Top Tips

You will likely find it helpful to rest a bit more but it is still important to keep active. This will help to avoid becoming stiff and your muscles becoming weak.

If you aim to get a balance between rest and activity it should help your pain to settle down. You may be sore at first, however, start slowly and gradually increase the amount you do.

Reduce movements or tasks that aggravate your symptoms. This can help especially in the early days.

Adopting positions or movements that reduce your pain can be useful.

Pain Relief

Analgesia

Analgesia also known as pain relief can be an important part in helping you manage your symptoms and allow you to stay active.

Taking suitable pain relief regularly allows you to move more normally and continue your usual activities without causing any damage. It is unlikely that medication alone will resolve your pain totally. For this reason we are using the term pain relief (A 30-50% reduction in pain would be deemed to be a good success).

Paracetamol

Paracetamol is a good general pain management medication. It is used to help manage lots of different types of pain.

Sometimes people believe they need something 'stronger' than paracetamol when in fact, taking a regular dose rather than a one-off dose is more effective.

Spreading the doses of the paracetamol evenly out over a day will help you control your pain. Visit NHS Inform for more detailed information on paracetamol.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

NSAIDs are medications that can reduce swelling around joints and nerve endings to give pain relief. They are particularly useful
in treating inflammatory type pain. Two commonly prescribed NSAIDs are ibuprofen and naproxen.

Although NSAIDs can be very useful they are not suitable for everyone. Visit NHS inform for further information related to NSAIDs.

There are other forms of pain relievers available. If you feel your current pain relievers are not helping your pain or you are
experiencing any side effects from your medication, please seek advice from your GP or pharmacist.

For general information on medication visit NHS Inform.

Staying in work and returning to work

We know that staying in work or returning to work as soon as possible is good for your mental and physical health.

If you have problems with activities at work, it may be helpful to ask for a workstation/workplace assessment or talk with your manager or Occupational Health Department. This can help with alterations or provision of equipment or altering your working day or tasks.

There are organisations which can support you at work or help you return to work. You can visit Knowledge Scotland for further information.

Weight Management

Weight Reduction - People who are overweight tend to have more prolonged pain and poorer tissue healing due to increased levels of inflammation in the body. Reducing your weight can generally help improve the healing process.

A good indicator of whether you need to lose weight is your body mass index (BMI), which you can calculate with the NHS BMI calculator.

If your BMI states you are overweight or obese it is likely that losing weight will reduce your symptoms. Carrying extra fat also increases your risk of heart disease, stroke, type 2 diabetes, and some cancers. Reducing your portion sizes and eating a balanced diet can be helpful in reducing weight. NHS informs provides a free online 12-week weight management programme to get you started right away.

If you need a little more help and feel that you would benefit from working with others in group sessions NHS Lanarkshire's Weigh to Go programme, groups in North and South Lanarkshire, will help you become more active, eat well and lead a healthier lifestyle.

Smoking

Smoking can affect how your body recovers from musculoskeletal problems. If you smoke then the good news is that by stopping smoking it can improve your health in many different ways. Giving up smoking is not something you have to do on your own. You're twice as likely to stop smoking successfully if you get the right support from the NHS. There is a free NHS stop smoking service available in Lanarkshire to help you succeed.

Chronic Pain

Some people will have pain which persists beyond the expected time frame for their condition. For further information on this and how best to manage it please visit our Chronic Pain webpage.

Pain Association Scotland is a national charity that delivers professionally led self-management pain education in the community.

Active Health Programme

South Lanarkshire
Active Health is a programme for residents of South Lanarkshire living with long term conditions. Residents are referred via Acute, Physio & specialist nurses to a 10-week programme and then signposted onto a wide variety of mainstream physical activity, sport & outdoor opportunities.

South Lanarkshire Leisure and Culture have many active community opportunities as well as specialised referral programmes. Full details of the 20 leisure centres can be found on the SLL website. Contact details across South Lanarkshire or call 01698 476262 to find out the number of your local leisure centre.

Please contact your health professional to discuss this referral or contact SLLC on 01698 476262.
Contact details North Lanarkshire
North Lanarkshire Leisure's Active Health Programme in partnership with NHS Lanarkshire provides a range of supported programmes to help individuals realise the benefits of becoming more physically active whilst also assisting those who are recovering from minor or even more serious illness.

The Active Health Programme has both a General Programme where individuals can access the mainstream health and fitness programmes running within NL Leisure Venues including swimming, jogging, golf and more!

A Specialised Health Class Programme which requires a referral from a health professional, this option is available to individuals who require additional specialised support in taking part in physical activity and classes include Strength and Balance, Cardio I, Cardio II, Back Care and Macmillan Move More classes.

A health and social care professional can make a referral by using the Active Health referral form found at the bottom of the page in the link below.
Contact Details - Health & Wellbeing Information

Mental Wellbeing

It is very important to look after your own mental wellbeing. This can have an influence on your recovery or management of your Musculoskeletal problem. Visit our mental wellbeing page for more information.

Your Feedback - comments, concerns and complaints

NHS Lanarkshire is committed to improving the service it provides to patients and their families. We therefore want to hear from you about your experience. If you would like to tell us about this please visit our feedback page.

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The shoulder is a ball and socket joint, it is made up of 3 bones that move together as one; the scapula (socket of the shoulder blade) and the head of the arm bone (ball section) and the collar bone. The joint is designed to give a large amount of movement.

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The NICE Clinical Knowledge Summaries (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories.

CKS content is produced by Clarity Informatics Limited. It is available to users outside the UK via subscription from the Prodigy website.

If you believe you are seeing this page in error please contact us.

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The NICE Clinical Knowledge Summaries (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories. CKS content is produced by Clarity Informatics Limited. It is available to users outside the UK via subscription from the Prodigy website. If you believe you are seeing this page in error please contact us.

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I think the section you need is about 20 minutes into the programme

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Kate and Guddi meet Hilda, a fashion influencer suffering from fibroids who confronts her debilitating condition, as well as grandmother Trudi, who is struggling with a frozen shoulder.

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BBC Two - Your Body Uncovered with Kate Garraway, Series 1, Episode 1

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We meet Hilda, who is suffering from fibroids, and Trudi, who has a frozen shoulder.

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Original Editors - Aiko Deckers

Definition/Description

Supraspinatus tendinopathy is a common and disabling condition that becomes more prevalent after middle age and is a common cause of shoulder pain. A predisposing factor is resistive overuse.

The supraspinatus tendon of the rotator cuff is involved and affected tendons of the musculoskeletal system and becomes degenerated, most often as a result of repetitive stresses and overloading during sports or occupational activities.
The tendon of the supraspinatus commonly impinges under the acromion as it passes between the acromion and the humeral head. This mechanism is multifactorial (see below).

The supraspinatus muscle is of the greatest practical importance in the rotator cuff, it derives its innervation from the suprascapular nerve and stabilizes the shoulder, externally rotates and helps abduct the arm, by initiating the abduction of the humerus on the scapula.
Any friction between the tendon and the acromion is normally reduced by the subacromial bursa.

The anterior margin of the supraspinatus is defined by the posterior edge of the rotator interval that separates the supraspinatus from the rolled superior border of the subscapularis. The posterior margin of the supraspinatus is marked by the extension of the raphe between supraspinatus and infraspinatus around the scapular spine. The anterior portion of the supraspinatus is composed of a long and thick tendinous component whereas the posterior portion has been shown to be short and thin.

An anatomic dissection study of the supraspinatus footprint found that the mean anterior to posterior dimension of the supraspinatus tendon was 25 mm, with a mean medial to lateral thickness of the footprint of 12 mm - the mean distance from the cartilage to the supraspinatus footprint was 1.5 mm at mid tendon.

The supraspinatus and infraspinatus tendons fuse 1.5 cm proximal to their insertions. Collagen is the major matrix protein of supraspinatus tendons, consisting of > 95% type I collagen, with lesser amounts of other collagens including collagen type III.

The anatomy of the supraspinatus' insertion is of key relevance in terms of its extracellular matrix composition and has been categorised into four transition zones. The first zone is proper tendon, made up of largely type I collagen and small amounts of decorin. The second zone is fibrocartilage and consists of largely types II and III collagen, with small amounts of types I, IX and X collagen. The third zone is mineralised fibrocartilage and consists of type II collagen, with significant amounts of type X collagen and aggrecan. The fourth zone is bone and is largely type I collagen with a high mineral content. This effective bone-tendon attachment is achieved through a functional grading in mineral content and collagen fibre orientation. The supraspinatus enthesis is a highly specialised in homogeneous structure that is subjected to both tensile and compressive forces.

Image: Overview of the rotator cuff muscles - sagittal view

Epidemiology/Etiology

The mean age of onset of this complication is in the sixth decade (age 50 to 59), and it is more frequent in diabetic patients. It is also a common cause of shoulder pain in athletes whose sports involve throwing and overhead motions.

The causes of supraspinatus tendinopathy can be primary impingement, which is a result of increased subacromial loading, and secondary impingement, which is a result of rotator cuff overload and muscle imbalance. The table below gives a view on the different extrinsic and intrinsic factors

Characteristics/Clinical presentation

Patients present with progressive subdeltoid aching that is aggravated by abduction, elevation, or sustained overhead activity. They feel also tenderness and a burning sensation in their shoulder. The pain may radiate to the lateral upper arm or may be located in the top and front of the shoulder. It typically becomes worse with overhead activity. Initially, the pain is felt during activities only, but eventually may occur at rest.

One has to think of supraspinatus tendinopathy when the patient says:

Pain increases with reaching.

Pain is felt after frequent repetitive activity at, or above shoulder.

Patient feels weakness of resisted abduction and forward flexion, especially with pushing and overhead movements.

Patient has difficulty sleeping at night due to pain, especially when lying on the affected shoulder.

Patient has difficulties with simple movements, such as brushing hair, putting on a shirt or jacket, or reaching the arm above shoulder height.

Patient has a limited range of motion in the shoulder.

Patient had a former shoulder trauma.

The shoulder may be warm and there may be fullness anterolaterally. Further, there is a painful arc between 70° and 120° of abduction.

Supraspinatus tendinopathy is usually consistent with anterior instability causing posterior tightness. The problems that patient with Supraspinatus Tendinopathy complain of are: pain, inflammation, decreased ROM, strength, and functional activity.

In general, the causes of an acute painful shoulder can be classified into different categories, according to the prevailing patho-anatomy. . These include

More probing investigations can narrow down the differential diagnoses, which could include:
blood for white cell counts, search for abnormal blood biochemistry and inflammatory markers, as well as radionuclide imaging and MRI.

The MRI findings of rotator cuff tendinopathy are characterised by thickened in homogeneous rotator cuff tendon with increased signal intensity on all pulse sequences. Fluid intensity filling an incomplete gap in the tendon on fat suppressed T2-weighted sequences changes are seen on MRI for partial-thickness tears. On MRI, an area of high signal intensity on all pulse sequences outlines complete disruption of the tendon

Diagnosis is usually clinical, but imaging can be useful. Shoulder x-rays can reveal calcifications in rotator cuff tendons and in the bursa. In longstanding cases, there may be degenerative changes, such as cystic/sclerotic changes at the greater tuberosity and decreased humeral head-acromion distance, secondary to upward migration of the humeral head. In acute calcific tendinopathy, calcifications may be irregular, fluffy and ill-defined. Dynamic ultrasound can demonstrate thickening of the subacromial bursa and impingement during abduction. Magnetic resonance imaging (MRI), rather than computed tomography (CT), is the preferred modality, since it produces more detailed soft-tissue images.

The anamnesis often reveals that, in case of a calcification, due to a trauma, pain emerges later on, after a few hours.
The physical examination consist of taking the fever, looking for external wounds or bruises over the affected shoulder and checking the skin temperature. Further, the examinator will palpate in the area of the tendinous insertion of the supraspinatus muscle for checking tenderness and pain. Both passive and active movements will be performed.

Specific questionnaires can be used: Simple Shoulder Test (SST), Oxford Shoulder Score (OSS).

With clinical examination, other causes of shoulder pain should be excluded. So the neck, shoulder and chest wall have to be examined
(Caroline, Adebajo, Hay & Carr, 2005)

The shoulders are inspected for symmetry, localized swelling and muscle atrophy. There may be tenderness below the acromion and over the greater tuberosity. Internal rotation of the shoulder can facilitate palpation of the supraspinatus insertion on the greater tuberosity. The most important clinical maneuvers are as follows:

Testings:

Neer's test Hawkin's sign Empty Can sign

If sonografy is done, the standard method for sonographic evaluation of the supraspinatus tendon requires the arm behind the back (Crass position) or hand on the back pocket (modified Crass position). Crass et al described scanning the shoulder in extension and internal rotation, achieved by placing the patient's hand behind the back.

Close-up view of the calcified lesion[33]

Yet diagnosis is usually clinical, but imaging can be useful. Shoulder x-rays can reveal calcifications in rotator cuff tendons and in the bursa. In longstanding cases, there may be degenerative changes, such as cystic/sclerotic changes at the greater tuberosity and decreased humeral head-acromion distance, secondary to upward migration of the humeral head (6). In acute calcific tendinopathy, calcifications may be irregular, fluffy and ill-defined. Dynamic ultrasound can demonstrate thickening of the subacromial bursa and impingement during abduction. Also sonografy and Magnetic resonance imaging (MRI) can be done.

Supraspinatus tendinopathy can be graded using a modified 4-point scale from 0 to 3 based on previous studies. Diagnosis is based on the appearance of the rotator cuff tendons (grading system) and the presence or absence of signs denoting involvement of the subacromial bursa and subacromial-subdeltoid plane

The treatment used to manage a supraspinatus tendinopathy depends on the etiology of the pathology. At first a conservative treatment is preferred. This treatment involves physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), ice treatments and resting. Corticoid injections can also be used additional to physical therapy. A surgical intervention can be a solution if there is no improvement after 3-6 months of conservative treatment.

NSAIDs may be the first choice for mild to moderate symptoms, if there are no contraindications to these agents[2]. A short term use (7-14 days) of NSAIDs is useful to relieve the pain associated with a tendinitis. However, there is little evidence supporting a long term course of NSAIDs.
Moderate to severe symptoms may require a local subacromial corticosteroid injection. For more information about c orticosteroid injections.

The major indications for surgery are ongoing pain, loss of function[1], failure to respond to conservative therapy for 3 months or evidence of an acute tear in a younger patient. Surgical approaches include calcium deposit resection, with or without subacromial decompression, bursal resectionA and acromioplastyB, using either arthroscopic or open methods. It's also possible to split off the coraco-acromial ligament to enlarge the space between acromion and humerus. This can cause instability, but we can compensate it with some training of the rotator cuff. With physical therapy it takes patients up to 4 months to recover. The goal of a surgery is to obtain pain relief, increased range of motion and increased power.
ABursal resection: Removement of the subacromial bursa.

Acromioplasty: Generally, it implies removal of a small piece of the surface of the acromion that is in contact with a tendon causing, by friction, damage to the latter tissue.

The main goal in the acute phase (initial phase) is to alleviate pain, inflammation, prevent aggravation of pain, reduce muscle wasting and normalize the arthrokinematics of the shoulder girdle. A period of rest should be considered in order to avoid further aggravation and shoulder discomfort.

Passive modalities should be considered in order to avoid painful aggravation. Modalities such as ultrasound, cryotherapy and electrical muscle stimulation can provide temperory relief in acute phase. Strengthening exercises such as isometric exercises should be considered in order to work out the shoulder girdle musculatures. Proper home exercise programs should also be taught in conjuction with proper ergonomics.

The management of a supraspinatus tendinopathy consists of different progressive exercises. There are three phases of treatment: Immobilization, passive/assisted range of motion, progressive resistance exercises .

Early management includes avoidance of repetitive movements that aggravate the pain. Patients should be informed about pain provoking postures and movements. Cryotherapy, soft tissue techniques and wearing a sling/taping are some other techniques to relieve pain. Gentle range-of-motion exercises, such as Codman's classic pendulum exercises, maintain range of motion and prevent development of adhesive capsulitis . Once pain has been reduced, joint mobilisations, massages, muscle stretches, active-assisted and active exercises are needed to improve the ROM again. Active-assisted mobilisations can be done by the patient himself/herself by using an exercise bar. We can also use a rope and pulley, this way the unaffected arm is able to pull the affected one into anteversion Strengthening exercises should work on the external rotators, internal rotators, biceps, deltoid, and scapular stabilizers

Strengthening these muscles will keep the shoulder joint more stable and prevent further injuries. Eccentric exercises will also be more effective than concentric exercises

I.E.:

Sidelying external rotation with dumbbell against gravity

Prone horizontal abduction with dumbbell against gravity

Prone anteflexion in the plane of the scapula

Prone row with external rotation

External rotation with Thera-tubing (standing position)

Horizontal abduction with Thera-tubing (standing position)

Rows with Thera-tubing (standing position)

Elevation in the plane of the scapula (standing position)

Scapula settings

Joint mobilization may be included with inferior, anterior, and posterior glides in the scapular plane.
Stretching exercises should be done by repeating the exercise 3 times and holding the stretch each time for 30 seconds.
Examples of the stretches for home exercise program are:

Neuromuscular control exercises also may be initiated. PNF patterns will increase strength in rotator cuff muscles and increase the stability of the shoulder. We can use four different patterns.

Modalities that also may be used as an adjunct include cryotherapy, hyperthermia, transcutaneous electrical nerve stimulation and ultrasound. Intensive ultrasound therapy has been shown to increase calcium resorption, but this requires frequent treatment that may not always be practical

Patient's starting position: sitting, arm abducted to a position before symptoms appear, contact with three finger tips of the left hand in the supraspinous fossa (a).

Movement: pressure into the supraspinous fossa, active adduction of the right glenohumeral joint, then releasing the pressure into the supraspinous fossa, and back to the starting position (b).

Patients suffering from non-calicfying supraspinatus tendinopathy may benefit from low energy extracorporeal shock wave therapy, at least in short-term

At the end of the therapy you should initiate plyometric and sports-specific exercises.

Patient education is again reemphasised, maintaining proper mechanics, strength, and flexibility, and having a good understanding of the pathology. The patient should also show an understanding of a home exercise program with the proper warm-up and strengthening techniques .

Supraspinatus tendinopathy is a common source of shoulder pain in athletes that participate in overhead sports (handball, volleyball, tennis, baseball). This tendinopathy is in most cases caused by an impingement of the supraspinatus tendon on the acromion as it passes between the acromion and the humeral head. Pain, and a decrease in range of motion, strength and functionality are the main complaints that accompany this injury and should be addressed in the physical therapy. There is enough evidence to prove that physical applications such as ultrasound , cryotherapy, hyperthermia, transcutaneous electrical nerve stimulation and extracorporeal shock wave therapy have a beneficial effect on the recovery of supraspinatus tendinopathy. But we have to remember that it is very important to use these methods as an adjunct to physical therapy (increasing ROM, strength training of the rotator cuff muscles and other shoulder stabilizers).

1. Overview of the rotator cuff muscles - sagittal view image - © Kenhub https://www.kenhub.com/en/library/anatomy/the-rotator-cuff

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3. Smith et al. Painful shoulder syndromes: diagnosis and management, clinical reviews. Journal of General Internal Medicine (Volume 7:May/June), 1992

4. SENBURSAet al. The effectiveness of manual therapy in supraspinatus tendinopathy. Acta Orthop Traumatol Turc 2011;45(3):162-167

5. Zlatkin, M.B., Iannotti, J.P., Roberts, M.C., et al. (1989). Rotator cuff tears: diagnostic performance of MR imaging. Radiology, 172, 223-229.

6. Louise Hasan, Aleisha Hill, Claire Maconochie. Supraspinatus tendinopathy. Site: http://supraspinatustendinopathy.synthasite.com/references.php (consulted on April 14, 2014).

7. AOS, Rotator cuff and shoulder conditioning program. http://orthoinfo.aaos.org/PDFs/Rehab_Shoulder_5.pdf (consulted on April 14, 2014).

8. Martin Jaeger, Frankie Leung, Wilson Li, (2011) Proximal humerus 11-C1.3 Nonoperative treatment.