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The shoulder joint (articulatio humeri) connects the upper arm (humerus) with the shoulder blade (scapula). It is enclosed by a joint capsule, has few ligaments and is mainly secured by the strong muscles (rotator cuff).
The shoulder joint, also known as the humeroscapular joint, is a ball joint with three degrees of freedom.
On the one hand, the arm can be moved forwards or backwards in the shoulder. This is called anteversion or retroversion.
In addition, the arm can be spread apart or placed on the body (abduction / adduction) and turned inwards or outwards (internal rotation / external rotation).
The sternoclavicular joint (articulatio sternoclavicularis), the acromioclavicular joint (articulatio acromioclavicularis) and two secondary joints (subacromial secondary joint and shoulder blade-thoracic joint) are also involved in the range of motion of the shoulder. However, the shoulder joint contributes by far the largest part to the range of motion.
The triangular muscle (deltoid muscle) and the rotator cuff, consisting of the supraspinatus muscle, infraspinatus muscle, subscapularis muscle and teres minor muscle, are the most important muscles of the shoulder.
The shoulder joint is formed by the head of the upper arm (caput humeri) and the elongated joint portion of the shoulder blade (scapula), which is also called cavitas glenoidalis and forms a concave surface. At the lower edge of this surface there is a lip made of fibrous cartilage (Labrum glenoidale), which serves to enlarge the cavitas. The joint head of this ball joint is many times larger than the socket.
This disproportion allows a large range of movement, but at the expense of stability. This is guaranteed by a firm muscle belt (rotator cuff).
Due to the mismatch between the humeral head and the articular surface of the shoulder blade and the weak ligament securing of the shoulder joint, the shoulder joint tends to dislocate (dislocations).
The upper arm head most often dislocates forward and front-down, especially when the arm is stretched outward, which is why this injury often occurs in sports accidents and falls. After the first dislocation, which still requires massive trauma, further dislocations often occur. With these, slight twists are usually sufficient to cause the shoulder joint to dislodge. These habitual luxations often occur even during sleep and are extremely uncomfortable. A dislocated shoulder is very painful and of course cannot be moved.
Such recurrent dislocations can damage the cartilage and even the underlying bone (so-called impressions), which is referred to as the Hill-Sachs lesion.
Shoulder arthrosis is quite common. They develop as a degenerative disease due to the wear and tear of the cartilage that covers the articular surfaces of the shoulder and are accompanied by severe pain and restricted movement. In severe cases, a shoulder prosthesis can be used here.
Impingement syndrome arises from the pinching of connective tissue (capsule or tendon tissue) or signs of wear and tear of the joint structures, which massively impairs mobility, in particular the spreading of the arm and the rotation.
The frozen shoulder is a temporary stiffening of one or both shoulders.
Severe pain in the shoulder joint is followed by relatively painless movement restrictions. Optimally, the symptoms subside by themselves.
The traumatic tearing off of the cartilaginous lip (labrum glenoidale) on the articular surface of the shoulder blade is called the Bankart lesion and is one of the causes of habitual luxations.
A shoulder joint dislocation is a dislocation of the shoulder joint, which can be accident-related (traumatic) or condition-related (habitual).
There are various forms of dislocation, of which anterior dislocation is the most common with over 90%. With an external rotation and an abduction, the arm can easily dislodge when inadequate movement, such as in an accident.
System-related factors, such as anomalies of the ligamentous apparatus or a misinervation of the muscles, can also cause the shoulder joint to luxate. A shoulder joint dislocation is quite common and is characterized by spontaneous and movement pain. The arm is resiliently fixed in an abnormal position and is held with the healthy arm.
If nerves are damaged (axillary nerve), the motor function and sensitivity of the arm can also be damaged. In most cases, the arm can be repositioned to its normal position without anesthesia using pain relievers. If this is not the case, anesthesia can be performed. However, this is rather rare.
Bursitis is inflammation of the bursa. Bursa reduce the friction between bone and soft parts in the body. Such a bursa is located under the so-called acromion, a bone process of the shoulder blade.
Inflammation, which can be traumatic or infectious, causes shoulder pain. Subacromial bursitis is usually traumatic.
But it can also occur in the course of metabolic diseases such as gout or in the context of rheumatoid arthritis. It is characterized by pain in the shoulder and a restricted movement of the shoulder joint. The joint should be spared in the acute phase of inflammation.
It is treated conservatively with physiotherapy exercises, glucocorticoid injections and non-steroidal anti-inflammatory drugs. If conservative treatment fails, the inflamed bursa can be surgically removed.
The so-called "limestone shoulder" is a very painful affair. The tendons of various muscles that secure the shoulder joint (supraspinatus / infraspinatus muscle, more rarely subscapularis / teres minor muscle) have limescale deposits.
The lifting of the arm and the pressure on the affected tendons are painful.
Treatment is conservative with the local application of non-steroidal anti-inflammatory drugs and physiotherapy exercises.
If the symptoms do not subside within six months, surgical measures are taken, which include, for example, arthroscopic removal of the calcareous areas or focused orthopedic shock wave therapy.
Omarthrosis is a degenerative change in the articular cartilage of the shoulder joint and usually occurs without an organic cause.
However, it can also be the result of frequent dislocations or injuries to the shoulder joint. Pain in the shoulder, which is aggravated by movement, is characteristic. Restrictions on movement and night pain are the result.
Conservative therapy includes physiotherapy exercises, treatment with non-steroidal anti-inflammatory drugs, but also cryotherapy and ultrasound treatments. In case of doubt, the joint can be artificially replaced in one operation. This is called a total endoprosthesis.
The frozen shoulder is a form of periarthropathia humeroscapularis. This collective term describes all possible degenerative diseases of the shoulder girdle. This also includes bursitis, tendinitis, signs of wear and tear on the muscles of the shoulder joint (rotator cuff), etc.
The frozen shoulder is a chronic, inflammatory change in the shoulder joint capsule. This stiffens the joint, which ultimately results in pain and restricted movement.
The peculiarity of this disease is that its symptoms run in 3 stages.
In the first stage, the pain is very dominant and especially strong at night. However, the movement is not restricted.
In the second stage the pain subsides, but the movement is increasingly restricted and in the third stage the symptoms subside.
The frozen shoulder is also treated conservatively with non-steroidal anti-inflammatory drugs and physiotherapy exercises.
If the symptoms have not subsided after 6 months, anesthesia mobilization is carried out. The joint is moved in all directions under short anesthesia in order to release the degenerative “adhesions”.
In extreme cases, the frozen shoulder can also be treated surgically.
Impingement syndrome is the painful pinching of the tendon of the supraspinatus muscle. The muscle belongs to the so-called muscle group of the rotator cuff and secures the shoulder joint. The pain mainly affects the lifting of the arm.
Pain arises when the arm is raised above the shoulder. The pressure on the tendon is also painful.
Biceps tendinitis: Tendinitis is tendinitis. The inflammation of the long biceps tendon is quite common and occurs in old age due to signs of wear. The tendon runs in the joint capsule of the shoulder joint.
Non-steroidal anti-inflammatory drugs and physiotherapy exercises can relieve the pain.
If there is pain after 6 months, the long biceps tendon can be shortened in one operation and fixed to the head of the humerus.
Diseases of the shoulder joint of inflammatory nature: arthritis, periarthritis, bursitis, osteoarthritis, polyarthritis, capsulitis, require complex treatment - taking medication, physiotherapy, physical therapy, massage.
Drug treatment is assigned to each patient individually, based on the characteristics of the state of his body. Our experts of the clinic OCC Tubingen prescribe patients tablets, injections, ointments. For patients suffering from diseases of the gastrointestinal tract, an excellent solution is electrophoresis, phonophoresis - the introduction of drugs directly into the affected tissue. Two plates are applied to the shoulder joint, under which there is fabric soaked in medicine. Radiation - electric current, ultrasound, moves the drug molecules into the blood, where they are activated.
Physiotherapy is prescribed to patients in combination with drug treatment. With arthritis, polyarthritis, periarthritis, shock wave therapy based on the effects of electric current is often used. During this procedure, the affected vessel is exposed to the healing effect of electrical energy, and the patient feels pleasant warmth spreading all over his body.
Paraffin applications help the patient to get rid of pain, reduce swelling in the shoulder joint. For applications, white melted paraffin wax is used, which is cooled to fifty to sixty degrees before application. Paraffin is applied to the surface of the shoulder with a brush, the patient must suffer a little bit: soon after the application, the burning sensation disappears.
Laser therapy using red (for superficial inflammation), infrared (for deep inflammation) radiation after the first procedure brings relief to the patient: reduces swelling, allows you to move without pain.
There are a variety of operations that are performed on the shoulder joint. The most common operations are discussed in more detail below with regard to the surgical techniques and their indication.
Arthroscopy is a minimally invasive procedure, which can serve therapeutic as well as diagnostic purposes.
An endoscope (arthroscope) is inserted over small incisions (athrotomies). Shoulder arthroscopy is a very common procedure because it can treat many shoulder diseases.
It is used as standard for shoulder mobilization (arthrolysis), shoulder corner resection, limescale removal, reconstruction or relocation of the long biceps tendon, shoulder stabilization and rotator cuff reconstruction.
In addition, the shoulder roof is expanded arthroscopically (subacromial decrompession). Not only the shoulder joint is treated arthroscopically, but also the shoulder corner joint (acromio-clavicular joint), the subacromial bursa (bursa under the shoulder roof) and muscle tendons, such as the long biceps tendon.
The advantage of arthroscopy is the relatively small wounds. In addition, joint structures can also be assessed under dynamic conditions, i.e. during movement.
Severe shoulder injuries, severe shoulder instability, calcification, or very pronounced tendinitis may require open shoulder surgery. This includes all major interventions such as artificial shoulder joint replacement after serious accidents or extreme degenerative changes. But tendon removal, tenotomy, can also be performed openly.
01.05.2019
Robert Karadjian heads the Center for Shoulder and Elbow Surgery
"It was ultimately a logical consequence of developments in recent years," says Jörg Schneider, Managing Director of the Nettetaler Hospital, about the appointment of Robert Karadjian as chief physician of the Center for Shoulder and Elbow Surgery (ZSE).
The field of shoulder surgery established itself increasingly in the Nettetaler hospital and grew under the care of Robert Karadjian over the last 20 years with steadily rising tendency. Whereas in 1997 there were around 25 shoulders operated on a year ago, Karadjian now reports more than 1060 interventions each year. He is thus high on the list of surgeons with the most experience in Germany. The necessity of operations is checked according to strict internal criteria in order to exclude preventable interventions. Care and quality are always at the center of the treatment. Seven to eight times a day, the new chief physician is on average in the operating theater. This is followed by intensive personal care for all patients at the wards. In addition, he offers the affected three office hours a week. "Sometimes we think he has no home at all," jokes a member of the staff. So indefatigable is the use of Karadjian for his patients.
The proportion of shoulder operations is considerably higher in the Nettetaler Hospital than in the nationwide average of the hospitals. "Shoulder surgery has become a focal point of our Arthroscopy and Arthroplasty Center, in addition to knee and hip surgery, thanks to Mr. Karadjian's commitment," says Schneider. Thus, the founding of a dedicated center for shoulder and elbow surgery is a logical step to ensure the further development in this area. The Center for Arthroscopy and Endoprosthetics will continue to be operated by Chief Physician Enno Steinheisser headed.
Meanwhile, Karadjian is well known far beyond the regional boundaries. Thus, some patients take a long journey and waiting times in order to be treated by the Nettetaler specialist. "There is no better recognition than word of mouth from satisfied patients," says Karadjian. As an entertaining example, he reports on a patient who took a very long journey in purchasing and came on warmest recommendation of her unknown holidaymaker in Mallorca to Nettetal, to operate here. Karadjian himself got the conversation at a neighboring table on the island. "That makes me happy, of course, and makes me a little proud."
Highly motivated, he starts his new task. "The well-being of the patient remains at the center of our activity. We will continue to improve for that. One of the next tasks is to shorten the currently long waiting times for an appointment in the shoulder consultation hour, "he confirmed full of energy. Another step is the expansion of personnel in the ZSE. From October, a new specialist in orthopedics and trauma surgery will begin work on the ZSE. In due course, we will inform you about the concrete developments in the Nettetaler Hospital. Robert Karadjian has been working as a surgeon at the Nettetaler Hospital since 1994. In 1997, he moved from General Surgery to the Department of Arthroscopy and Endoprosthetics, where he was appointed Senior Physician a year later. Since August of this year he is chief physician at the Center for Shoulder and Elbow Surgery.
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