Unlike the knee and hip, shoulder disorders are largely dominated in frequency (80% of cases) by damage periarticular structures: tendons of the muscles constituting the rotator cuff (infra- and thorny, grandson round and subscapularis), tendon of the long head of biceps (which is intraarticular on part of his journey), joint capsule and bursa sub-acromiodeltoïdienne. The achievement of one or more of these structures is the cause of a scapulohumeral periarthritis (HIP), dismembered into several very different prognosis entities.
The frequency of the HIP must not forget that shoulder pain can be linked to other causes:
– Scapulohumeral arthropathy, mechanical or inflammatory;
– Neurological pathology;
– Osteoarticular neighborhood.
He specifies :
– The installation mode of pain: sudden or progressive, post-traumatic or spontaneous;
– The topography of pain: often before or external (V deltoid), rarely posterior or global;
– Any radiation: down (arm, elbow, forearm and wrist and hand sometimes) or bottom (trapezoid, cervical region);
– The schedule of pain: mechanical or inflammatory. It should be noted at the outset that mechanical pathology of the shoulder is readily insomniante side lying on the affected side.
– The intensity of the pain, its changing profile and sensitivity to conventional treatment (analgesics and anti-inflammatory drugs [NSAIDs]);
– The functional impact (styling, shaving, stapling bra, etc.) and professional;
– History, general signs, symptoms remotely, etc.
It is always bilateral and comparison on a patient shirtless, sitting and standing. At the inspection, search:
– Atrophy (deltoid, susépineuse pit);
– Edema, swelling, bruising;
– Deformation of the bone relief, especially in cases of trauma.
Palpation can search effusion, especially noticeable at the front of the joint, and a point of painful pressure of a tendon insertion.
The study of the mobility of the shoulder should cover active mobility, passive and active against resistance. Normal active and passive amplitudes are 180 ° in forward flexion and 60 ° retropulsion, 180 ° abduction and 40 ° adduction, 90 ° internal rotation and 60 ° external rotation, the elbow flexed to 90 ° and glued to body. The existence of a painful arc in the movement of the arm active abduction should be sought.
The shoulder radiographs, comparative or not, combine the best:
– The impact of face in neutral, internal rotation and external rotation;
– The impact profile (axillary, or glenoid cap), less interesting in practice.
The main interest of standard radiographs of the shoulder is the highlight of tendon calcifications, the diagnostic significance should always be discussed.
Note the interest in the workup of a frozen shoulder (adhesive capsulitis), the chest radiograph of face.
Other imaging tests:
They are justified in two situations:
– If HIP rebellious to treatment, in order, primarily, to clarify the status of the rotator cuff;
– In case of suspicion of arthropathy an even infraradiologique stage.
Many tests can be performed:
– Bone scan: suspicion of osteonecrosis of the humeral head or reflex sympathetic dystrophy; arthrography, often supplemented with a scanner (arthrography), interest in cases of suspected rotator cuff tear, adhesive capsulitis, damage to the labrum or pathology of synovium;
– Ultrasound, increasingly used for the diagnosis of lesions of the rotator cuff;
– Arthroscopy for the treatment of certain tendon and cartilage damage.
The search for an inflammatory syndrome may distinguish an inflammatory arthropathy of acute hyperalgesic shoulder.
The puncture of synovial effusion, detected on clinical examination or imaging (ultrasound, MRI), is still justified.
Other tests may be recommended depending on the etiological.
Before incriminate originally a shoulder pain, joint itself or capsulotendineuses structures surrounding it, should be eliminated by careful clinical examination, some locoregional disease (Box 1 ).
Box 1. Differential diagnosis of shoulder pain
Cervical radiculopathy, especially truncated C5.
Parsonage-Turner syndrome: Major shoulder pain and pure motor deficit and the atrophy of the shoulder, usually reversible.
Reaching the suprascapular nerve.
Reached the nerve of the serratus (scapular winging in antepulsion).
Regarding the scapula, clavicle or humerus: infectious or aseptic osteitis (SAPHO), benign tumor, malignant tumor (metastases frequent) pagetic location osteomalacic crack Looser-Milkman, etc.
Pancoast’s syndrome should always be mentioned when regional pain with neurological deficits.
Especially the acromioclavicular joint disease, post-traumatic, degenerative or inflammatory: painful irradiation frequent in front of the chest and pain awakened by the local pressure. Shots centered on that joint can be requested. visceral diseases
With projected pain of vesicular origin, pancreatic, pleural or heart.
Mechanical appearance of pathology:
The existence of a pathology on periarticular structures must be considered a priority by argument frequency and until proven guilty. Several clinical presentations can be individualized, corresponding to distinct mechanisms of injury.
Simple painful shoulder:
This is the form of HIP by far the most common, before possibly without or despite treatment, other clinical forms.
It corresponds to the achievement of one or more tendons constitute the rotator cuff (tendinitis subacute or chronic).
Simple shoulder pain usually involves subjects 30 to 60 years, sometimes occurring after triggering movement, or professional sports, but often almost spontaneously. The pain of varying topography according to the concerned tendon structure, readily radiates to the arm or even forearm. It is triggered by certain elective movements and can be insomniante side lying towards the achievement shoulder.
Clinical examination often clarify the affected tendon structure, with, in all cases, a normal passive mobility, subnormal but painful active mobility, pain to the pressure of the tendon insertion and pain in tensioning annoyed:
– Supraspinatus tendinitis, by far the most common: pain in subacromial external pressure, painful arc between 60 ° and 120 ° of active and pain in abduction thwarted abduction;
– Infraspinatus tendinitis: Pain pressure subacromial posterolateral and upset external rotation;
– Biceps tendinitis long: pain on pressure of the previous intertubérositaire gutter and palm-up test.
The biological parameters of inflammation are normal and plain radiographs may be normal or reveal tendon calcifications (hydroxyapatite) or erosion with densification of the greater tuberosity.
The response to treatment (analgesics, NSAIDs and even one or two injections of a steroid derivative, rehabilitation) is generally favorable, but relapses are possible. In case of resistance to treatment, a surgical solution can be recommended (open acromioplasty or per-arthroscopic).
Acute shoulder hyperalgic:
It corresponds to a microcrystalline acute bursitis caused by the detachment of a tendon calcification and its migration and its decay in the bursa under acromiodeltoïdienne. The table can be integrated into a simple painful shoulder context known or reveal the periarticular pathology.
Sometimes the hyperalgesic acute shoulder integrates itself as part of a disease multiple tendon calcifications (rheumatism or hydroxyapatite). Pain, especially brutal and intense, is permanent and insomniante that may falsely suggest making an inflammatory condition, especially as a thermal shift is possible (but sedimentation rate and C-reactive protein are normal or modestly elevated ). It is the cause of an often total functional impairment.
On examination, the active and passive mobilization is impossible.
X-rays can reveal the fragmentation of calcification or its latérohumérale migration in the bursa subdeltoid, then he disappeared.
The outcome was favorable in a few days under treatment with analgesics, NSAIDs or oral corticosteroids. The realization of infiltration is often difficult because of the pain. After disappearance of pain, indicating a radio-crushing puncture can be discussed when one or more persistent calcification volume.
It testifies to the rotator cuff tear, which schematically observed in two very different contexts:
– Be frank, acute rupture, succeeding direct trauma, sports in general, in young patients with severe pain, almost no active motion and bruise;
– Or progressive degenerative rotator trophic perforation, occurring spontaneously or after minor trauma in an elderly patient with moderate pain and reduced mobility active but not zero.
In both cases, the passive mobility is preserved and neurological examination did not find any defi cit. Biology is normal. The standard radiology reveals an ascent of the humeral head and rupture of omohuméral hanger. The solution of continuity within the cap may be objectified by ultrasound, arthrography or MRI.
Treatment varies depending on the context of occurrence.
The clean break in young patients justifies a surgical suture (sometimes per-arthroscopic).
The trophic perforation in the elderly should be treated medically, with an emphasis to rehabilitation techniques, which allow usually a good functional recovery. The surgery is not indicated in this form.
Frozen shoulder (or frozen shoulder, or adhesive capsulitis):
It can complicate the evolution of another form of HIP, especially neglected a simple sore shoulder, or fit into a context of CRPS of the upper extremity (shoulder-hand syndrome or) whose causes are multiple (Box 2).
After a period of pain, of varying intensity and duration, occurs a progressive stiffness in the shoulder, clinical examination, reduced active and passive mobility.
Biology is normal. Radiology is also the standard or may reveal abnormalities associated with reflex sympathetic dystrophy: demineralization, possibly microgéodique of the humeral head.
Arthrography reveals disappearance capsular recess with reducing joint capacity, but MRI is not contributory.
The evolution is usually favorable, with a gradual recovery of mobility at the cost of often prolonged physiotherapy care (several months to two years).
Hemorrhagic senile shoulder:
It is the sudden onset of hemarthrosis in a former break context of the rotator cuff in the elderly: the pain is sharp, with total functional disability, palpable joint swelling and bruising of the shoulder stump .
The standard radiology often reveals glenohumeral osteoarthritis lesions (glenohumeral osteoarthritis).
The puncture confirms hemarthrosis, eliminates sepsis and can quickly relieve pain.
_ Mechanical shoulder arthropathy
Scapulohumeral osteoarthritis (or glenohumeral osteoarthritis):
The glenohumeral osteoarthritis is never primitive, but always succeeds another pathology often an old rotator cuff tear, sometimes osteonecrosis of the humeral head trauma sequelae (recurrent dislocation) or sepsis, a articular chondrocalcinosis.
It causes a painful limitation of active and passive mobility, with crunches.
Radiological abnormalities associated glenohumeral a pinch (with, if rotator cuff, an ascent of the humeral head and néoarthrose acromiohumérale), osteophytes, mainly sub-capital and subacromial, and osteosclerosis joint banks.
It typically develops in two stages:
– A painful inflammatory pseudo-phase;
– Then a phase of little or no stiffness painful (adhesive capsulitis), reversible in several months.
Box 2 shows the main causes of CRPS of the upper extremity.
Box 2. Causes of reflex sympathetic dystrophy of the upper limb (shoulder-hand syndrome)
– Neurological pathology: hemiplegia, Parkinson’s disease, shingles, brachial plexus injury
– Thoracic Pathology: bronchopulmonary tumor, ischemic heart disease, myocardial infarction
– Prolonged ingestion of barbiturates (gardénalique rheumatism)
– Anti-tuberculosis treatment (especially isoniazid)
– Predisposing circumstances: diabetes
Aseptic necrosis of the humeral head:
She is happy when bilateral respond to conventional etiologies of osteonecrosis (see hip osteonecrosis) or unilateral when it succeeds local trauma.
The radiological lesions are superimposed to those found at the hip. Again, scintigraphy and especially MRI are the most sensitive tests. The advanced osteonecrosis of the humeral head is currently one of the best indications of the shoulder prosthesis.
Rare mechanical arthropathy:
Arthropathy of syringomyelia should be considered in a painless destructive damage of the joint.
The pathologies of the synovium (primitive chondromatose, villonodular synovitis, etc.) are suspected in case of locking phenomena;
Arthropathy pagetic a complicated disease location in the humeral head.
Inflammatory pathology of pace:
Pain is insomniante, with general signs and inflammatory syndrome. We must then discuss:
– Infectious arthritis, pyogenic or tuberculous.
Interest synovial puncture with systematic implementation of liquid culture, other bacteriological samples (blood cultures, gateway, etc.) and in case of suspected tuberculosis, synovial biopsy with culture and histology; rheumatic arthritis (rheumatoid arthritis, spondyloarthritis, psoriatic arthritis), the shoulder arthritis usually occurring in the evolution of a previously identified disease;
– Polymyalgia rheumatica, with bilateral involvement, willingly associated with inflammatory neck pain or even a violation of the pelvic girdle, in the elderly. The inflammatory syndrome is important and should always look for signs suggestive of GCA; microcrystalline arthritis: chondrocalcinose hydroxyapatite or rheumatism, gouty arthritis of the shoulder being exceptional.