Shoulder conditions

Pain is commonly felt on the outer side of the shoulder, worsens when the arm is raised and may disturb sleep. The rotator cuff tendons and subacromial bursa may be involved; this clinical picture is sometimes described as impingement.

Diagnosis is primarily clinical. Initial treatment is usually based on activity modification and targeted rehabilitation; investigations are chosen when they may clarify a suspected problem or change the treatment plan.

One or more tendons may tear partially or completely, either through injury or degeneration. Night pain, weakness when lifting or rotating the arm, and difficulty with everyday activities are common, although some tears cause no pain.

Treatment depends on the type and age of the tear, muscle strength, activity level and response to rehabilitation. Not every tear requires surgery; arthroscopic repair is considered when a meaningful functional benefit is realistic.

Calcium deposits in the rotator cuff tendons may cause episodes of severe pain or persistent symptoms with movement. X-rays and ultrasound can confirm the location of the deposit.

Treatment is tailored to the severity and course of the symptoms and may include pain relief, rehabilitation and selected procedures. Calcification found incidentally does not in itself require treatment.

Adhesive capsulitis causes pain and a progressive loss of movement, both actively and when the examiner moves the arm. It may arise spontaneously or after immobilisation, injury or surgery, and is more common in people with diabetes or thyroid disease.

The condition usually progresses slowly. Pain relief and carefully paced rehabilitation are central to treatment; interventional or arthroscopic procedures are reserved for selected cases.

After a dislocation, some patients continue to feel that the shoulder is unstable or experience repeated episodes, particularly in certain positions or during sport. Labral injuries and bone loss can affect the risk of recurrence.

A shoulder that remains dislocated is an emergency, and the patient should not attempt to put it back in place. For recurrent instability, the choice between rehabilitation and surgical stabilisation depends on age, activity level, the number of episodes and associated injuries.

Bankart, SLAP and posterior labral injuries, as well as disorders of the long head of the biceps tendon, can cause deep or front-of-shoulder pain, clicking, catching, weakness or instability.

An abnormality on MRI is not automatically the cause of the pain. Arthroscopy is considered when the symptoms, examination findings and imaging are consistent and conservative treatment has not been sufficient.

Glenohumeral osteoarthritis causes deep pain, progressive stiffness and crepitus. A large chronic rotator cuff tear can lead to a distinct pattern of joint damage known as rotator cuff tear arthropathy.

Treatment begins with non-surgical measures. If pain and loss of function remain severe, anatomical or reverse shoulder replacement may be considered according to the condition of the rotator cuff, bone and joint.

Osteoarthritis of the acromioclavicular (AC) joint causes pain directly on top of the shoulder, often when the arm is brought across the chest. AC joint separation usually follows a direct fall onto the shoulder and may cause a visible prominence.

Many of these injuries can be treated conservatively. Reconstruction is reserved for certain grades of injury, marked deformity or persistent symptoms.

Fractures of the collarbone, proximal humerus and shoulder blade occur after a fall or impact. Stiffness, deformity, osteonecrosis of the humeral head or post-traumatic osteoarthritis may persist after healing.

Treatment depends on fracture displacement, bone quality, age and functional requirements, and may range from support and rehabilitation to internal fixation, reconstruction or joint replacement.