The main tendon that enables you to lift your arm (supraspinatus tendon) slides through a relatively confined space between the humeral head and the acromion (upper shoulder bone). In order to allow it to perform its important function well, the tendon is protected by a bursa which eases sliding and protects the tendon against impact. If the space is too tight, the bursa gets chafed and inflamed (bursitis) and the tendon may get pinched and damaged. As a person gets older, bony deposits may form at the acromion, which often causes problems. A piercing pain is felt when lifting one’s arm. This is called impingement. The inflammation frequently results in debilitating pain during the night and leads to a considerable impairment of one’s quality of life. Injections, physiotherapy, and minimally invasive methods are used to treat pain, eliminate the cause, and restore the tendon’s function by allowing smooth sliding again.
Tendons are the connections between muscles and bones and therefore act as absolute load carriers. If tendons are damaged, or partially or fully torn through accidents, impingement or excessive use, they lose their ability to function. In the shoulder, for instance, a person may lose the ability to raise their arm quickly if the main tendon responsible for that movement is partially or even fully detached. Most often, this is accompanied by inhibiting pain. It might take only a minimally invasive operation to fix this damage and reattach the tendon. Thanks to modern medicine, this arthroscopy, as doctors call it, allows surgeons to work with microscopic magnification and cameras as well as sensitive tools and state-of-the-art materials without having to make large incisions. It involves working on bones and tendons. After the operation, tendons and muscles heal and functioning is restored.
When bones are subjected to stresses exceeding their natural elasticity, they break. Anatomic reconstruction is often required to regain full functionality, but also because the broken ends of a bone need to be re-joined to allow healing. In fact, some fractures cannot heal without medical treatment. Minimally invasive surgery isn’t primarily about cosmetic benefits; its main purpose is to allow patients of any age and fitness level to regain their functionality and performance as soon as possible. Minimally invasive procedures also have the advantage that muscles remain attached to the bones and other tissue remains intact; unlike open surgery, where tissue has to be severed to make space. When minimally invasive operations are performed for fractures, small incisions allow for the bone position to be restored without tissue, muscles, ligaments or skin being affected…
As for the collarbone (clavicle), the upper arm (humerus) and the shoulder blade (scapula), there are various procedures and materials that have to be chosen for treatment of the individual fracture. The classification of the AO Foundation (working group for bone fusion issues) is used worldwide to diagnose fractures. It forms an important basis for decision-making on whether and how to operate. Sometimes fractures can produce sharp splinters that may injure vessels or nerves if not treated correctly. If fractures heal in the wrong position, they can also result in destruction of joints (post-traumatic arthrosis). Without the right treatment patients might, in the long run, experience pain, restricted mobility and significantly reduced quality of life.
MOTORCYCLISTS, MOUNTAIN BIKERS, RACING CYCLISTS
Cyclists and motorcyclists are particularly prone to shoulder problems, even though that might not be one’s initial assumption. When they fall, riders often fracture their upper arms or collarbones. On impact, the rim of the motorbike helmet hits the shoulder since the cervical spine cannot support the head at such acceleration. A fall from a two-wheeler frequently causes a separation of the acromioclavicular joint; such an AC joint ligament injury (classified by Tossy and Rockwood) occurs when the ligaments joining the collarbone and the shoulder blade tear. But even without accidents, wind resistance puts great strain on the shoulders…
MOTORCYCLISTS, MOUNTAIN BIKERS, RACING CYCLISTS
Even when wearing functional clothing. On longer trips, the shoulder is constantly in the same position: it is scarcely moved, yet takes strain since the rider leans on the bike with varying force. Even just holding the handlebar without being propped up can cause an irritation or even inflammation of the “shoulder shock absorbers”. The bursa gets chafed. An ensuing bursitis often leads to excruciating pain, especially at night. The person’s quality of life is severely compromised, and soon it’s not just motorcycling, mountain biking and cycling that can’t be enjoyed any more.
SHOULDERS OF WHEELCHAIR USERS
While working at the German Centre for Spinal Cord Injuries in Bad Wildungen and subsequently, I have learnt a lot from wheelchair users and from my paraplegic patients.
The shoulder is a wheelchair user’s crucial joint for mobility and quality of life. When I treat shoulders of wheelchair users, it’s like treating the shoulders of high-performance athletes. Getting into and out of bed, and into the car, moving around the house and the bathroom, interacting with others and, of course, using a handcycle – all these activities demand top performance from the shoulders. Understanding and treating paraplegics requires special and often innovative medical approaches. We all need our shoulders, particularly wheelchair users.
ARTHROSIS, LOSS OF CARTILAGE
Like every joint, the shoulder consists of what could be described as gliding surfaces. These cartilaginous surfaces ensure that movements are smooth and almost frictionless, and may become damaged as a result of earlier tendon injuries or muscular instability after bone fractures or accidents. If cartilage gets thinner, like used car tyres or worn-down shoe soles, there is increased friction in the joint. With bones rubbing against each other, every movement eventually becomes painful. Unlike other types of tissue, like muscles, tendons and bones, cartilage does not regenerate. Various physical treatments and injections often offer considerable improvement of symptoms; in some cases, an artificial joint (endoprosthesis) is the best therapy to regain mobility and put an end to pain.
ENDOPROSTHESIS (ARTIFICIAL JOINT)
An endoprosthesis is an artificial joint. The worn-down, painful joint surfaces are removed, and a new surface replacement is implanted. In practice reverse shoulder prostheses have good results, even after a loss of tendons or after previous operations. The material used is adapted to the person’s individual needs and conditions such as nickel intolerance and osteoporosis.
The objective of a new joint is the restoration of free mobility without pain.