Anatomy: The large Deltoid muscle (M Deltoideus) is a thick triangular muscle, emanating around the shoulder, covering the shoulder joint and forming the rounding of the shoulder. The muscle is fastened on the humerus. The various parts of the deltoid muscle take part in nearly all movements of the shoulder joint.

Symptoms: In light cases a localised tenderness can be felt following the load (“muscle strain”, “imminent pulled muscle”). In more severe cases sudden shooting pains in the muscle can be felt (“partial muscle rupture”) and in the worst cases a sudden snap is felt, rendering the muscle unusable (“total muscle rupture”) this is very rare, and is almost only seen in conjunction with other damage in the shoulder. With muscle injuries the following three symptoms are characteristic: pain upon pressure, stretching and activating against resistance.

Acute treatment: Click here.

Examination: Light cases with only minimal tenderness and no discomfort when using the arm do not necessarily require medical examination. The extent of the tenderness is, however, not always a mark of the degree of the injury. In case of more pronounced tenderness medical examination is advised with the aim of securing a correct diagnosis and treatment. Pain will be present when pressure is applied to the damaged muscle, which will be aggravated when the muscle is activated against resistance and when the muscle is stretched. Ultrasound is well suited to ensure the diagnosis.

Treatment: The treatment primarily involves relief, discontinuance of the injury inducing activity, stretching and increasing fitness training.

Complications: If satisfactory progress is not made, a physician should be consulted to ensure that the diagnosis is correct and that no complications have arisen. Amongst others the following should be considered:

• Rupture of the upper shoulder blade muscle
• Inflammation of the upper shoulder blade muscle
• Rupture of the lower shoulder blade muscle
• Tendon sheath inflammation of the biceps
• Luxation in the joint between the shoulder blade and the collarbone
• Partial luxation in the shoulder joint
• Frozen shoulder
• Muscle infiltrations
• Sprained shoulder (distorsio art. humeroscapularis)
• Meniscus lesion in the shoulder (laesio labrum glenoidale)
• Impingement
• Nerve entrapment on the back of the shoulder blade

Anatomy: The biceps muscle (M biceps brachii) has two tendons, fastened on the shoulder blade. One tendon (caput longum) passes through the shoulder joint. The two tendons join the biceps muscle on the upper arm and are anchored just below the elbow on the forearm. The function of the biceps muscle is to bend the elbow and supination (rotation) of the forearm. The long head of the biceps tendon has a tendon sheath that communicates with the shoulder joint.

Symptoms: Slowly insetting localises tenderness exterior and to the front of the shoulder after load. Sometimes radiating down the upper arm. Pain deteriorates, when external pressure is applied to the biceps tendon, the front of the shoulder, when the muscle is activated (attempting to bend the arm against resistance) and when the muscle is taut (stretching and at the same time rotating inwards in the elbow (pronating)).

Acute treatment: Click here.

Examination: In light cases with only minimal tenderness medical examination is not necessarily required. In case of more pronounced pain and in lieu of progress a medical examination should be carried out to ensure the correctness of the diagnosis and to commence the correct treatment. Ordinary medical examination is often sufficient to form the diagnosis, but if uncertainty exists, it should be supplanted by ultrasound, which is the most suited examination for shoulder injuries (article) (Ultrasonic image).

Treatment: The treatment consists of relief and slow rehabilitation of the biceps muscle and the other muscles around the shoulder. Only in cases of total rupture of the biceps muscle should surgery be considered, the vast majority are treated with rehabilitation. If no progress is made with relief of the tendinitis, medical treatment may be considered in the form of rheumatic medicine (NSAID) or draining of the fluid in the tendon sheath and injection of corticosteroid in the tendon sheath, which must be performed with ultrasound guidance. Since the injection of corticosteroid is part of a long-term rehabilitation of a long-term injury, it is often necessary that the rehabilitation period stretches over several weeks, to reduce the risk of recurrences and ruptures. Naturally the tendon can not sustain maximum load after only a short rehabilitation period.

Complications: If smooth progress is not achieved the correctness of the diagnosis, or whether complications have arisen should be considered. Amongst others the following should be considered:

• Rupture of the upper shoulder blade muscle
• Inflammation of the upper shoulder blade muscle
• Rupture of the lower shoulder blade muscle
• Inflammation of the bursa (bursitis subacromiale
• Impingement syndrome
• Rupture of the deltoid muscle
• Partial luxation of the shoulder joint
• Luxation of the joint between the shoulder blade and the collarbone
• Frozen shoulder
• Muscle infiltrations
• Sprained shoulder (distorsio art. humeroscapularis)
• Meniscus lesion in the shoulder (laesio labrum glenoidale)
• Nerve entrapment on the back of the shoulder blade

…and ailment inside the shoulder (the fluid in the biceps tendon may be from the shoulder joint).

Anatomy: The biceps muscle (M biceps brachii) has two tendons, fastened on the shoulder blade. One tendon (caput longum) passes through the shoulder joint. The two tendons join the biceps muscle on the upper arm and are anchored just below the elbow on the forearm. The function of the biceps muscle is to bend the elbow and supination (rotation) of the forearm. The long head of the biceps tendon has a tendon sheath that communicates with the shoulder joint.

Symptoms: Sudden insetting localised tenderness exterior and to the front of the shoulder after load. Sometimes radiating down the upper arm. Pain is aggravated when external pressure is applied to the biceps tendon, the front of the shoulder, when the muscle is activated (attempting to bend the arm against resistance) and when the muscle is taut (stretching and at the same time rotating inwards in the elbow (pronating)). A swelling can often be observed (the contracted biceps muscular belly) above the bend of the arm (cubital fossa).

Acute treatment: Click here.

Examination: In case of sudden insetting pain and swelling above the elbow a medical examination should be carried out to ensure the correctness of the diagnosis and to commence the correct treatment. Normal medical examination is often sufficient to form the diagnosis, but if any doubts exist the examination should be supplemented by an ultrasound scan, which is the most suited examination for shoulder injuries (article) (Ultrasonic image).

Treatment: The treatment consists of relief and slow rehabilitation of the biceps muscle and the other muscles around the shoulder. Only in cases of total rupture of the biceps muscle should surgery be considered, as the vast majority of ruptures are treated with rehabilitation.

Complications: If smooth progress is not achieved the correctness of the diagnosis should be considered, or whether complications have arisen. Amongst others the following should be considered:

• Inflammation of the biceps
• Rupture of the upper shoulder blade muscle
• Inflammation of the upper shoulder blade muscle
• Rupture of the lower shoulder blade muscle
• Inflammation of the bursa (bursitis subacromiale)
• Impingement syndrome
• Rupture of the deltoid muscle
• Partial luxation of the shoulder joint
• Luxation of the joint between the shoulder blade and the collarbone
• Frozen shoulder
• Muscle infiltrations
• Sprained shoulder (distorsio art. humeroscapularis)
• Meniscus lesion in the shoulder (laesio labrum glenoidale)
• Nerve entrapment on the back of the shoulder blade

…and pain inside the shoulder (the fluid in the biceps tendon may emanate from the shoulder joint).

Anatomy: The large chest muscle (M pectoralis major) is fan shaped covers the front surface of the chest wall and fastens on humerus (crista tuberculi majoris). The function of the chest muscle is, amongst others, to bring the arm along the body and to bend and rotate inwards in the shoulder (like when throwing). The large chest muscle forms the forward fold in the armpit.

Symptoms: In light cases a local tenderness is felt after the load (“muscle strain”, “imminent pulled muscle”). In severe cases a sudden jolting pain is felt in the muscle (partial “muscle rupture” or “pulled muscle”) and in the worst case a violent snap, rendering the muscle unusable (“total muscle rupture”). In muscle injuries the following three symptoms are characteristic: pain upon pressure, stretching and activation against resistance. In total ruptures a defect can often be seen and felt at the forward fold in the armpit.

Acute treatment: Click here.

Examination: In light cases with only minimal tenderness and no inconveniences with normal usage of the arm, medical examination is not necessarily required. Though the severity of the tenderness is not always a measure of the severity of the injury. In case of more pronounced tenderness or pain medical examination is required to ensure the diagnosis and treatment. A normal medical examination is usually sufficient in order to make the diagnosis. Pain will be present when pressure is applied to the damaged and deteriorated muscle, when the arm is squeezed to the body against resistance (adduction) and when the muscle is stretched. If there is uncertainty regarding the diagnosis, the medical examination should be supplemented with an ultrasound or MRI scan, which is the most suitable examinations to ensure the diagnosis (article).

Treatment: In athletes with total ruptures located at the point of attachment on the humerus, most advise surgery (article). If the rupture is not total or if the rupture is in the muscle belly, relief and careful rehabilitation is recommended. In total ruptures a rehabilitation period stretching over several months must be expected before maximal loading can be resumed.

Rehabilitation naturally depends on the degree of rupture and the treatment (conservative / operative). It is advised to avoid fitness training the first couple of months, and hereafter resume it with a very low load so as not to rupture the muscle again.

Complications: If progress is not smooth, it should be considered whether the diagnosis is correct or whether complications have arisen. Amongst others the following should be considered:

• total rupture of the upper shoulder blade
• rupture of the deltoid muscle
• rupture of the biceps muscle
• luxation of the joint between the shoulder blade and the collarbone
• partial luxation of the shoulder joint
• sprained shoulder (distorsio art. humeroscapularis)
• eniscus lesion in the shoulder (laesio labrum glenoidale)

Anatomy: Four muscles are part of the rotator cuff surrounding the shoulder joint, and controls, coordinates and assists movement of the shoulder: M infraspinatus (the lower shoulder blade muscle), M supraspinatus, M subscapularis and M teres minor. The infraspinatus muscle rotates the arm outwards.

Symptoms: In light cases a local tenderness is felt after the load (“muscle strain”, “imminent pulled muscle”, “inflammation of the tendon”), which can precede larger ruptures if the exercise intensity is not altered. In severe cases a sudden shooting pains are felt in the muscle (“partial muscle rupture”, “pulled muscle”) and in the worst case a violent snap is felt, rendering the muscle unusable (“total muscle rupture”). In case of muscle damage the following three symptoms are characteristic: pain upon pressure (externally, on the back of the shoulder), stretching and activation against resistance (rotation outwards against resistance).

Acute treatment: Click here.

Examination: In light cases with only minimal tenderness medical examination is not necessarily required. In case of more pronounced pain and in lack of progress a medical examination should be carried out to ensure the correctness of the diagnosis and to commence the correct treatment (article-1) (article-2). A normal medical examination is usually sufficient in order to make the diagnosis, however, if there is any doubt concerning the diagnosis the medical examination should be supplemented with an ultrasound scan, which is the most suitable examination for shoulder damage (Ultrasonic image) (article).

Treatment: The treatment primarily involves relief from the pain inducing activity, stretching and rehabilitation of the muscles around the shoulder. In light cases with slowly insetting tenderness after load, without the sensation of a snap and good function of the muscle (“muscle strain”, “imminent pulled muscle”, “inflammation of the tendon”), medical treatment in the form of rheumatic medicine (NSAID) or injection of corticosteroid (usually in the subacromiale bursa over the infraspinatus muscle). Since the injection of corticosteroider is part of a long-term rehabilitation of a long-term injury, it is often necessary for rehabilitation to stretch over several weeks to months to reduce the risk of recurrences and ruptures. The tendon can of course not sustain maximum load after a prolonged injury-period and only a short-term rehabilitation period. Ultrasound guided injection gives the maximal effect with minimal risk, since “blind” injections hit the wrong structures in more than half the cases (article). In case of lack of progress in rehabilitation and medical treatment, an operative treatment can be attempted.

Complications: If progress is not smooth, it should be considered whether the diagnosis is correct or whether complications have arisen. Amongst others the following should be considered:

• Rupture of the upper shoulder blade muscle
• Inflammation of the upper shoulder blade muscle
• Inflammation of the bursa
• Rupture of the deltoid muscle
• Rupture of the biceps muscle
• Tendinitis in the biceps muscle
• Partial luxation in the shoulder joint
• Luxation in the joint between the shoulder blade and the collarbone
• Frozen shoulder
• Muscle infiltrations
• Sprained shoulder (distorsio art. humeroscapularis)
• Meniscus lesion in the shoulder (laesio labrum glenoidale)
• Impingement syndrome

Anatomy: Four muscles are part of the rotator cuff surrounding the shoulder joint, and controls, coordinates and assists movement of the shoulder: M supraspinatus (the upper shoulder blade muscle), M infraspinatus, M subscapularis and M teres minor. When the arm is moved away from the body and above the head (abducated) the supraspinatus muscle slips under the upper bone projection of the shoulder blade (acromion).

Cause: In case of repeated loads with the arm above the head (tennis, swimming) the upper shoulder blade muscle tendon (M supraspinatus) become inflamed swells and may become squeezed between the head of the upper arm (caput humeri) and the upper bone projection of the shoulder blade (acromion). Additionally this causes fraying and weakening of the tendon with risk of ruptures. It is not uncommon for tendinitis to be seen in conjunction with inflammation of the bursa (bursitis subacromialis).

Symptoms: Slowly insetting local tenderness after load, exterior and to the front of the shoulder. Sometimes radiating down the upper arm. The pain deteriorates when external pressure is applied to the supraspinatus muscle, on the front of the shoulder, when the muscle is activated (the arm is lifted to the side) and when the muscle is stretched (hand is brought to the loin). Due to the inflammation and wear and tear changes, calcification can occur in the shoulder muscle.

Acute treatment: Click here.

Examination: In light cases with only minimal tenderness medical examination is not necessarily required. In case of more pronounced pain or trouble lifting the arm away from the body and in case of lack of progress, a medical examination should be performed to ensure the correctness of the diagnosis and treatment. Ordinary clinical examination is often sufficient to make the diagnosis (article-1) (article-2). If there is uncertainty surrounding the diagnosis, it should be supplemented with an ultrasound scan, which is the most suitable examination for shoulder injuries (article).

Treatment: The treatment primarily involves relief from the pain inducing activities, stretching and rehabilitation of the muscles around the shoulder. If lack of progress in rehabilitation a medical treatment in the form of rheumatic medicine (NSAID) or injection of corticosteroid (usually in the bursa above the supraspinatus muscle) may be considered. Since the injection of corticosteroid is part of a long-term rehabilitation of a long-term injury, it is often necessary that the rehabilitation period stretches over several weeks to months, to reduce the risk of recurrences and ruptures. Naturally the tendon can not sustain maximum load after only a short rehabilitation period. If calcification is present in the shoulder muscle, an attempt may be made to extract this at the same time corticosteroid is injected around the calcification (article). The optimal effect at minimal risk can be accomplished by performing the injections guided by ultrasound. The wrong structures are hit in more than half the cases where the injection is done blindly (article). In lack of progress with rehabilitation and medical treatment a surgical treatment can be attempted.

Complications: If smooth progress is not achieved, it should be considered whether the diagnosis is correct or whether complications have arisen. Amongst others the following should be considered:

• Rupture of the upper shoulder blade muscle
• Rupture of the lower shoulder blade muscle
• Rupture of the deltoid muscle
• Rupture of the biceps muscle
• Ttendinitis of the biceps muscle
• Luxation of the joint between the shoulder blade and the collarbone
• Frozen shoulder
• Muscle infiltrations
• Sprained shoulder (distorsio art. humeroscapularis)
• Meniscus lesion in the shoulder (laesio labrum glenoidale)
• Impingement syndrome
• Nerve entrapment on the back of the shoulder blade

Anatomy: Four muscles are part of the rotator cuff surrounding the shoulder joint, and controls, coordinates and assists movement of the shoulder: M supraspinatus (the upper shoulder blade muscle), M infraspinatus, M subscapularis and M teres minor. When the arm is moved away from the body and above the head (abducated) the supraspinatus slips under the upper bone projection of the shoulder blade (acromion).

Symptoms: In light cases a local tenderness is felt after the load (“muscle strain”, “imminent pulled muscle”). In severe cases a sudden shooting pain in the muscle is felt (partial “muscle rupture” or “pulled muscle”) and in the worst case a sudden snap is felt, rendering the muscle unusable (“total muscle rupture”). With muscle damage the following three symptoms are characteristic: pain upon pressure, stretching (hand to the loin) and activation against resistance (lifting the arm to the side or above the head). The pain is localized on top and external to the shoulder. After a longer period, loss of muscle can be observed on the back of the shoulder blade. With many older people the rupture has not produced symptoms.

Acute treatment: Click here.

Examination: Light cases with only minimal tenderness do not necessarily require medical examination. In case of more pronounced pain or trouble lifting the arm away from the body and in case of lack of progress, a medical examination should be carried out to ensure the correct diagnosis and treatment. Ordinary medical examination is often sufficient to make the diagnosis (article-1) (article-2). Returning to the bedside: using the history and physical examination to identify rotator cuff tears, 2) The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator cuff tears. If there is uncertainty about the diagnosis it should be supplemented with ultrasound, which is the most suitable examination for shoulder injuries (article) (Ultrasonic image). If there is doubt as to whether it is a total or partial rupture, the doctor can inject a local anaesthetic around the rupture. If, after this, the arm is able to move freely, it is not a total rupture (diagnostic blockade).

Treatment: Only in cases of near total rupture of the supraspinatus muscle can surgery be considered. Renewed ruptures occur relatively frequently after surgery (article). In partial ruptures and total ruptures in the elderly the treatment is short-term relief and careful rehabilitation of the part of the supraspinatus muscle, which has not ruptured.

Complications: If progress is not smooth, it should be considered whether the diagnosis is correct or whether complications have arisen. Amongst others the following should be considered:

• Total rupture of the upper shoulder blade
• Inflammation of the upper shoulder blade muscle
• Rupture of the lower shoulder blade muscle
• Rupture of the deltoid muscle
• Rupture of the biceps muscle
• Tendinitis of the biceps muscle
• Luxation of the joint between the shoulder blade and the collarbone
• Partial luxation of the shoulder joint
• Frozen shoulder
• Muscle infiltrations
• Sprained shoulder (distorsio art. humeroscapularis)
• Meniscus lesion in the shoulder (laesio labrum glenoidale)
• Impingement syndrome

Anatomy: Around the shoulder joint are numerous bursas, reducing the pressure on muscles, tendons and ligaments, where these lie close to bone projections. Between the upper bone-projection (acromion) and the upper shoulder blade muscle (M Supraspinatus) lies the largest bursa in the shoulder (bursae subacromiale), which often communicates with the shoulder joint (Photo).