Hombro doloroso

Hombro doloroso

Las lesiones tendinosas del manguito de los rotadores principal causa de dolor en el hombro.

El hombro es una articulación compleja, que goza de gran movilidad, pero también es la articulación más inestable del organismo, siendo relativamente frecuente la aparición de luxaciones (hombro que se sale) de la misma, sobre todo en traumatismos deportivos.
Existe una gran incidencia de dolor en el hombro tanto en relación al deporte, como al trabajo y en muchas ocasiones sin causa desencadenante aparente.

Detrás de este dolor no suele existir ningún problema de gravedad aunque en ocasiones es muy intenso y tiene predominio nocturno, lo que impide al paciente dormir y descansar adecuadamente. En otras ocasiones aparece con determinados movimientos como levantar el brazo por encima de la cabeza para peinarse o llevarlo hacia la espalda para desbrochar el sujetador o ponerse la chaqueta.

En la mayoría de las ocasiones este dolor está producido por inflamación de los tendones responsables del movimiento del hombro, que reciben el nombre de “manguito rotador”

¿Qué es el manguito rotador?

Se llama manguito rotador o de los rotadores al complejo muscular formado por cuatro músculos que rodean a la articulación del hombro,  sirviendo de estabilizadores dinámicos de la misma. Los músculos que forman el manguito rotador son el subescapular, supraespinoso, infraespinoso y redondo menor. Los músculos del manguito rotador pueden desgarrarse y romperse por traumatismos agudos y crónicos. Los desgarros parciales y las tendinosis suelen responder bien a tratamiento conservador (calmantes, rehabilitación, infiltraciones…), mientras que la ruptura suele requerir tratamiento quirúrgico, que hoy en día se suele realizar mediante artroscopia (cirugía guiada por una cámara de televisión que se introduce en el hombro por una incisión de 5 mm)

Estos músculos, sobre todo el supraespinoso, que es el que con más frecuencia se afecta, están cubiertos por una bursa sinovial que en ocasiones se inflama y puede ser también causa de dolor

Otra estructura que con frecuencia es responsable  del dolor en el hombro es el tendón de la porción larga de bíceps que discurre por dentro de la articulación, sobre la cabeza del húmero, hasta alcanzar su inserción en la escápula.

¿Cómo se desencadena el dolor?

En general suele aceptarse que el dolor aparece al existir un conflicto de espacio para que los tendones del manguito de los rotadores se desplacen libremente en los movimientos que se realizan para elevar el brazo. Estos tendones se encuentran entre la cabeza del húmero y el acromion, dos estructuras que delimitan un estrecho canal denominado desfiladero subacromial, a través del cual discurren. Si este canal se estrecha por la formación de osteofitos (hueso nuevo) estos tendones pueden rozar con el hueso, llevando a su inflamación e incluso su ruptura.

La bursa subacromiodeltoidea, que es el saco de fluido que amortigua el tendón, también puede dañarse.

¿Qué pruebas se utilizan para valorar el hombro?

La exploración meticulosa por un traumatólogo es la prueba que más información aporta, pues nos permite sospechar la causa del dolor y prescribir la prueba de imagen más adecuada así como el tratamiento inicial.

La radiografía simple nos permite descartar la presencia de artrosis, calcificaciones del tendón, tumores… así como valorar el desfiladero subacromial (el espacio de paso de los tendones). No nos permite valorar los tendones.

La ecografía es la prueba de imagen que más información nos aporta para la valoración de la existencia de lesión en los tendones, ya que nos permite realizar una exploración dinámica, es decir mientras el paciente mueve el hombro, y comprobar si existe choque o roce de los tendones con el hueso.

El problema es que, como comenta el Dr Fernando Jiménez Díaz, experto en ecografía músculo-esquelética, depende del médico que realice la exploración y su experiencia.

La resonancia magnética también permite visualizar los tendones, pero no permite su valoración mientras se mueve el brazo. Nos da una foto fija del hombro cuando el dolor aparece habitualmente con el movimiento.

En ocasiones es necesaria la visualización directa del hombro mediante una artroscopia para dar con la causa del dolor.

¿Son buenas las infiltraciones?

Puede ser el tratamiento más rápido y resolutivo en muchas ocasiones. Tienen poca popularidad debido a muchas circunstancias, pero si están bien indicadas y colocadas en el lugar donde está el problema y no más de tres con un intervalo mínimo entre ellas de tres semanas, son muy eficaces sobre todo si el problema viene dado por una inflamación de la bursa (bursitis) Lo más frecuente es infiltrar corticoides, que son potentes antiinflamatorios, junto a anestesia local.

La infiltración guiada por ecografía permite actuar directamente en el sitio donde está el problema. También consigue buenos resultados en la disolución de calcificaciones, incluso las de gran tamaño.

¿Qué otros tratamientos existen?

Los analgésicos y antinflamatorios pueden ayudar en las fases de mayor dolor. Evitar los movimientos que producen dolor y el dormir sobre el hombro afecto mejoran el proceso. La aplicación de frío suele ser también beneficiosa.

La rehabilitación, en forma de potenciación y reeducación de la coordinación muscular, ultrasonidos, electroterapia y laserterapia puede ser muy útil en muchas ocasiones.

Las ondas de choque se han utilizado con éxito, sobre todo en aquellos hombros donde existen calcificaciones.

Hay que tener en cuenta que algunos problemas del hombro relacionados con los deportes (tenis, jabalina…) o el trabajo son causados por una técnica deficiente. Es importante prevenir tales lesiones aprendiendo una técnica apropiada mediante reeducación del gesto laboral o deportivo.

En problemas crónicos de larga evolución y sobre todo cuando hay ruptura del tendón hay que recurrir a la cirugía artroscópica.

La cirugía permite valorar el interior de la articulación con incisiones mínimas mediante la introducción de una cámara de video conectada  a una televisión a través de la cual el traumatólogo opera.

Una vez valorado el hombro, se procederá a reparar las lesiones tendinosas que existan mediante sutura, eliminar la bursa inflamada y aumentar el espacio para el paso de los tendones mediante una acromioplastia (limar el hueso para que no roce).

La cirugía abierta consigue también buenos resultados pero el postoperatorio es más doloroso y la recuperación más lenta.
Su traumatólogo le aconsejará cuál es el mejor tratamiento para el dolor de su hombro.

Dr. Andres Barriga

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