Shoulder Conditions

Information about Shoulder related conditions

Arthritis of the shoulder is a condition where the joint surface between the humeral head which is the ball, and the glenoid which is the socket, lose its normal articular and smooth surface and it starts to become rough and stiff. This causes pain, stiffness and limited movement as the smooth articulation stops. It is sometimes associated with tendon problems, i.e. rotator cuff tears.

The presentation is usually gradual. The shoulder starts to become painful and stiff, sleep gets disturbed and the person doesn’t feel comfortable moving the arm around due to the pain. Once the range of motion and pain become unacceptable treatment is then offered.

Treatment varies depending on the presentation. Sometimes just a debridement with an arthroscopy can provide a short to medium term relief and help to improve a little range of motion. However, ultimate relief is provided with a joint replacement.

Joint replacement of the shoulder are of two types; one is considered the primary and anatomical joint replacement where the ball and socket are replaced in the respective places and sometimes a reverse geometry joint is put in when the tendons of the rotator cuff are ineffective and irreparable to allow better function.

Once the joint replacement is performed the recovery for full function usually takes place between 6-8 weeks and people usually can return to gentle normal activities of daily living.

Cuff Tear Arthropathy

Cuff tear arthropathy is also arthritis of the shoulder in which the ball of the shoulder pushes through the torn area of a chronic cuff tear, creating a rather significant arthritis between the acromion and humerus head. This almost always requires a reverse geometry joint replacement as the tendons are ineffective in allowing movement and the shoulder relies heavily on the deltoid muscle for mobility.

Shoulder dislocations are an extremely common sports related problem in the shoulder. It usually happens in people of a younger age group. Shoulder dislocations can become a chronic problem, also known as recurrent dislocation of the shoulder.

Treatment for a first time dislocation is usually reduced with sedation, pain medication and sometimes even a general anaesthetic is required. Depending on related criteria, flexibility, and mechanism of injury and if there are no fractures, the first time dislocations are by and large treated with physiotherapy and rest. The return to normal function is at an early date. Sometimes, depending on the injury and the sporting demands of the person, an early stabilisation i.e. repair of the torn capsule, is undertaken arthroscopically for a better result.

Recurrent dislocation of the shoulder is not uncommon in young people. Recurrent dislocations or subluxations lead to apprehension, discomfort and significant restrictions in the form of playing sports and overhead throwing activities. This can become quite a nuisance for a young person and affect their sporting and social activities.

Sometimes recurrent dislocations can take place by mere trying to put on a jacket or a coat when the arm is lifted up and externally rotated.

Treatment for such conditions is decided by appropriate diagnosis with an examination, x-rays and MRI scans. Operations to stabilise the shoulder can be done by either an arthroscopic stabilisation or by an open operation which involves a bone block and a tendon transfer. The appropriate operation is then discussed with the patient for the desired outcome.

Fracture of the clavicle

Clavicle, or the collar bone as it is commonly known, can get fractured when a significant fall occurs and you land on the outstretched hand. One of the most common reasons is falling off a push bike at reasonable speed. Collar bone fractures historically have been treated in a sling of various kinds as normal healing is quite good if the fracture is not terribly displaced or in multiple pieces.

However when the fracture displacement is significant and several pieces are involved, the healing doesn’t always take place, either in good line or leads to delayed or non healing situations. In such an instant a decision is made after initial observation of healing, to go ahead and operate and fix it with an internal fixation implant to stabilise the collar bone and allow it to heal appropriately.

Once the fracture is fixed the healing usually takes place between 4-6 weeks. Following complete healing normal activities are resumed.

Fracture of the humerus head

The proximal part of the shoulder joint, which is formed by the head of the humerus is commonly involved in fractures by a fall on the outstretched hand. This fracture can be quite severe and damaging to the shoulder joint, depending on the way it is fractured. The fracture sometimes involves the head itself and the surrounding parts of the bone where important tendons are attached. When the fracture takes place these pieces do get displaced and the treatment then varies depending on the kind of displacement and the injury taking place.

Treatment varies significantly depending on the kind of fracture that has taken place which is either in the form of internal fixation or in joint replacement. This is a complex situation and is assessed with x-rays and CT scans. The patient’s age and function are also taken into consideration to make the correct decision to give the desired outcome.

Frozen shoulder presents as a very stiff, painful shoulder with pain radiating down to the middle of the arm with night waking and significant discomfort.

The cause is usually unknown but is common following a trivial trauma for example a fall, injury, sudden pull or even infection. The usual presentation of a frozen shoulder is that of a gradual onset of stiffness getting worse over several months resulting in it becoming very stiff. Its natural cause allows it to settle down over a period of several months and sometimes even years.

It is also common with people who have metabolic disorders. The treatment for a frozen shoulder has been varied from conservative management to operative.

Investigations involved are x-rays, MRI scans and sometimes an ultrasound examination. The essential treatment is pain relief, reduce the swelling and anti-inflammatories to keep the shoulder mobile as much as possible while it runs its natural course. Sometimes intervention in the form of manipulation with an injection or even an arthroscopic debridement is undertaken.

Impingement of the shoulder involves a symptom of pain when trying to lift the arm up, either to the front or side. The area that gets damaged and swollen is the subacromial space which is the space between the humerus head and the under surface of the acromion. This usually consists of a bursa which gets inflamed. In an acute condition the causes can be a deposition of calcium, infection, trauma or an unknown cause. The presentation can be quite painful and initial treatment involves an injection of steroid, anti-inflammatory tablets, rest, ice and physiotherapy.

Should the problem become chronic and not improve then treatment in the form of an arthroscopic debridement and decompression is considered.

Investigations in the form of x-rays, MRI and ultrasound scans are performed to ascertain the health of the rotator cuff and also to look at the bony anatomy and changes.

Recovery from an impingement arthroscopic surgery, which involves a decompression, is fairly swift. It is considered a very user friendly operation and people can usually return to normal activities within the week and return to majority of work activities and driving in about 2 weeks or so.

The journey starts off with the operation being booked in and a date being set after a detailed discussion and agreement with the patient. Indications of starving instructions and when medication should be stopped are provided in great detail in advance. Sometimes a pre-anaesthetic check up is required if there are co-existing medical problems to ensure appropriate treatment is received.

A complete discussion takes place as regards to what type of procedure is being performed, what the benefits and risks are and also when the patient can return to work is discussed, depending on the procedure.

Physiotherapy is also discussed and organised before the operation occurs to ensure that it is started at the correct time to enable the desired outcome.

The journey always starts with an initial consultation which involves an examination and a discussion about the plan of treatment.

The patient is admitted into the Hospital for the treatment or operation after a complete understanding of the procedure and outcomes have been decided. The patients are looked after in a private Hospital with experienced nursing staff.

In all, the journey is done in a manner of complete relaxation and smoothness in order to ensure that the experience is a pleasant one even though one gets an operation.

The rotator cuff is a group of muscles which end in the shoulder in the form of tendons going around the front, top and back of the shoulder forming a ‘cuff like’ appearance. These muscles are essentially responsible for the initial mobility of the shoulder to rotate it from side-to-side and also to initiate lifting. These tendons are flat in appearance and contour and are quite susceptible to injury due to the way that they are placed. The muscles are majoritly used to pull and are therefore under tension. Most of the common injuries happen when there is an eccentric loading, in the form of a fall or chronic and continuous irritation by a bony spur from the underside of the acromion. When the tendons get worn, degenerate or torn acutely they stop acting as effectively leading to pain and weakness when lifting the arm.

Rotator cuff tears are treated either conservatively; when trying to re-educate the other muscles with physiotherapy, providing pain relief in the form of injections and anti-inflammatories to see if the desired function is achieved in case of chronic conditions. In people with acute tears and with a very active lifestyle an appropriate diagnosis is made with investigations in the form of x-rays, MRI and ultrasounds. Surgical intervention is undertaken in the form of either repairing the rotator cuff arthroscopically or reconstructing it if it is irreparable.

Rotator cuff repairs do need a significant amount of commitment from the patient in the form of continuous physiotherapy. Recovery to full function can take approximately nine months to a year. The common tendons in the rotator cuff that are injured are the supraspinatus and sometimes even the infraspinatus tendons.

In cases of chronic rotator cuff tears, which are irreparable, tendon transfers i.e. rotating the muscle groups and tendons round to take over the function. These are complex operations and are performed after detailed discussions with the patient including the desired outcomes and the functional expectation.

Rotator cuff is a group of muscles which surrounds the shoulder glenohumeral joint in the form of a cuff. The front muscle is called the subscapularis and the superior and posterior muscles are known as the supraspinatus, infraspinatus and Teres minor. The most commonly torn rotator cuff muscle is the supraspinatus followed by the infraspinatus. These particular muscles help to stabilise the shoulder when the individual lifts the arm either upwards or sideways. These muscles attach onto the humeral head with a thin strap-like tendon which is prone to getting torn, particularly in the instance of trauma or chronic degenerative tears which can occur with regular use. The presentation is that of weakness when lifting the arm up or pain radiating down the side of the arm. The diagnosis of this is confirmed with an x-ray, ultrasound or MRI scan.

The treatment for some of these tears is repairing the rotator cuff tendon which can be performed arthroscopically if the tear is not extremely large or old. Each factor also determines the reparability and health of the tissue and concludes whether the tendon can be repaired or not.

Arthroscopic repair can be undertaken by mobilising the tendon and attaching it to the original place with the help of anchors and sutures. A decompression is initially performed to allow more space and then the rotator cuff is repaired and seated down with the help of anchors and instruments.

Physiotherapy is the key to success with rotator cuff repairs and the recovery can take anywhere between three and six months with the final functional recovery taking place between nine months and a year. With a significant amount of time, effort and dedication on behalf of the patient the recovery is desirable as expected.

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