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TYPES OF SHOULDER JOINT ISSUES

  • Rotator Cuff tear
  • Recurrent Shoulder dislocation (Instability)
  • SLAP Tear
  • Impingment Syndrome
  • Frozen shoulder
  • Osteo arthritis – Shoulder Replacement
  • AC joint Injuries

ROTATOR CUFF TEAR

  • Rotator Cuff is confluence tendors of a group of four muscles around the shoulder. The major role of cuff is to keep the shoulder ball centered over the cup, while other stronger muscles lift the shoulder joint.
  • If these muscles are torn, this sunchronized function of the shoulder is affected. In extreme cases it is impossible to lift the shoulder at all.
  • Rotator Cuff tear is usually occur in elder age group. The usual story is minor fall leading to pain in the shoulder. X-rays are normal in such patients diagnosis is done by clinical examination and confirmed by MRI.
  • Minor tears may heal up with time, or may become symptom less over a period of time. Tear of moderate size may continue to produce pain and weakness.
  • If not fixed, the tear increases in size, and the concerned muscles loose their bulk and strength.
  • The repair used to be done by open surgery in the past, but it is now done with arthroscopic (key-hole) technique.
  • For refixing the tendon to the bone, special device called anchors are used, The shoulder is rested in a sling for 4 – 6 weeks, after which physiotherapy is begun. It takes anywhere from 3 – 6 months to recover.
  • Post surgery physiotherapy is as critical to recovery as the operation itself.
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RECURRENT SHOULDER DISLOCATION (INSTABILITY)

Shoulder joint is most mobile joint of the body. The downside of the mobility is that it is prove to dislocation. First episode of dislocation occurs, usually as a result of trauma such as fall on an old stretched hand. As the shoulder dislocates, it tears away the tissue controlling it. After it is re positioned the tissue heal up. In some cases, this healing does not happen, and there is tendency to dislocate again and again. Once the shoulder starts dislocating again and again the only treatment is to fix it surgically(Bankarts repair).

  • In past, It used to be treated by open surgery, which lead to scarring and limitation of shoulder movements.
  • This has been now replaced with arthroscopic surgery(key-hole surgery), where the refixation of the torn tissue is done via key-holes without opening joint. Anchors are used to refix the tissues to the bone.
  • The advantages of this method are minimum pain, quick recovery and no loss of flexibility.

  • When there is significant gleniod bone loss only labrum repair is not suficient treatment.
  • In this case, coracoid bone along with tendon is transfer to antero-inferior glenoid rim – latarjet procedure.

SLAP TEAR

A SLAP tear is an injury to the labram of the shoulder, which is the ring of cartilage that surrounds the socket of the shoulder joint. The term SLAP stands for superior Labrum Anterior and posterior. In a SLAP injury, the top(superior) part of the labrum is injured. This top area is also where the biceps tendon attaches to labrum. A SLAP tear occurs both in front(anterior) and back (posterior) of this attachment point. The biceps tendon can be involved in the injury as well.

  • Injuries to superior labrum can be caused by acute trauma or by repetitive shoulder motion.
  • Acute SLAP injury may result from a motor vehicle accident a fall on outstretched arm, forceful pulling on the arm, vapid or forcefull movement of the arm when it is above the level of the shoulder or shoulder dislocation.
  • People who participate in repetitive overhead sports such as throwing athletes or weightlifters can experience labrum tears as a result of repeated shoulder motion.
  • Many SLAP tears, however are the result of a wearing down to the labrum in older age group.
  • The common symptoms of the SLAP tear are sensation of locking, popping, catching or grinding, pain with movements, pain while lifting objects, decrease shoulder strength feeling of having a “dead arm” after pitching in pitchors.
  • In many cases, the initial treatment for a SLAP injury is nonsurgical. This includes NSAIDs and physical therapy. This exercise programme can be continued anywhere from 3 to 6 months.
  • If pain doesnot improve with nonsurgical methods, surgery may recommend.
  • This surgery is done by arthroscopy (Key-Hole) of SLAP tears. Depending upon the type or patern of tear it may require simply removing torn part of labrum or reattaching the torn part using stitches. Some SLAP injuries requires cutting the biceps tendon attachment.
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IMPINGEMENT SYNDROME/ROTATOR CUFF TENDINITIS

There is a lubricating sac called a bursa bewteen the rotator cuff and the bone on the top of shoulder(acromion). The bursa allows the rotator cuff tendons to glide fresly when you move you arm.

The rotator cuff is a common source of pain in the shoulder. Pain can be the result of :

Tendinitis : The rotator cuff tendons can be irritated or damaged.

Bursitis : The bursa can become inflamed and swell with more fluid causing pain.

Impingement : When you raise your arm to shoulder height the space between the acromion and rotator cuff narrows. The acromion can rub against (or impinge on) the tendon and the bursa, causing irritation and pain.

Impingement syndrome in both young athletes and middle aged people. Young athletes who use their arms overhead for swimming, baseball and tennis are vulnerable. Those who do repetitive lifting or overhead activities using the arm such as hanging construction or painting, teachers are also susceptible.

Patient may have pain and stiffness when lifting the arm, is lowered from an elevated positions. As the problem progresses, the symptoms increase pain at night, loss of strength and motion.

  • The goal of treatment is to reduce pain and restore function.
  • In most cases, initial treatment is nonsurgical. Although it may take several weeks to months, many patients experience a gradual/improvement and return to function. Non surgical treatment includes rest NSAIDs, physiotherapy and sometimes steroid injection.
  • When nonsurgical treatment doesn’t relieve pain, surgery should be done. The goal of surgery is is to create more space for the rotator cuff.
  • This is done by removal of inflammed portion of bursa(Bursectomy), removal of anterior part of acromion(acromioplasty).
  • This is known as subacromial decompression arthroscopic technique.

FROZEN SHOULDER/SHOULDER CAPSULITIS

Frozen shoulder also called adhesive capsulitis cause pain and stiffness in the shoulder overtime the shoulder becomes very hard to move.
In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of the tissue – called acthesis develop. In many cases, there is less synovial fluid in the joint.
The hallmark sign of this condition is being unable to move your shoulder – either on your own or with the help of someone else. I develops, in three stages each last approximately for 3 months.

Freezing : In the freezing stage, you slowly have more and more pain. As the pain worsens, shoulder loses rouge of motion.

Frozen : This is phase of stiffness. Painfull symptoms may actually improve during this stage but the stiffness remains Daily activities may be very difficult.

Threwing : This is phase of resolution, Shoulder motion may improve during this stage. Complete return to normal or close to normal strength and motion typically takes 2 to 6 months.

  • More than 90% of patients improves with relatively nonsurgical treatment to control pain and restore motion.
  • If patient not respond to conservative treatment requires manipulation under anaesthesia (MUA) or Arthroscopic capsular release.
  • Most patient have good outcomes with this procedures.

OSTEO ARTHRITIS - SHOULDER REPLACEMENT

OA is a condition that destroys the smooth outer covering (cartilage) of bone. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bone decreases. During movement, the defective joint surfaces rub against each other causing pain.
OA may occur due to “wear and tear” arthritis, Rhematoid arthritis post traumatic arthritis, rotator cuff arthropathy or Avascular necrosis(AVN).

Shoulder Joint Replacement :

  • Advanced arthritis of shoulder joint can be treated with shoulder replacement surgery, in which the damaged parts of joint are removed and replaced with artificial components called a prosthesis.

Just head of the humerus is replaced by an artificial component Normally done in fractures of head of humerus which are not salvagable.

Both head of the humerus and a glenoid are replaced. A plastic ‘cup’ is fitted into the glenoid and a metal ‘ball’ is attached to the top of the humerus. Rotator cuff must be normal functioning for good outcome.

In reverse total shoulder replacement the socket and metal ball are opposite a conventional total shoulder replacement. The metal ball is fixed to the glenoid and the plastic cup is fixed to the upper end of the humerus. A RSA works better for people with cuff tear arthropathy because it relies on differnet muscles – not the rotator cuff – to move the joint.

SHOULDER TRAUMA

  • The shoulder joint is made up of three bones: scapula (shoulder blade), Clavicle (collar bone) and numerus(arm bone).
  • Fractures of clavicle or the proximal numerus can be caused by a direct blow to the area from a fall, collison or motor vehicle accident.
  • scapula is protected by the chest and surrounding muscles, it is not easily fractured.
  • Treatment of fractures around shoulder joint includes conservative or surgical repair depending upto type and severity of bone fractured.

ACROMIO CLAVICULAR (AC) JOINT INJURIES

  • The AC joint is where the collar bone(clavicle) meets the highest point of the shoulder blade(aeromion).
  • AC joint injuries occur most commonly due to fall directly onto the shoulder.

Treatment :

  • Most people return to near full function with this injury, even if there is a persistant significant deformity.
  • It is worthwhile to wait and see if reasonable function returns without surgical treatment.
  • Surgery can be considered if pain persists or the deformity is severe. Surgery may includes primary repair of cc ligament, reconstruction of ligament with semitonalinoses or just lat end clavicle excision with good satisfactory results.
  • Whether treated surgically or conservatively, the shoulder will require rehabilitation to restore and rebuild motion, strength and flexibility.

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