• Arthritis
  • Frozen shoulder (Adhesive capsulitis)
  • Impingement
  • Rotator cuff 
  • Instability
  • Arthritis of the shoulder

    Arthritis is characterized by the thinning or complete absence of the normally smooth cartilage lining of the joint. The process is irreversible and develops over a prolonged time. Symptoms are dominated by pain, stiffness and loss of function.

    The most common cause of arthritis is age related wear and tear and and is known as osteoarthritis. In posttraumatic arthritis recurrent trauma like dislocations or a previous fracture lead to a destruction of the joint. A more rapid progression is observed in inflammatory conditions such as rheumatoid arthritis.

    In the early stages arthritis can be treated non operatively. Accurate pain management and  physiotherapy can maintain mobility of the joint and strengthen the shoulder muscles.

    Shoulder joint replacement surgery is warrant in advanced cases. During surgery the worn areas are removed and replaced with a prosthetic ball and socket joint. This addresses the pain associated with advanced arthritis. In most cases an improvement in the range of motion and function of the now artificial joint is noted.

    In patients with advanced arthritis in combination with tendon tears of the shoulder muscles a so called reverse shoulder replacement is preferred. This implant overcomes the problems of poor function and instability associated with a standard total shoulder replacement in patients with a tendon deficient shoulder.

    Surgery is performed under a general anaesthetic. The average hospital length of stay is 2-3 days. During this time the patient commences a gentle physiotherapy program to regain strength and prevent stiffness.

    Improvements in shoulder replacement designs and advances in surgical techniques allow shoulder replacements to last for 10-20 years.


    Frozen Shoulder (Adhesive capsulitis)

    Adhesive capsulitis is a painful and disabling condition with a gradual loss of passive and active motion. Often a cause can not be established but there is an association with diabetes and an increased frequency after surgery and fractures.

    Recovery is slow and symptoms can last in excess of 18 months. 

    The condition progresses normally through 3 phases. Pain and stiffness are dominant in the initial phase which last 3 to 4 months. The second phase is characterised by the resolution of pain and stiffness is becoming the main complain. In the third phase the stiffness gradually disappears.

    Treatment is usually non-operative and includes oral medication to address the pain . Gentle physiotherapy and hydrotherapy can be beneficial. Intraarticular local anaesthetic and corticosteriod injections can be helpful in the acute inflammatory phase. 

    Rarely surgery is required with the aim to release the tight and scared capsule  and the tendons of the shoulder joint. Arthroscopic shoulder surgery is performed followed by a diligent physiotherapy program to maintain the range of motion regained during surgery.


    Impingement

    Shoulder impingement and bursitis is a painful catching on elevation of the arm to shoulder height. It occurs when the space between the shoulder head and the arch of the shoulder blade (acromium) is narrowed. 

    This space is occupied by the rotator cuff tendons , a fluid filled sac a so- called bursa acting as a lubricator and the coraco-acromial ligament. Narrowing interferes with the normal movement of the tendon leading to pain on overhead activities and night pain especially when sleeping on the affected side.

    Cause for narrowing include bony spurs arising from the undersurface of the acromium or a hook shaped acromium. A degenerative acromium calvicular joint reduces the space available for the rotator cuff tendons. An inflamed bursa as a result of repetitive trauma or a thickened rotator cuff confine the subacromial space.

    The bursa which function is to assist with lubrication between the rotator cuff tendon and the acromium can become inflamed and painful as a result of repetitive trauma. This is called subarcomial bursitis.

    Initial treatment of impingement symptoms include simple pain medication and physiotherapy. An injection of local anaesthetics combined with a steriod solution can treat the inflammation and can have a longer lasting effect.

    Non-operative treatment is encouraged for 6 months. At this stage arthroscopic surgery (key hole surgery) is advised. During the procedure any bony causes for impingement and the inflamed bursa are removed leading to a highly successful outcome.

    The Surgery is requires an anaesthetic and possible nerve block. Patients  are usually in hospital overnight. A sling is worn for comfort but early mobilisation is encouraged. A physiotherapy program is designed to prevent any stiffness and help regain  shoulder function.


    Rotator cuff tears

    The rotator cuff consists of 4 muscles (Supraspinatus, Infraspinatus, Teres minor and Subscapularis) and their tendons surrounding the shoulder joint. These tendons centralise the ball of the shoulder joint in its relatively small socket and assist in providing stability. A tear in one or more tendons can unbalance the shoulder leading to pain, weakness and functional loss of the joint. Stiffness can be also be a complain.

    Most commonly the Supraspinatus on top of the shoulder is torn but other tendons can also be involved. Partial thickness tears of these tendons can often be treated with activity modification, simple pain medication and a physiotherapy program strengthening the rotator cuff. If a partial tear progresses to include the full thickness of the tendons surgical treatment is often required.  

    Acute traumatic tears often occur in the younger population. An early repair generally allows a solid reattachment of the tendon and a full functional recovery.

    Chronic degenerative tears can become large and the quality of the tendon might be poor. The torn tendon also affects the muscle appearance. Shrinkage of the affected muscle combined with the retraction of the tendon sometimes make a complete repair impossible. In these cases a partial repair might be beneficial to address the pain.

    A rotator cuff repair depending on its presentation can be repaired arthroscopically or through a mini open approach.

    Surgery is generally performed under a general anaesthetic in combination with a nerve block to control postoperative pain. Patients usually stay in hospital overnight and return home the following day. A shoulder sling is used for 4-6 weeks and a the patients undergoes a specific physiotherapy program to regain shoulder function and to prevent stiffness


    Instability

    The shoulder joint is a ball in a socket joint which is prone to dislocations. It’s extreme range of motion and it’s less favorable size ratio between the socket (glenoid) and the ball (humeral head) lead to a reduced stability. Intact bony surfaces and soft tissue structures are essential for stability. 

    Trauma leading to a dislocation can cause loss of bony structures and soft tissue restrains making the shoulder joint more unstable. It requires then less force for the shoulder to re-dislocate. 

    Particularly in the juvenile and adolescent population re-dislocation rates are extremely high (95%). Non operative treatment often fails in this patient and stabilisation procedures are recommended.

    Preoperative radiological assessment of the shoulder joint in form of a CT and/or MRI scan helps to terminate how much soft tissue and bony components are involved. In most cases damage to the bony structures is minimal and a simple keyhole soft tissue procedure is sufficient to regain stability. Extensive damage to the bony structures of the socket need to be addressed with a bone graft a so called Laterjet procedure to replace the deficient bone.

    Surgery is performed under a general anesthetic and a nerve block to manage postoperative pain. Most patients stay overnight in the hospital and return home the day after surgery. Sling treatment is required for 4-6 weeks when a gentle physio program is introduced to regain shoulder function.

    In most patient a return to pre-injury levels of sport and activity is expected.