Conditions & Treatments (Shoulder)
Arthritis
What are the symptoms of shoulder arthritis?
- Pain – which is aggravated by activity and progressively worsens
- A deep, aching pain in the joint
- Soreness to touch the joint
- Difficulty lifting arms to comb hair or reach to a shelf
- Click and grinding sounds may also be noticeable as you move your shoulder
- Difficulty sleeping due to shoulder pain
- If the glenohumeral shoulder joint is affected, the pain is centered in the back of the shoulder and may intensify with changes in the weather.
- Arthritis relating to the acromioclavicular (AC) joint is focused on the top of the shoulder and this pain can sometimes travel to the side of the neck.
- Someone with rheumatoid arthritis may have pain throughout the shoulder if both the glenohumeral and AC joints are affected.
- Someone with osteoarthritis may have pain throughout the shoulder if both the glenohumeral and AC joints are affected.
What are surgical treatments?
- If non-surgical treatments such as cortisone, physiotherapy and medication do not relieve pain surgical treatments may be very helpful in reducing pain, improving sleep and helping you return to everyday activities.
- Advanced arthritis of the shoulder can be treated with a shoulder replacement (arthroplasty).
- In this procedure, the damaged parts of the shoulder joint are removed and replaced with artificial components called prostheses.
What are the different types of shoulder replacements?
- Although shoulder replacements aren’t as common as hip or knee replacements, they offer the same success in returning function and relieving pain.
Total shoulder replacement
- In total shoulder replacement, the damaged bone of the humerus and of the glenoid are replaced with metal and poly replacement components.
Reverse Total Shoulder Replacement
- Some patients with shoulder arthritis are diagnosed with a special type of shoulder arthritis called cuff tear arthropathy. Patients with cuff tear arthropathy will not benefit greatly from a total shoulder replacement because the cuff is a very important part of being able to lift the arm. Alternatively, a reverse total shoulder replacement changes the anatomy of the shoulder such that the deltoid muscle can function without a rotator cuff muscle, allowing the patient to lift their arm pain free.
- In all, reverse total shoulder replacements are becoming a more popular choice of shoulder replacement for all shoulder arthritis conditions.
Mathys Short Stem Total Shoulder Replacement
- The critical factors when looking at shoulder replacement are stability and function. The shoulder is not a weight bearing joint like the knee and so different considerations are important.
- This option is best suited for younger patients. The Mathy’s short stem shoulder replacement is bone preserving and has a variable angle interface to maximise and restore biomechanical function.
Personalised Reverse and Total Shoulder Replacement
- The shoulder is not a weight bearing joint like the knee and so different considerations are important. Best suited for patients with abnormal anatomy, patient specific instrument technology (PSI) is tailor made for your joint, rather than a one-size-fits-all approach – giving you maximum stability from your prothesis placement. This condition is also multi-purpose and addresses both rotator cuff tears AND arthritis.
Arthroscopy
- Also called key hole or minimally invasive surgery, arthroscopic surgery is a simple day stay procedure which involves Dr Herald using a special instrument known as an arthroscope.
- The arthroscope allows Dr Herald to look into your joint (shoulder, elbow or knee) via a very small incision (usually less than 1cm) without having to open the joint up.
- With fibre-optic light and a magnifying glass, the arthroscope provides a very accurate view of your joint to determine what needs a clean up, repair or reconstruction.
- A miniscule camera simultaneously transmits images of your joint to a TV monitor for Dr Herald to view.
What conditions is arthroscopy used to diagnose and treat?
Arthroscopy is useful for many acute sports and work injuries including
- Shoulder Arthritis
- Shoulder Instability
- Shoulder stiffness
- Subacromial Decompression (shoulder impingement)
- Frozen Shoulder
- Removal of loose bodies floating around the joint
What are the benefits?
- Day surgery, so there’s no need to stay in hospital for lengthy periods
- Optimal recovery due to less invasive procedures
- Less risk of infection or after care issues
Burners And Stingers
What are the symptoms?
- Burners and Stingers are terms used to impact injuries to nerve tissue and commonly occur when the shoulder is hit with an elevated arm.
- They describe the type of pain that is experienced at the time of impact which may spread form the site of impact on the shoulder along the entire length of the nerve to the fingers.
- Burners and stingers often happen in contact sports where they may also be called a “dead arm”.
What is the treatment?
- Like a temporary bruise, treatment usually involves rest or gentle range of motion (ROM) exercises until the nerve recovers. Over the counter medications can be used for pain relief or anti-inflammation medication for more persistent injury.
Emergency and Sporting Injuries
Shoulder injuries commonly occur as an overuse problem during throwing sports such as baseball and swimming or as a direct impact injury during a fall in collision sports such as rugby.
- During these matches, acute first aid treatment is usually performed by onsite physiotherapists or by a nearby hospital emergency department or a GP.
- Injuries are usually splinted using a sling and it is important to reduce swelling with ice and elevation where possible.
- Once imaging has been performed definitive treatment can be decided on the sooner the better. The treatment may be non-surgical or surgical.
SLAP lesions are common in overhead throwing athletes and are difficult to diagnose. If you have symptoms with throwing and all previous tests are normal you may require an MR Arthrogram to diagnose the problem.
Fractures
- They can occur as a result of a high-energy injury in a strong bone or a low energy injury in weak bone.
- Initial first aid treatment includes pain relief and a sling to rest the shoulder.
- Ice and compression should be used to reduce the swelling and imaging performed to decide on treatment.
- Most injuries can be treated conservatively with a sling and some physiotherapy usually for around 2 months.
- Sometimes, due to deformity or poor healing, surgery is needed to reduce the fractured bone fragments and secure them to allow early movement.
- It is important that early movement occurs after surgery or injury as otherwise the development of a frozen shoulder can occur.
Collarbone fracture (clavicle)
- A clavicle fracture is also known as a broken collar bone. Broken collar bones are very common and are usually caused by a direct blow to the bone itself or from falling on an outstretched arm.
- X-ray will confirm severity of the break. Non-displaced fractures can heal without surgery, whereas displaced fractures typically require surgery.
Scapula or Shoulder Blade fractures
- Shoulder blade fractures are very uncommon. Typically shoulder blade fractures occur in the lower or inferior aspect of the bone.
- Many of these fractures can be treated without surgery. Symptoms include extreme pain and swelling close to the site of injury.
Upper Arm or Proximal Humerus Fracture
- These kind of fractures frequently occur in elderly people when there is a fall from an outstretched arm.
- A fall can be a simple fall from standing in the elderly to a more vigorous fall from a bike in a younger person.
- They are commonly seen as osteoporotic or weak bone injuries in older people.
What is the treatment?
- While many proximal humeral fractures may no need surgery, they can be very dangerous due to the risk of cutting the nerve and blood supply which runs along the humerus to the hand.
- It is always best to get the right advice for your proximal humeral fracture.
Frozen Shoulder
Frozen shoulder (adhesive capsulitis) is a painful stiffness of the shoulder that often occurs between the ages of 40 and 60 and is more common in women.
Symptoms of frozen shoulder include:
- Pain and stiffness that makes it difficult to carry out a full range of normal shoulder movements such as bathing, dressing, driving and sleeping comfortably.
- Symptoms vary from mild to severe where it may not be possible to move the shoulder at all.
- It may be a self-limiting condition often resolving or “thawing” out, over a 2 year period.
What are the signs that I might need surgery?
Persistent pain that does not go away needs assessment. Remember, either shoulder can be affected, in many cases the non-dominant shoulder (eg the right shoulder in a left-handed person).
In about 20 per cent of cases the condition also develops in the other shoulder.
People with diabetes and thyroid conditions are thought more likely to develop frozen shoulder.
What does surgery involve?
Once a diagnosis has been made, (and if the pain is severe and prolonged), your surgeon may recommend an arthroscopic capsular release to speed up recovery.
During this procedure, the scarred capsule is divided or released to allow full shoulder movement.
Although this is a day surgical procedure, there is usually a 6-12-week period of physiotherapy required afterwards to ensure it does not refreeze.
Dr Jonathan Herald assesses and treats frozen shoulder (both non-surgically and surgically).His active assisted exercises for patients to do at home to help thaw a frozen shoulder are here and here. Dr Herald does not perform cortisone injections but can advise whether they are suitable or not for you and refer on.
Rotator Cuff and Other Tears
Common signs of rotator cuff injury include:
- Swelling and pain in the front of the shoulder and side of the arm
- Pain felt when raising or lowering the arm
- A clicking sound when raising the arm
- Stiffness
- Pain that causes you to wake from sleep
- Pain when reaching behind the back
What is the treatment?
- Steroid injections, anti-inflammatory medication and physical therapy may all be useful in the treatment of rotator cuff tears. Even though most tears cannot heal on their own, good function can often be achieved without surgery.
- If, however, you are active and use your arm for overhead work or sports or have pain, then surgery is usually recommended because many tears will not heal without surgery and may get larger with time. Surgery is generally recommended if you have persistent pain or weakness in your shoulder that does not improve after several months of non-surgical treatments.
- Surgery is also generally recommended when the tear is large (more than 3cm) and often recommended when the tear is caused by a recent, acute injury or getting larger on serial scans.
What does surgery involve?
- During a rotator cuff repair, the tendon is reattached to the tuberosity bone of the humerus from which it has been torn. This is done using suture anchors in minimally invasive, arthroscopic fashion.
- Bone spurs can also be removed in a similar fashion to prevent further tendon injury. Being a completely arthroscopic surgery, rotator cuff repair surgery is now a more minor procedure than it used to be and is often done as a day surgical procedure.
- The recovery however, still often requires a sling for 6 weeks to protect the repair until it heals.
Other Shoulder Tears
Labral Tears
A shoulder joint labral tear is an injury to the labrum of the shoulder, or to the fibrous ring surrounding the glenoid or socket of the shoulder. When the labrum (made of fibrous cartilage tissue) is torn, it can make the shoulder unstable and cause the shoulder to dislocate. Labral tears are often caused by:
- Falling on an outstretched arm
- Falling on a shoulder
- Bracing with your outstretched arm in a car accident
- Lifting heavy objects repeatedly or too suddenly
- Doing a lot of overhead activities, such as throwing a baseball
There are several different types of labral tears:
- A labral tear above the middle of the socket is called a SLAP Tear. Slap tears occur at the top of the shoulder (11 o’clock to 1 o’clock).
- If the tear is at the front of the shoulder, it is called a Bankart Tear (3 o’clock to 6 o’clock)
- When the tear is at the back of the shoulder (6 o’clock to 11 o’clock it is known as a Reverse Bankart Tear
- Sometimes tears occur in combination and these tears are called 270 degree tears.
What are the symptoms?
- Pain with overhead movements like throwing a ball
- Popping, clicking, or catching in the shoulder
- Pain when you move your arm over your head or throw a ball
- Weakness or instability in the shoulder
- People often have a hard time describing or pinpointing where the pain is or describe it as an “aching” pain.
What is the treatment?
- Usually, a significant labral shoulder tear will need surgery for the best outcome and function. This is generally done via a minimally invasive procedure known as arthroscopy, which can be done as a day surgery. Physiotherapy will be required post surgery.
Biceps Tendon Tear at the Shoulder
What is it?
- The biceps muscle has two tendons at the shoulder; a long head and a short head. At the distal end there is one tendon which crosses the elbow. The biceps muscles allow you to bend the elbow and pronate (rotate) the arm.
- At the shoulder, the long head biceps tendon attaches to the top of the shoulder socket, and the short head biceps tendon attaches to the coracoid process.
- Proximal biceps tendon tears can be partial or complete and most often associated with incomplete tears of the long head of biceps tendon.
- A complete rupture will result in a “Popeye Deformity” where the bicep bunches up and bulges out like Popeye’s arms.
What are the symptoms?
- Popping sounds at injury
- Pain, tenderness and weakness at the shoulder or elbow
- Trouble turning the palms face up or face down
- Bruising
- Bulging above the elbow
- Sharp and sudden upper arm pain
What is the treatment?
- While you may be able to live with a Popeye deformity of a proximal biceps tendon tear, a distal biceps tendon tear needs prompt treatment as the distal biceps tendon can retract from the bone and cannot heal itself.
- Permanent weakness can occur if the tendon is not repaired surgically and a deformed and high riding biceps muscle can cause you to lose more than half of your elbow strength.
- For these reasons, surgical repair is most effective within first two weeks of symptoms. There is about a 3 month recovery post surgery.
Unstable/Dislocating Shoulders
- Our shoulders are the most mobile joint in the body, and any disturbance to the normal anatomy of the shoulder structure can cause shoulder instability which increases risk of dislocation.
- Previous dislocations can make a shoulder feel unstable
- Athletes are also highly prone to this injury (particularly in sports like baseball, swimming and volleyball)
- People who are double jointed are more likely to have this condition, due to looseness in the joint
What are the symptoms?
- Pain caused by shoulder injury
- The shoulder joint feeling “loose” as if the ball is falling out of the socket
- Repeated shoulder dislocations
- Repeated instances of the shoulder giving out
What if it becomes “chronic”?
Once a shoulder has been injured by dislocation, it is highly vulnerable to repeat episodes. When a shoulder has dislocated multiple times it becomes loose and may dislocate spontaneously.
What is the treatment?
- The good news is that this condition can frequently be treated with Arthroscopy – a minimally invasive day procedure.
- Surgical stabilisation (via arthroscopy) involves repairing the torn ligaments.
- As it is usually a day surgical procedure – today it is considered a significantly more minor procedure than it used to be.
- The recovery however still often requires a sling for 6 weeks to protect the repair until it heals.
Dislocated Shoulder
What is a dislocated shoulder?
- The shoulder is a ball and socket joint and is the most mobile joint in the body. But for every advantage the shoulder gains in mobility – it loses in stability.
- The shoulder is highly vulnerable to dislocation and this may be described as a partial (subluxed) or complete dislocation and anterior, posterior or multi-directional.
- Shoulders are frequently dislocated when there is instability.
What are the symptoms of shoulder dislocation?
- Swelling or bruising
- A shoulder that is visibly deformed or out of place
- Severe pain
- Inability to move the joint
- When a shoulder dislocates, the ball of the joint (the humerus), falls out of the socket of the joint (the glenoid).
- In some instances of dislocation, the head of the humerus may be fractured by the glenoid as it dislocates. This is known as a Hill-Sachs lesion.
What is the treatment?
- Dislocated shoulders require urgent medical attention and treatment can range from anti-inflammatory treatments, to physiotherapy, splinting and a closed reduction (doctor popping the shoulder back in place) or an open reduction (doctor popping the shoulder back in place during surgery).
- This condition is extremely painful so while you’re waiting for medical attention, don’t move the joint.
- Splint or sling in current position
- Do not try to put the shoulder back in place – which can damage the joint and nerves.
- Ice the shoulder to prevent swelling.