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Shoulder Joint

Shoulder Joint Injuries & Treatment

Shoulder Joint Treatment

Shoulder joint enjoys the maximum mobility among all joints in the body. The shoulder joint is like a golf ball on its tee where the humeral head (ball) is large than the glenoid (tee). There are various ligaments and muscles around the shoulder, which stabilize this joint. There is a layer of ligaments over the bones. In addition there is a ring of tissue called as labrum around the glenoid, which acts like a fence against humeral head dislocation. Over the ligaments there is a second layer of muscles, which provide additional stability. These muscles are called the rotator cuff. There are four muscles in the rotator cuff group of muscles- subscapularis at the front, supraspinatus at top and infraspinatus with teres minor at the back.

Types of Shoulder Injuries & Treatments

1. What is shoulder dislocation?

Shoulder dislocation happens when the ball (Humerus head) loses contact with tee (glenoid) and comes to lie commonly in the front or in the back.

2. What happens in shoulder dislocation?

Most commonly shoulder joint dislocation is in front (anterior). When the shoulder dislocates anteriorly it tears off the glenoid and the labrum on the side it dislocates. In some patients this may heal and there is no further dislocation. However in patients where these ligaments do not heal the shoulder continues to dislocate. Every time the shoulder dislocates the some part of the cartilage and bone of the humerus head and the glenoid is damaged. In the long term this damages the joint and may lead to arthritis. Secondly due to apprehension in taking shoulder to certain positions patients’ compromise on activities and quality of life is affected.

3. When is surgery needed?

When there have been more than 2 shoulder dislocations or if there is a fracture after a dislocation.

4. What are the investigations needed?

An X-ray and MRI of the shoulder are essential. A CT scan may be needed in some cases.

5. What kind of surgery is required?

That is evaluated on a patient-by-patient basis depending on the clinical condition, severity of damage, number of dislocations, MRI findings, age and occupation of the patient. Either an arthroscopic repair can be done or sometimes an mini-open surgical repair and reconstruction may be required.

6. What is the hospital stay? When can I resume office?

Hospital stay is of 2-3 days. You can resume office usually within the first week itself. However the operated arm has to be kept in a arm pouch strapped to the chest for the first 3 weeks.

1. What is rotator cuff? What is rotator cuff tear?

This is a group of 4 muscles which envelope the shoulder joint. They are attached to the edge of the humerus head. They are subscapularis at the front, supraspinatus at top and infraspinatus with teres minor at the back.  Sometimes due to injury or in the ageing process these muscles tear off from the humerus head.

2. What is rotator cuff tendinitis?

When there is swelling and inflammation in the rotator cuff it is called rotator cuff tendinitis.

3. What are the symptoms?

A ‘pop’, giving away sensation or severe pain in the shoulder after falling or lifting heavy weights indicates a rotator cuff tear. Patients with weak rotator cuff muscles may tear in daily activities as well. Patients have pain in overhead activity, lifting weights or pain in night especially on sleeping on the same side. Am MRI will be required for accurate diagnosis.

4. Does it always need surgery?

Most of the partial tears and rotator cuff tendinitis can be treated with non-operative treatment. The treatment includes rest, modifying activities that aggravate the problem, supervised physiotherapy and medications.

5. Does a rotator cuff tear need surgery? What is this surgery?

A complete cuff tear, which is symptomatic with pain and difficulty in shoulder movements, needs surgery. The surgery is an arthroscopic surgery with small portals or keyhole incisions are made. Bio-absorbable suture anchors are inserted in the humerus head bone. These anchors have threads that are used to suture the torn cuff back to bone. Over a period of time the rotator cuff heals onto the bone.

6. What is the recovery period?

The patient stays in the hospital for 2-3 days. The arm is in a ling strapped to the chest for 3 weeks and the physiotherapy is started. Usually patients have near normal movements at the end of 3-4 months. Patients can usually join office at the end of 7-10 days if it is a clerical job. For patients who do jobs involving lifting of heavy weights at least 3-4 months are required.

7. I have diabetes and hypertension. Can I undergo this surgery?

Patients with medical illnesses like diabetes, hypertension, thyroid disorders are evaluated before surgery. In most of the patients the medical management can be carried out successfully allowing the surgery to be carried out.

8. What if I neglect the tear and do not get operated?

The complete rotator cuff tears are known to increase in size. Simultaneously the torn muscle gets weak and fragile. In such cases the patient is not able to lift the hand beyond chest level. This is called ‘Pseudoparalysis’. In many patients arthritis may set in called ‘Cuff tear arthropathy”. After a particular point of time the surgery becomes difficult and results are not so rewarding. In patients with severe arthritis a reverse shoulder replacement may be needed.

There are basically 2 types of shoulder replacement.

  • Anatomical shoulder replacement
  • Reverse total shoulder replacement

The age, activity, the kind of shoulder disease, stage of disease and whether the rotator cuff is intact and healthy or not dictate the kind of shoulder replacement the patient needs.

1. What is shoulder arthritis?

Cartilage is the protective covering over the opposing surface of bones, which form a joint. They facilitate smooth and painless movement of both the bones on each other. When this cartilage cover is completely lost and there is pain on movement of the joint it is called as arthritis.

2. What is the cause of arthritis?

Arthritis may be due to various causes.

  • Age related: In elderly patients due to wear and tear over the years the cartilage gets damaged and there is arthritis
  • Rheumatoid arthritis, Psoriatic arthritis etc.: In patients with long standing rheumatoid arthritis, psoriasis, gout and other diseases which affect the joints; the shoulder joint can also get involved leading to arthritis
  • Post infection: Sometimes shoulder arthritis may be seen long after a infection in the shoulder joint has occurred and has been cured. Patients have pain; which starts slowly and progressively increases in severity
  • Post traumatic: Similarly in many patients arthritis may set in after a shoulder injury many years back or some shoulder surgery for fracture months or years back.
  • Avascular necrosis humerus head: This is a condition in which the bone under the cartilage of the head of humerus collapses due to loss of blood supply and death of the bone. Eventually the smooth surface of the cartilage becomes rough and arthritis sets in. It may happen in patients with fracture, after surgery for fracture of head, in patients with sickle cell disease or rarely after deep-sea diving or high mountain climbing.
  • Rotator cuff arthropathy: In patients

3. What are the symptoms of arthritis?

Pain and difficulty in movement of the shoulder are the initial symptoms. Patients have difficulty in sleeping on the affected side. Sleep disturbance, inability to lift hand above face level, grating sensation in the shoulder are seen in later stages.

4.What is the treatment for Shoulder arthritis?

If rest, activity modification and physiotherapy do not help then the only option for clinically significant arthritis is shoulder replacement. There are 2 types of shoulder replacement: anatomic shoulder replacement and reverse shoulder replacement.

Anatomic Shoulder replacement

Here the spherical structure of the head and cup structure of glenoid is kept intact and the diseased cartilage and bone is replaced with metallic surfaces. This removes the pain generating cause from the shoulder and gives relief to the patient.

Reverse shoulder replacement

Here the diseased cartilage and bone is removed and the spherical structure of the head is converted into a cup and the glenoid has a globular shape. This is needed in patients with arthritis due to rotator cuff arthropathy. Because of the unique design of this replacement prosthesis patients who are initially not able to lift their arms are able to lift their arms overhead, able to do their daily activities and pain is almost completely gone.

5. What is the hospital stay? What is the recovery period? Do I need bed rest?

The hospital stay is of 2-3 days. Recovery period varies from patient to patient. Please ask the doctor during consultation about the details. No bed rest is needed. Patients start moving and are independent the same day after surgery.

6. What is the age limit to undergo this surgery? What if I have diabetes, hypertension or thyroid disorders?

As such there is no age limit. Every patient needs to be evaluated individually. Patients who are active and their lifestyle is disturbed due the shoulder arthritis need this surgery. Medical diseases if present have to managed properly before, during and after surgery. Otherwise patients who are deemed fit by the anesthetist can undergo this surgery and have a good result.

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