Shoulder Injuries & Treatment

Shoulder Injuries: Arthroscopic shoulder stabilization / bankart repair

Arthroscopic stabilization of the shoulder is a procedure performed to repair the ligaments and cartilage located in front part of the shoulder using an arthroscope. This surgical procedure is recommended when a shoulder is unstable whereby the shoulder joint has become partially loose (subluxation) or completely separated (dislocation). The instability may cause arthritis with intense pain felt at the joint.
Instability of the shoulder may be caused by the labrum (cartilage band), ligaments and capsule surrounding the shoulder joint (rotator cuff) separating or tearing from the shoulder socket bone, a condition known as Bankart tear or lesion.
Tearing causing instability is more likely to happen among older individuals, and placing braces can assist in reduction of the repeated dislocation.

Signs and Symptoms of Shoulder Instability
Instability of the shoulder caused by Bankart lesion presents various signs and symptoms including:

What to do If You Experience Shoulder Instability
Before seeking medical attention for shoulder instability, you should:

Diagnosing Shoulder Instability

For a definitive diagnosis, the orthopaedic surgeon will perform a physical examination to identify the dislocation. This is mostly done by touching the joint. An MRI scan is performed to show the injured tissues, and a CT scan done to check the extent of the damaged bones that are not visible in x-ray.

Dislocation of the shoulder may be either anterior (front of the socket) or posterior (back of the socket). A partial loosening or subluxation indicates the stretching of ligaments and capsule which are not separated from the cartilage.

Arthroscopic Stabilization of Shoulder – Surgery for Shoulder Instability

Arthroscopic stabilization of the shoulder is often performed when there is replicating dislocation and a Bankart tear has formed that needs to be repaired/reconstructed. This is recommended at an early stage to avoid loosening or dislocation of the shoulder.

During the procedure, an instrument known as an arthroscope that has a camera attached to it is inserted into the affected area of the shoulder through an incision. There are usually 2-3 incisions made through which the arthroscope and another medical device known as a shaver are inserted to reconstruct the damage.

During the reconstruction, ligaments located at the front part of the shoulder are tightened and mended through thermal shrinkage. An alkaline solution is injected into the joint to dilate it. If there are any identified tears in the rotator cuff they are also stapled.

All these are done through the incisions and are guided/monitored by the arthroscope which displays the images on a monitor. When the procedure is complete the incisions are sutured and dressed with a waterproof dressing to avoid soaking the wound.

Arthroscopic stabilization of the shoulder has various pros which include:

Follow-up treatment options for shoulder instability undertaken after the surgery include:

Possible Complications of Arthroscopic Stabilization of the Shoulder

Just like any other surgical procedure, there may be complications after the arthroscopic stabilization surgery. These include:

Post-op Care After Arthroscopic Stabilization
After the arthroscopic stabilization surgery, a sling will be provided to be worn for approximately 6 weeks and a continuous passive motion machine will be used throughout the duration of physical therapy to avoid rigidity of the arm and to regain the range of motion. Other exercises that strengthen the arm and shoulder will be advised on by a physiotherapist.
For pain management and soreness, medication will be administered in the first 24 hours after the procedure, and some oral pain medications will be prescribed for the next 5 days. The dressing will be removed after 2 weeks when the wound has healed.
Normal activities can be resumed after 9 months at most, which is dependent on the healing.

Shoulder Injuries: Rotator cuff injury

What is a Rotator Cuff Injury?

The rotator cuff is found in the shoulder and is made up of four muscles and tendons that surround the shoulder joint. Its purpose is to keep the head of your upper arm bone inside your shoulder socket, providing stability when you lift and rotate your arm. Repetitive movements that put a strain on the rotator cuff can cause an injury such as a tear to occur.

Common signs and symptoms

If you have a rotator cuff injury, you may feel:

• A dull ache in the shoulder
• Disturbed sleep caused by pain from sleeping on the affected shoulder
• Difficulty combing your hair or reaching behind your back
• Weakness in your arm
• Swelling at the front of the shoulder
• “Clicking” in your shoulder when raising your arms above your head

Common causes of rotator cuff injury

Rotator cuff pain can be caused either by a substantial injury or from wear and tear of the tendon which happens over time. Repetitive movements or a history of heavy lifting may cause degeneration of the rotator cuff.

You’re more likely to get an injury to your rotator cuff if you:

• Are over 40. The injury risk increases with age and people above aged 40 are more commonly affected by rotator cuff tears.
• Play certain sports.Sports like tennis, baseball and archery can cause rotator cuff injuries due to the repetitive arm motions involved.
• Work in construction.As with some sports, there are also certain jobs which can contribute to rotator cuff problems. Occupations that involve a repetitive strain on the arms, such as plastering and painting, are more likely to cause wear and tear.
• Have a family history of rotator cuff injury. Rotator cuff injuries have been shown to be more common in certain families, so you may be more susceptible due to genetics.

Diagnosing a rotator cuff injury

To reach a diagnosis, your doctor will examine your shoulder and test the strength of your shoulder muscles. You may also be referred for imaging tests (scans) such as:

• X-ray – to detect bone spurs or arthritis that may be causing the pain
• Ultrasound – to look at the soft tissues of the shoulder and assess how they appear during movement
• Magnetic Resonance Imaging (MRI) scan – to look at all the structures of the shoulder in more detail

Once you doctor has established the extent of your injury, they will decide on an appropriate treatment plan for you.

Treating a rotator cuff injury

Most rotator cuff injuries can heal with conservative treatment such as self-care and physiotherapy. More severe cases where a complete tear is present may require surgery.

Self-care

• Avoid any activities that cause pain or weakness in your shoulder
• Ice. Apply ice to the area for 15 to 20 minutes every few hours
• Once the pain has subsided, you can use a heat pack to help with any stiffness you may be experiencing
• Your physiotherapist or doctor may have recommended some stretches which you can do to increase the strength and movement in your shoulder.

Medications

Over the counter painkillers are usually strong enough to help with pain relief and inflammation.

Physiotherapy

Your doctor may refer you to a physiotherapist who will prescribe exercises for you to follow. It is important that you carry out the advice you have been given in order to aid a successful recovery.

Injection Therapy

If non-invasive treatment has not helped to resolve your pain, your doctor may administer an injection to the area. However,  injections usually only provide short term relief and it is not advisable to have them repeatedly, as it could result in damage to the tendon.

Surgery

When conservative treatment has failed, surgery may be necessary. There are different types of surgical options available for rotator cuff injuries and your doctor will decide on which approach is most appropriate for you:

• Arthroscopic tendon repair. This is a keyhole procedure where a tiny camera (arthroscope) is inserted into a small incision in your shoulder and tools are then used to reattach the torn tendon to the bone.
• Open tendon repair. An open repair involves making a larger incision to reattach the torn tendon to the bone.
• Tendon transfer. Sometimes it may not be possible to reattach the tendon to the bone, due to excessive damage to the tendon. In this case, the surgeon may take a nearby tendon and use it as a replacement.
• Shoulder replacement. In extreme cases where the rotator cuff is very badly damaged, a shoulder replacement may be the best option. The surgery involves the use of an artificial joint to improve stability. The procedure is called a reverse arthroplasty.

Recovering after a rotator cuff injury

Minor injuries may heal within weeks, depending on the treatment taken.

After surgery, recovery can take four to six months, depending on the size of the tear and other contributing factors. Immediately after surgery, you may need to wear a sling for four to six weeks. Over the counter medication can help with pain relief.

It is also likely that physiotherapy will be prescribed as part of your post-operative recovery plan. The length of the course of physiotherapy will depend on the type of repair that took place.

Shoulder Injuries: Shoulder arthroscopy

Shoulder Arthroscopy in Dubai

Shoulder Arthroscopy is a surgical procedure used to repair damaged tissues around or inside the shoulder joint. A tiny camera known as arthroscope is inserted through an incision made to examine the shoulder joint as the repair is being done.

The shoulder arthroscopic procedure is considered advantageous compared to open surgery because there is minimal damage to the tissues during the procedure, and the incisions made are quite small, hence a shorter healing period and minimal stay in the hospital.

An Overview of the Shoulder

The shoulder contains various bones, which include:

• The collarbone also known as the clavicle
• Shoulder blade also known as Scapula
• Humerus bone located in the upper arm

In addition to the bones mentioned above, there are other components that make up the shoulder. These are:

The ball and socket: Ball is the head of the humerus bone which fits into the rounded socket of the scapula. Articular cartilage is a greasy tissue that covers the surface of the ball and socket to prevent friction.

The socket has a ring formed on it known as the labrum cartilage which helps in the stability of the joint motion and the cushioning of the joint.

Rotator cuff: These are tendons that surround the shoulder capsule and assist the arm bone to remain centered in the socket.

Shoulder capsule: This is formed by ligaments at the joint of the shoulder which is then lined by a thick membrane known as the synovium. The synovium produces a fluid called synovial fluid which helps in lubricating the joint.

Bursa: This is a lubricating sac found between the acromion bone (top shoulder bone) and the rotator cuff, which helps in smoothening the movement of the rotator cuff.

Indications for Shoulder Arthroscopy

• Labral tears such as SLAP (superior labrum from anterior to posterior) that cause shoulder instability. This instability occurs when one of the tendons of the biceps muscles slips on the labrum due to the shallowness of the shoulder socket.
• Impingement syndrome (shoulder bursitis) which is caused by inflammation of the bursa.
• Biceps tendonitis whereby the biceps tendons are inflamed leading to pain due to impingement syndrome and tearing of the rotator cuff.
• Tearing of the rotator cuff which leads to difficulty in lifting movements of the shoulder. The tendons also end up getting injured.
• Acromioclavicular joint (AC joint) caused by arthritis.
• Frozen shoulder (adhesive capsulitis) – This occurs when the shoulder joint’s motion becomes stiff and painful, leading to the inability to move the shoulder due to the formation of adhesions (thick bands of tissues) and the reduction of synovial fluid in the joint.

Techniques Involved in Shoulder Arthroscopy

During a shoulder arthroscopy procedure, the arthroscope is inserted through small incisions into the shoulder to examine the bones and the tissues around the joint. The arthroscope has a camera that projects visuals of the target areas on a screen. Other incisions are made through which the damaged tissues are removed and/or repaired. This procedure is performed under light general anesthesia together with a nerve block whereby the shoulder and arm are numbed during and a short while after the procedure.

• In repairing of the rotator cuff, the tendon edges are pulled together and attached with small sutures(anchors) to the bone. The sutures are usually made of plastic or metal and are not necessarily removed after the procedure. Rotator cuff tear can be treated with physical therapy, anti-inflammatory medications, cortisone injections or surgery.
• Repairing of shoulder bursitis or impingement syndrome is done by removing the damaged tissues from the joint. The ligament known as coracoacromial can also be removed, and an overgrown acromion bone which causes the impingement resulting in inflammation is also shaved.
• Labral tears such as SLAP and Bankart tears are repaired by attaching the ligaments.
• Frozen shoulder usually requires physical therapy and pain relief. However, if it worsens surgery may be recommended. The surgical procedure used for treating a frozen shoulder is known as arthroscopic capsular release.
• For affected AC joint arthritis, the damaged collarbone or clavicle is removed.

When the repair is complete the incisions are sutured, and the wound is covered with a dressing.

Possible Complications of a Shoulder Arthroscopy

Just like any other surgical procedure, there are some risks involved in shoulder arthroscopy, but they are minor and can be resolved. These risks include:

• Blood clotting
• Excessive bleeding
• Infection
• Damage to the nerves or the blood vessels

Recovery After Shoulder Arthroscopy

After a shoulder arthroscopy procedure, the patient can stay in a recovery room for up to two hours so that the wound can be monitored as medication is administered for pain relief. A sling is also provided to support the shoulder.

For a frozen shoulder the recovery is achieved through stretching and physiotherapy but if surgery is involved the motion is regained more slowly, which can be after few weeks or even months.

Cold compresses and pain medication such as non-steroidal anti-inflammatory drugs are recommended to relieve pain and swelling. The position which helps the shoulder in healing fast would be a propped-up bed and sitting on a reclined chair. The patient should avoid lying flat as it may pull the shoulder and cause discomfort. Direct contact of the wound with water should be avoided for faster healing.

Exercise and physiotherapy are recommended for better rehabilitation of the motion and shoulder strength.

Shoulder Injuries: Shoulder impingement

Shoulder impingement is one of the most common causes of shoulder pain and occurs when the acromion (outer end of the shoulder blade) and rotator cuff (tendons and muscles surrounding the shoulder joint) rub against each other as a result of increased pressure, which leads to irritation and inflammation in the bursa (jelly fluid between the joint bones).

Also known as swimmer’s shoulder or impingement syndrome, shoulder impingement can occur as a result of repetitive activity that strains the shoulder such as lifting heavy weights, tennis, swimming, and painting amongst other overhead activities and sports. This can lead to pain on the upper shoulder bone, as well as difficulty reaching behind the back and arm weakness.

Symptoms of Shoulder Impingement

Some of the common signs and symptoms of shoulder impingement include:

• Persistent pain while extending the arm backwards or overhead
• Inflammation of the bursa and rotator cuff
• Weakness of the arm and/or shoulder
• Stiffness of the shoulder
• Tenderness in the front part of the shoulder
• Tearing and wearing of the biceps muscles if not treated early
• Pain while sleeping on the affected side

Causes of Shoulder Impingement

The main cause of shoulder impingement is overuse or straining of the shoulder and arm through overhead and backward activities such as swimming, heavy weightlifting, softball, tennis, painting, baseball, construction or packing goods. These activities, when done for a long period of time can result in shoulder impingement.

The impingement syndrome can also be as a result of:

• Sore or irritated bursa
• Swollen or torn tendons
• Flat or bone spurs on the acromion

Diagnosis of Shoulder Impingement

During the diagnosis of a shoulder impingement, the orthopedic surgeon first checks the patient’s medical history, which is followed by a physical examination to know the causes of the shoulder impingement symptoms. Previous surgical procedures and the mobility of the arm are ALSO assessed, and to find out the presence of any other damage or arthritis, imaging tests such as MRI scan and x-ray will be carried out.

Treatment Options for Shoulder Impingement

Non-surgical Treatment of Shoulder Impingement

Medication: Specific anti-inflammatory drugs are recommended to aid in relieving the pain and recede the soreness. Injection therapy may are given when medication has not been effective.

Home remedies: An ice pack is recommended, which is effective in relieving soreness and pain. For this option, the patient is advised to place an icepack on the shoulder for approximately 15 minutes. Additionally, resting and avoiding activities that can strain the shoulder is highly recommended.

One should avoid using a sling if he/she has not undergone a surgical procedure as this can lead to stiffness and weakening of the shoulder.

Physical therapy: Physiotherapy is important in speeding up the healing process for shoulder impingement. This is done through mild exercising of the arm, shoulder and chest to help in regaining range of motion and strength. Some of the exercises include:

• Shoulder blade flexion where one stands with the arms and back straight and the palms facing forward. Stretch the chest outwards and the shoulders backwards and hold for 5-10 seconds. This motion is repeated a few times while holding the flex motion.
• Crossover arm stretch: This involves lifting the arm of the affected shoulder and pulling it with the other arm across the chest and holding for 5-10 seconds, then releasing.
• Doorway shoulder stretch: This exercise involves holding the doorway frame at shoulder height with the arm of the affected shoulder, turning the body slowly away from the arm and holding for 15-20 seconds.

Surgery

Surgery for shoulder impingement is considered when conservative treatments are not effective. During the procedure, the tissues and bone spur are repaired through a procedure known as arthroscopic shoulder decompression surgery. An arthroscope and an instrument known as a shaver are inserted via small incisions, and part of the acromion is removed. This procedure helps in broadening the space between the rotator cuff and the acromion and therefore reducing friction. An arm sling is provided after the surgery but only for a short period in order to prevent stiffness.

Recovery After Shoulder Impingement Surgery

The arm sling provided after the surgical procedure is usually removed after 2-4 weeks whereby the patient can slowly resume his/her normal activities. The complete healing process takes an average of three to six months or even a year depending on the severity of the damage.

Shoulder Injuries: Shoulder instability

The shoulder is a ball-and-socket joint that is responsible for a wide range of movement. It is comprised of the upper arm bone (the ‘ball’ or humerus) and the shallow cavity (the ‘socket’ or glenoid) located on the shoulder blade. The humeral head (ball of the humerus) is meant to stay close to the socket and is held in place by the lining of the joint known as the capsule. The capsule has thickenings known as ligaments and a cartilage rim (the labrum). Shoulder instability is a term that is used to describe what happens when the humeral head separates from the glenoid.

Types of Shoulder Instability

Shoulder Subluxation and Dislocation

Significant trauma to a normal joint can forcefully cause subluxation or dislocation of the humeral head. Shoulder subluxation is when the ball or humerus partially slides in and out of the socket quickly. Shoulder dislocation is when the humerus completely comes out of the socket or glenoid. It can fall back into place over time on its own or be put back with medical assistance.

During shoulder subluxation and dislocation, the capsule, labrum, or ligaments can be torn, stretched, or detached from the bone. When the humeral head is back in place, these structures can heal in a stretched or loose position which may increase the risk of future chances of dislocation or subluxation. With each episode of dislocation or subluxation, more tissue damage can occur thus increasing the chances of future instability.

Labral Tear

Shoulder instability can also occur when the labrum is peeled off or torn off the glenoid (socket). It can happen after a shoulder trauma, shoulder dislocation, or due to repetitive motion (such as throwing a ball).

Genetic Condition

Some individuals can be born with loose shoulder ligaments due to a spacious or loose capsule. For them, shoulder instability can occur following a minor injury or sometimes without any trauma. There is also a hereditary condition that can cause looseness in the joints and predispose the individuals to shoulder weakness or instability.

Causes of Shoulder Instability

There are a number of different mechanisms that can cause shoulder instability and they include:

• Diving or sliding head first

• Falling onto the arm

• Overuse of the shoulder resulting in muscle weakness

• Collision with an object or another individual

• Seizure disorders

Symptoms of Shoulder Instability

Individuals with instability of the shoulder joint can experience a number of symptoms including:

• Significant pain

• Inability to move the shoulder

• Sensation of a pop in the shoulder

• Difficulty in lifting the arm overhead

• Sensation of increased movement in the shoulder joint

Risk Factors of Shoulder Instability

Risk factors that can increase shoulder instability include:

• History of previous shoulder injury

• Being young and regularly participating in contact sports

• Having generally loose ligaments

• Seizure disorders

Diagnosis of Shoulder Instability

Diagnosing shoulder instability involves a physical examination done by a physician and a complete medical history. The physical examination will include palpation to check for specific areas of tenderness and determine the strength and range of motion of the shoulder joint.

Specific tests will be done to determine the degree of laxity of the shoulder joint and the shoulder laxity. Some of the tests done include:

• X-ray: This is done to rule out other causes of shoulder pain such as a fracture and to get information about the possible cause of the instability

• Magnetic Resonance Imaging (MRI)

• Computed tomography (CT scan)

The above two tests can be done to further evaluate the tissues and bones of the shoulder joint.

Treatment of Shoulder Instability

The first line of treatment for patients with shoulder instability includes non-operative management with focused physical therapy, possible bracing, and activity modification. The pain and swelling can be controlled with NSAIDS (non-steroidal anti-inflammatory drugs). The goal of the therapy is to increase the strength of the shoulder muscles and restore shoulder motion.

Surgery is an option for patients who are at a high risk of recurrence such as contact athletes, those with other types of damages to the shoulder such as fractures and cartilage tears, and those who are prone to multiple instability events.

There are different surgical treatment options but they are all aimed at improving the stability of the shoulder and allowing patients to resume their activities as soon as possible.

Surgery for shoulder instability involves examining the shoulder to assess the extent of the instability while the muscles surrounding the shoulder are relaxed. An arthroscope can be used to inspect the inside of the shoulder joint and evaluate its cartilage and joint. If the degree of laxity or looseness is mild, the shoulder can be stabilized by arthroscopic techniques.

For severe instability, open surgery is necessary. It involves a surgeon making an incision over the shoulder and moving the muscles to have access to the joint capsule, ligaments, and labrum. The structures are either reattached, repaired, or tightened depending on the extent of the injury.

Physical therapy will be needed following the surgery and full range of motion can return in six to eight weeks.

Shoulder Injuries: Shoulder labral tear

What is a shoulder labral tear (SLAP tear)?

On the outside rim of your shoulder socket, there is a ring of cartilage called the labrum. Its purpose is to help hold the ball shaped end of your humerus (your upper arm bone) in place within the shoulder socket. The labrum can become torn in different places, but the most common area is at the front and back where it attaches the bicep muscles in your arm to the tendons. This type of tear is called a SLAP tear, which stands for Superior Labrum Anterior and Posterior.

Common signs and symptoms of a SLAP tear

Often, SLAP tears are symptomless with the pain only occurring when you try to do certain movements with your arm:

• Shoulder pain

• A feeling of the shoulder locking, clicking or catching

• Reduced movement and stiffness in the joint

• A feeling of unsteadiness and weakness in the shoulder

Common causes of a SLAP tear

SLAP tears are usually caused by:

• Trauma – Injury can occur during sports or during an accident where you fall and stretch your arm out to break your fall. The impact of bearing weight on your arm in this way can cause the labrum to tear. It may also happen if you are involved in a car accident or dislocate your shoulder.

• Repetitive movements – Certain repetitive movements such overhead motions during work or sports can result in a SLAP tear.

• Wear and tear – Chronic conditions such as osteoarthritis (wearing down of cartilage in the joints) can make the labrum prone to tearing, as can general wear and tear during your lifetime. If you are over 40, you can be at a higher risk of getting a tear.

Diagnosing a SLAP tear

It can be difficult to diagnose a SLAP tear because you can also tear your labrum in other areas. To reach a diagnosis, your doctor will assess the condition of your shoulder by moving your arm into various positions and reviewing how much movement and pain you have.

Imaging tests

Your doctor may wish to send you for an imaging scan to help look at your shoulder in detail. You may be asked to go for either or both of the following types of scan:

• X-ray – to detect fractures and structural abnormalities

• MRI scan – to look at soft tissue damage in more detail. You may need to have an injection of a contrast material into the joint. This will help to identify the tear if you have one

Treating a SLAP tear

Your doctor will decide on the best course of treatment based on the symptoms and exact diagnosis. Conservative treatment with the use of medication and therapy is usually enough to treat a SLAP tear, but in some cases, surgery may be required.

Medication

Your doctor may suggest you try medication to relieve your shoulder pain. Options may include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as Brufen (ibuprofen)

• An injection of corticosteroids into the joint to provide temporary relief

Therapy

Physiotherapy may be recommended to help improve your strength, movement and stability. Your therapist may also be able to tell you what kinds of movements are contributing to the problem so that you can avoid them.

Surgery

Surgery is an option when conservative treatment isn’t appropriate or hasn’t helped. An arthroscopic (keyhole) procedure may be required to repair or remove the torn tissue in the shoulder joint. In rare cases, you may need to have open surgery where a larger incision is made.

Recovering after a SLAP tear

Your recovery may differ depending on the extent of your tear and the treatment undertaken. For minor tears requiring conservative treatment, it is possible that you may recover in a few weeks as long as you have followed the advice given by your doctor and physiotherapist.

If you have had arthroscopic surgery, you may need to wear a sling for 4 weeks. In total, it could take up to 2 months for your shoulder to recover after surgery and a further 2 months to regain the strength you had before the injury.

Your doctor and physiotherapist will be able to guide you on when it is safe to return to exercise and more intense activities (such as lifting).