Shoulder Conditions

Shoulder osteoarthritis | Rotator cuff tear | Rotator cuff tendonitis | Shoulder dislocation

Shoulder Osteoarthritis

How it happens

Arthritis may be due to chronic degeneration over time, which may be partly genetic in origin. It may also occur due to chronic repetitive trauma or a previous injury.

How it feels

Osteoarthritis of the shoulder can be a very painful condition. The pain is usually felt as a deep, boring pain in the shoulder and is usually localized deep in the shoulder joint. Arthritis pain is often improved with the use of medication such as Tylenol or non-steroidal anti-inflammatory drugs. Advanced osteoarthritis of the shoulder will generally not respond to physical therapy, since end ranges of motion will usually worsen the pain. Arthritis of the shoulder is diagnosed by plain x-rays. MRI is generally not required to diagnose this condition.

How it is fixed

If the shoulder arthritis is mild, or not very severe, it can be treated with medications such as Tylenol or anti-inflammatory drugs, such as ibuprofen. Cortisone injections may be helpful. If the arthritis is very severe and limiting daily activities and/or limiting the ability to sleep due to pain, surgery may be appropriate. Shoulder surgery for advanced arthritis involves replacing the joint. This operation is known as shoulder replacement surgery or total shoulder arthroplasty. Total shoulder replacement surgery involves removing the end of the top of the arm bone and replacing it with a metal component. The socket part of the shoulder joint (or glenoid) is replaced with a small plastic component, which is cemented into place. Shoulder replacement surgery is a very effective operation for reducing pain and improving quality of life. The results of shoulder replacement surgery are similar to the results for hip and knee replacement.

Recovery/Post-Surgery

After shoulder replacement surgery, the patient generally remains in hospital for two days. At that the point, they are usually ready to go home. The arm is kept in a sling for six to eight weeks. Physical therapy is started the day after the total shoulder replacement. Total recovery following the surgery takes three to six months until the patient has good use of the arm with limited or no pain.

Rotator cuff tear

The rotator cuff is a group of muscles that forms a common tendon that helps to stabilize the shoulder. The rotator cuff can tear either by tissue degeneration over time or from an acute traumatic episode. Sometimes the rotator cuff tear will be due to both of these factors. Rotator cuff tears can lead to pain and/or weakness in the shoulder.

How it happens

Over time, the rotator cuff tissue degenerates. This is in large part due to the blood supply of this tendon, which is somewhat limited. The rotator cuff tendon may also tear due to chronic repetitive trauma, or a single traumatic episode.

How it feels

Rotator cuff tears can cause pain in the shoulder. This pain may be felt deep in the shoulder, or along the lateral arm. Rotator cuff pain may also be referred down the arm and patients may feel the pain along the upper arm, or even into the forearm or hand. When the rotator cuff tendons are torn, the shoulder may be weak. This weakness may also be accompanied by pain, when trying to lift objects or trying to use the arm overhead or in a forceful manner. The rotator cuff tear can often be diagnosed by physical examination; however, magnetic resonance imaging (MRI) of the shoulder can be helpful to determine if the rotator cuff is torn.

How it is fixed

Symptomatic rotator cuff tears may be treated non-operatively or with surgery. If the symptoms have been going on a short time and there is no acute trauma, non-operative management may be appropriate. Non-operative management includes physical therapy, anti-inflammatory medication and/or cortisone injection. Rotator cuff repair surgery is appropriate for patients who have longstanding symptoms that do not respond to non-operative management. Surgery is also appropriate for rotator cuff tears that occur following trauma leading to severe weakness in a patient who had a previously normal shoulder. The rotator cuff is repaired to the bone using sutures to stitch the tendon back into its normal position. Rotator cuff surgery, when done technically well for the appropriate patient, has a high rate of success with the vast majority of patients experiencing a significant improvement.

Recovery/Post-Surgery

After rotator cuff repair surgery, patients generally wear a sling for their arm for a total of six weeks. They have several months of physical therapy to recover their range of motion and strength. The vast majority of patients experience a significant improvement in their symptoms, when rotator cuff repair surgery is done appropriately for correctly selected patients.

Shoulder Activity Level in the Preoperative Assessment of Patients with Rotator Cuff Tears (KSSTA)

Rotator cuff tendonitis

The rotator cuff is a group of muscles that forms a common tendon that helps to stabilize the shoulder so that the bigger muscles such as the deltoid and the pectoralis major can move the arm. Rotator cuff tendonitis of the shoulder is also known as bursitis, impingement syndrome, and tendonopathy. This condition involves inflammation of the subacromial bursa – a small, fluid-filled sac – which lies between the rotator cuff and the under-surface of the Acromion Bone in the shoulder.

How it happens

Rotator cuff tendonitis can be initiated by an injury or overuse, or there may not be an inciting event at all. Overuse may be related to an increase in the frequency or intensity of weight-lifting, particularly involving pressing movements or a recent increase in overhead activity such as painting the walls at home.

How it feels

Rotator cuff tendonitis causes pain around the shoulder, most commonly on the outside or lateral part of the shoulder. Pain can often be felt down the arm and even as far as the elbow or below. Less commonly, people have pain in the front or back of the shoulder itself. When the pain related to the rotator cuff is present with activities of daily living, such as getting dressed or lifting light objects, or if the pain causes difficulty with sleep, consultation with a healthcare professional is generally recommended. In some cases magnetic resonance imaging (MRI) of the rotator cuff is helpful to determine if the rotator cuff is torn or if there is another problem in the shoulder.

How it is fixed

If the symptoms have only been going on for a few days, this problem will often go away on its own. After several weeks or months, patients will generally require anti-inflammatory medication, physical therapy, and time away from lifting to allow the rotator cuff pain to settle down. If these measures don’t work, a cortisone injection in the subacromial space will often relieve the symptoms. For other patients, in whom the above measures do not relieve the pain, surgery for the rotator cuff may be considered to achieve relief. This involves arthroscopic surgery, where the inflamed bursal tissue is removed, and more room is created for the rotator cuff tendons by using a burr to remove some of the underside of the Acromion Bone.

Recovery/Post-Surgery

After the pain is relieved, the patient can gradually get back to full activities including lifting and sports. The return to activity must be gradual to avoid reoccurrence. It is generally recommended that all lifters do some rotator cuff strengthening to avoid this problem. Light external rotation either performed with a cable or a dumbbell while lying on the side (also know as the L-fly) is effective. Prevention is the best cure, and by maintaining a strong rotator cuff this problem can be headed off before it begins.

Shoulder dislocation and instability

The shoulder is the most mobile joint in the body. Due to this, it is also the most frequently dislocated joint. The shoulder can dislocate in many directions, but anterior instability is by far the most common. Shoulder instability can range from subluxations – partial shoulder dislocations where the joint does not come completely out of the socket – to true shoulder dislocations, where the joint comes apart completely and remains in the dislocated position until it is reduced, or put back in joint. In some cases, the shoulder can dislocate posteriorly, although this is much less common than the anterior shoulder dislocations.

How it happens

Shoulder dislocations are usually caused by trauma. The trauma may involve a sporting injury, a motor vehicle accident or a fall. For anterior shoulder dislocations, the arm is usually away from the body, sometimes with the hand overhead. For posterior dislocations, the arm is usually in front of the body, reaching forward.

How it feels

Shoulder dislocations can be extremely uncomfortable when they occur. Generally, when the shoulder is reduced, or placed back in joint, the pain improves significantly. For some patients, shoulder dislocations are not very uncomfortable, while for others it can be extremely painful. Some patients are able to put their shoulder back in joint on their own, while others require medical attention in order for their shoulder to be reduced. For patients in whom the shoulder dislocations become recurrent, they may limit their activities to avoid further dislocations.

How it is fixed

In general, surgery is required to prevent shoulder dislocations, once the dislocations have become recurrent. Patients who are young and who participate in contact athletics are at very high risk of recurrence even after a first shoulder dislocation. In such individuals, surgery may be considered after the first dislocation. The surgery involves repairing the torn ligaments to the bone, and in some cases, also tightening (or shortening) the ligaments of the shoulder to prevent the shoulder from dislocating. The surgery can be done arthroscopically or using an open approach. The selection of the technique for surgery depends on the type of pathology or injury involved. The surgery is usually done arthroscopically.

Recovery/Post-Surgery

After surgery, the arm is kept in a sling for three to four weeks. Some gentle exercises may be started during this time. When the sling is discontinued, more aggressive physical therapy is undertaken to restore motion and strength. Full return to athletics in all sports is generally at six months following the surgery.

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