Shoulder Pain: Acute Injury and Chronic Conditions
The shoulder joint has the greatest range of movement of any joint in our body ensuring that our arms and hands get where they need to be to carry out all aspects of our daily lives at home, at work and in our chosen sports and activities. When healthy, the shoulder joint demonstrates an exquisite balance of strength, flexibility and stability. Mr. Andrew Irwin, Consultant Orthopaedic Surgeon practicing at Spire Hospital Harpenden and The Elms Consulting Rooms, St Albans joins Mark Adshead Managing Director of Physio2go St. Albans in reviewing the impact of normal aging and the potential for “wear and tear “of the shoulder joint. Mr Irwin discusses frequently seen shoulder pathology and sports related injuries and explores the assessment and management of these injuries.
Recent advances in diagnosis and management
Over the past ten years the diagnosis and treatment of shoulder injuries has been revolutionised by advances in available technology. Doctors are no longer restricted to x-ray imagery in their patient assessment; MRI scans have become more available, and diagnostic ultrasound now provides much sharper images of the many vulnerable tendons within the shoulder complex. All this allows the medical team to specifically diagnose the affected structure and prescribe the most effective treatment.
Mr. Andrew Irwin adds “As a shoulder surgeon, I generally get to see the minority of patients who have ongoing pain, stiffness or weakness of the shoulder despite a course of physiotherapy. After the appropriate examination and investigations, localising diagnostic injections are often helpful but may not be curative. It is this small group of patients who suffer ongoing pain who may benefit from arthroscopic (keyhole) examination and repair of the shoulder joint.”
Sports related injuries: Rotator cuff injuries and impingement; dislocations and frozen shoulder
The most commonly affected structures in shoulder problems are the tendons of the ‘rotator cuff’ and the long head of biceps muscle.
These are most often injured as the result of overuse either in the sporting arena or in routine activities of daily living. Racket sports are frequently associated with repetitive arm and shoulder movement and can lead to injury of the shoulder joint; over training at the gym, either by attempting to lift too heavy a weight or by performing too many exercises with the arms above and behind the head can lead to a condition called rotator cuff impingement, where the tendons are squeezed and eventually damaged by the bony structures that make up the shoulder joint. It is much more common in the over 55 age group where there may be some roughening of the acromioclavicular joint which then gradually rubs on the tendons to inflame them and if the action is continued it can cause fraying of the tendon and in rare cases rupture.
Injuries in the younger athlete
In younger teenagers where the bones and muscles have yet to fully mature, excessive repetitive training can cause inflammation from the rubbing action as previously described. It is important therefore to always increase practice routines and drills gradually to avoid developing lifelong chronic injuries. Young patients who have dislocated the shoulder sometimes experience recurrent dislocation requiring stabilisation surgery. Mr. Irwin adds “the arthroscopic techniques for this type of surgery are now well established and this decreases the amount of scarring associated with the surgery and speeds the recovery time.”
Although the most common sports injuries of the shoulder are rotator cuff strains and traumatic dislocations, there are also a number of “ frozen shoulders”(adhesive capsulitis), where some structures of the shoulder joint become inflamed, resulting in stiffness and a decrease in range of movement.
Physiotherapy treatment of the inflamed rotator cuff tendons is aimed at resolving the inflammation with a combination of electrotherapy (such as ultrasound) and manual therapy techniques followed by a specific exercise programme often using elastic resistance bands of increasing tensile strength. A frozen shoulder responds to the same modalities but also requires manual stretching techniques and a regime of self-stretching exercises to facilitate recovery. Acupuncture can be very effective in helping to reduce the pain. In a small percentage of cases the inflammation will require a steroid injection prior to physiotherapy treatment.
Should conservative management fail to settle the condition or if the damage is too severe then modern surgery has a very high success rate. The shoulder lends itself to arthroscopic (key hole) surgery, probably the biggest advancement in orthopaedic surgery. Total joint replacement may be more dramatic, but arthroscopy has a greater effect on more people of all ages. It is vitally important for optimal results following shoulder surgery to be followed up as soon as possible with physiotherapy.
In some sports such as rugby, skiing, or snowboarding, shoulder injuries often result from impact. The main impact injuries are fractures and dislocations of the shoulder joint and the acromioclavicular joint. These types of injuries always need to be assessed by an orthopaedic surgeon and often require surgical repair. Mr Irwin continues, “Just as with the knee joint, the minimally invasive surgical technique has revolutionised shoulder care with much quicker recovery times. Unless the tendons (rotator cuff) require repair, many patients are returning to work within a week or two or even sooner if their work does not involve heavy lifting. Prompt post-operative physiotherapy greatly improves the recovery times and increases the confidence of the patient to move their uncomfortable joint.”
Osteoarthritis of the Shoulder
Arthritis is a degenerative disease caused by either wear and tear of the cartilage (osteoarthritis) or by inflammation (rheumatoid arthritis) of one or more joints. Arthritis also affects the supporting structures of those joints, such as muscles, tendons and ligaments. Arthritis caused by wear and tear is much more commonly seen in weight bearing joints such as the hips and knees however shoulder joints also suffer degenerative changes over time.
As with sports injuries, conservative management with physiotherapy is very helpful alongside anti-inflammatory medication. Mr. Irwin comments “If the shoulder cartilage has been destroyed by arthritis, but the shape of the joint is maintained, the less invasive resurfacing shoulder operation can be performed. This allows smaller incisions and much faster physiotherapy rehabilitation. This is similar to the resurfacing of the hip, which has revolutionised treatment of osteoarthritis of the hip in recent years. It allows patients to have surgery earlier in the course of the condition before they lose much needed muscle power thus allowing a much more active life following surgery. Each individual case will have different factors affecting possible timing of intervention, however the sooner professional help is sought then the better the long term prospects for a full and active recovery.”
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