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Shoulder
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Shoulder Anatomy

The shoulder is a ball and socket synovial joint. It has a ball (the head of humerus) articulating with the  flat socket called the glenoid. The stability is dependent on the bony contours being intact, the cartilage and labrum (the rim of the socket) being competent, the capsule not too loose or torn, and the ligaments (static structures connecting the humerus and glenoid) strong and adequate.

The muscles and tendons help move the joint and contribute to its stability. The muscles closely applied to the joint are the rotator cuff muscles of Supraspinatus on the top, the subscapularis in the front and the infraspinatus and teres minor at the back. Muscle insertion pattern provides infinite variety of moments around humeral head to rotate humerus.

The acromion is a flat plate of bone above the shoulder joint and is like a scaffold.

Venkat - Anatomy of Acromion

 
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The Painful Shoulder

Rotator Cuff Tendonitis and Impingement Syndrome

Download The Impingement Syndrome Treatment
Impingement Syndrome Treatment

The subacromial area lies between the top of the arm bone (Humerus) and a bony prominence on the shoulder blade (acromion). A fluid filled cushion (bursa) lies between rotator cuff tendon and the acromion. With certain positions the bursa and the tendon can become pinched and inflamed. The pain that you have been experiencing is caused by this pinching and is typically felt on movements such as reaching and putting your arm into a jacket sleeve.

 

Venkat - Painful Shoulder - Impingement

 

 

Treatment can involve injection therapy, physiotherapy, and surgery. Surgery is done if patients do not respond to nonoperative measures and is called arthroscopic subacromial decompression. The operation is done by ‚Äėkey hole surgery‚Äô; usually through two or three 5mm puncture wounds. It involves cutting the ligament and shaving away part of the acromion bone. This increases the size of the subacromial area and reduces the pressure on the muscle and bursa allowing them to heal.

Shoulder Arthroscopy

The Operation

The operation is done by key hole surgery; usually through two or three 5mm puncture wounds. It involves examination of the shoulder joint using a tiny telescope with television camera introduced through a key hole.

What is Rotator Cuff Tear?

Venkat - Anatomy of Rotator Cuff Muscle

The rotator cuff consists of four muscles and their tendons. These surround the ball of the shoulder joint. The muscles fine tune the movements of the shoulder joint and assist other large muscles in moving the arm. The tendons run under the acromion (part of the shoulder blade) where they are very vulnerable to being damaged. This can lead to a tear resulting in a painful, weak shoulder.

Download Rotor Cuff Tear and Treatment
Rotor Cuff Tear and Treatment

Download Exercises for Massive Rotor Cuff Tear
Excercises for Rotor Cuff Tear

 

Muscle Wasting Associated with a Rotator Cuff Tear

 

 

 

 

 

 

 

 

 

 A tear may result suddenly from a single traumatic event or develop gradually as part of a degenerative process. Treatments would involve typically injections into the shoulder, physiotherapy and if these fail surgery.

 

 


Venkat - Arthroscopy of Tear in Rotator CuffVenkat - Ultrasound of SubscapularisVenkat - Ultrasound of Supraspinatus

Rotator Cuff Repair - Arthroscopic

A repair involves stitching the torn tendon back onto its attachment to the arm bone (Humerus). It can be performed through keyhole surgery.

 

Healed Portals after Arthroscopy (keyhole) Rotator Cuff Repair

 
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Stiff or Frozen Shoulder

A shoulder becomes frozen when the soft tissues around the joint become tight and short. It is of uncertain aetiology and can be more common in diabetics. It can occur after trauma or surgery when it is known simply as post-traumatic stiff shoulder. The scarring prevents the shoulder from moving and leads to the pain and stiffness. The problem may resolve over time but it can take up to few years or sometimes even 10 years. Treatments involve physiotherapy, injection or steroids and exercises, or surgery if the above measures fail.


Manipulation Under Anaesthetic (MUA) OR Arthroscopic Release

Download The Manipulation of Frozen Shoulder
Manipulation of Frozen Shoulder

 

MUA technique is used in the treatment of frozen shoulders. The aim of the manipulation is to reduce the recovery time by stretching the joint to gain full range of movement. If the shoulder is very stiff even after a MUA an arthroscopic release of the tight capsule may be necessary.

Regular physiotherapy (exercise therapy and stretching) in the first few weeks following your procedure is paramount to keep the stretched structures at operation from contracting and scarring again. Recovery takes 3-6 months.

Arthritic shoulders can also present like frozen shoulders but the x-rays will show evidence of wear and tear and loss of articular cartilage

Stiff and Arthritic Shoulder

Arthritis and Shoulder Replacement

The shoulder is a ball and socket joint with a large range of movement. Usually when severe arthritis (wear of the bearing surfaces of the joint) affects the joint surfaces the shoulder becomes painful and difficult to move with stiffness, crepitus and significant night pain.


Venkat - Xray of Osteoarthritis of ShoulderVenkat - Surface Replacement ArthroplastyVenkat - Surface Replacement Arthroplasty

This operation is to reduce the pain in your shoulder if physiotherapy/ painkillers fail. The operation replaces the damaged surface of the ball of the joint (see pictures) This shoulder replacement called "the Copeland Shoulder". Occasionally a different type of replacement may be used (Stemmed implant or Reverse Shoulder prosthesis).  Stemmed replacement is sometimes necessary if the joint damage is severe The doctors will discuss your individual surgery.
The reverse shoulder is done when you have lost all the rotator cuff muscle in the shoulder as happens with degeneration of tendons with age.


Venkat - Xray of Rotator Cuff ArthropathyVenkat - Xray of Reverse Shoulder ArthroplastyVenkat - Reverse Shoulder Arthroplasty

A physiotherapist will see you in hospital to give you advice about using your arm and exercises. Outpatient physiotherapy will be arranged when you are discharged.

Download The Shoulder Replacement Surgery
Shoulder Replacement Surgery
 
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UNSTABLE SHOULDER

Download The Unstable Shoulder and Its Treatment
Arthroscopic stabilisation of dislocating shoulder

Shoulder Dislocations and Instability

The shoulder joint is designed to give a large amount of movement. Therefore support from the ligaments and muscles is essential. Labrum is the cartilage which deepens the socket and is torn with a dislocation and the ligaments can be torn or stretched and in some cases need to be repaired. Treatment includes physiotherapy but in the younger patient operation may have to be first choice. Operation involves repairing the over-stretched or torn ligaments and labrum deep around the shoulder joint. If suitable, the surgeon may perform Arthroscopic (Keyhole) Stabilisation.

Venkat - Arthroscopy of Labral TearVenkat - Arthroscopy Showing Labral RepairVenkat - Repaired Labrum

Arthroscopic Stabilisation

Download Arthroscopic Stabilisation of the Shoulder
Arthroscopic plication Stabilisation of the Shoulder

 

This keyhole operation is usually done through two or three 5mm puncture wounds. There will be no stitches only small sticking plaster strips over the wounds. These should be kept dry until healed. This usually takes 5 to 7 days.

Rarely an incision at the front of the armpit within the natural skin crease is made to stabilise the joint. This is open surgical stabilisation.

The other kind of stabilisation operation done through the keyhole is Arthroscopic plication stabilisation of the Shoulder. When a shoulder dislocates (comes out of joint) or subluxates (partly comes out of joint) the capsule (lining of the joint) stretches. This is seen more commonly with people with lax joints. We call it multidirectional instability if it is unstable in more than one direction. Here there is no labral damage but a stretched capsule.

 
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SHOULDER FRACTURES

Proximal Humeral fractures

Third most common # in the elderly and 2nd most common in the upper limb. It is twice as common in females due to osteopenia

Problems

  • Elderly population, poor bone stock.
  • High comminution, displacement & complexity.
  • Proximity to shoulder-impairing function.
  • Avascular necrosis due to damage to all blood supply to the bone, where the bone dies.
  • Pull of rotator cuff muscles-displacing tuberosities.
  • Stiffness ‚Äď need for intensive rehabilitation.


   



Acromioclavicular Joint Dislocations

These are injuries of the joint between the collar bone and the acromion (a projection of the scapula bone above the shoulder). It can produce a bulge on the top of the shoulder due to prominent bone. Usually treated non-operatively it may need fixation depending on the patient and injury characteristics. Treatment involves reducing the joint back to its position and using a fixation device to hold it in place.

 

 
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