Subacromial Impingement Syndrome (SIS) is a condition where the upper Rotator Cuff Muscles of the shoulder are caught underneath a bony prominence, the Acromion, from the shoulder-blade.
Shoulder arthritis is a generally painful condition where the joint between the Humeral Head (the bone of the upper arm) and the Glenoid (the socket on the Scapula, the shoulder-blade) is worn. With increasing wear movements are restricted and the joint often becomes deformed.
Shoulder instability is a condition where the Humeral head (the ball) dislocates and no longer articulates fully with the Glenoid (the socket).
The shoulder is the joint most commonly suffering from instability. As it is a joint with an extreme range of movement this is not surprising; in fact it is a surprise that instability is not a more common.
Frozen shoulder or Capsultis to the shoulder joint is a painful condition associated with marked stiffness to the shoulder joint. It may have a rather sudden onset with severe pain of the shoulder. Within weeks the shoulder becomes increasingly stiff whilst the pain often subsides. Over the following months (12 – 18 months) the shoulder movements gradually improve although a return to full movements may not be occur.
SIS is usually an age-related condition – rarely seen before the age of 40 ys – caused by the Supraspinatus muscle (one of the four Rotator Cuff muscles) being caught between the head of the Humerus and the undersurface of the Acromion. Once the muscle (and often also the neighbouring Infraspinatus muscle) becomes irritated a vicious cycle ensues: the irritated muscle becomes less efficient at controlling the position of the humeral head on the Glenoid (the socket of the shouldewr joint) resulting in the humeral head riding up high pinching the muscle even further.
The underlying cause may be recurrent strains to the rotator cuff, frequent over-head activities, tears to the rotator cuff but most frequently degenerative changes to the cuff muscles.
Patients with SIS suffer from pain when reaching out to the side, above shoulder height or behind their body (reaching for the bra or for the rear pocket can be very painful). Quick movements forward – or in any direction – are also associated with pain. Racket sports or throwing any objects are almost impossible. Night-time pain is common.
The pain is normally located to the fleshy outside of the upper arm; sometimes even radiating down towards the thumb.
Avoid the painful activities – be they sports, hobby or work related. Pain in general is nature’s way of saying DON’T! Rest the arm, place a cold compress over the shoulder rounding, take Anti Inflammatory Tablets.
Use your arm below shoulder height – keep it moving, do not allow it to stiffen up. This can be supported by a physiotherapist with shoulder knowledge aiming for movement and rotator cuff strengthening.
If physiotherapy is unsuccessful a steroid injection into the Subacromial Space may give relief, but if the symptoms persist surgery may be indicated. At the surgical procedure (usually key-hole) the undersurface of the acromion is trimmed and excess scar tissue excised. If a Rotator Cuff Tear is encountered this may require repair as cuff tears do not heal on their own.
Following a standard Sub Acromial Decompression (SAD) relief of symptoms generally is seen within 3-6 months but full recovery may take up to 12 months. In general 90 % of patients will have experienced significant pain relief by then. Most patients can look after themselves within days of the operation but driving may be put off until 4 weeks later (driving can be resumed whenever one feels confident about this). Physiotherapy will aid the return to function.
If the patient is in manual employment return to light duties may be possible after 6 weeks.
If a Rotator Cuff Tear has been repaired recovery often takes longer. Even though the torn muscle is repaired it will take 3 months before biological healing has taken place and for that period the shoulder will need some protection. For the first 6 weeks after surgery driving is not advisable. During the same period the arm should only be used passively i.e. lifting it up using the other hand. Gradually further exercises are added but heavy lifts must not be undertaken for a minimum of 3 months.
If the Acromio-Clavicular joint is arthritic and painful this may require excision, normally done during the same key-hole procedure. The Biceps Tendon may also be a cause of shoulder pain and require surgery; this is done either as a Tenotomy (cutting the tendon origin inside the shoulder joint) or a Tenodesis (moving the tendon outside the joint and attaching it to the bone. The outcome of these two procedures is clinically similar but Tenodesis mas the advantage of maintaining the near-normal bulge of the biceps.
Complications may be seen following any surgical procedure – they are rare following shoulder key-hole surgery but infections, shoulder stiffness, and re-rupture of repaired structures may be seen. Unfortunately pain is initially an issue (the procedure is generally performed in a general anaesthetic supplemented by a nerve block). A regular intake of painkillers and anti-inflammatory tablets and the use of ice on the shoulder may ease these symptoms.
In general the cause of arthritis is unknown; there is probably a genetic component. In other cases it may be seen in connection with a generalized inflammatory arthritis (such as Rheumatoid Arthritis) of following significant trauma to the shoulder.
Shoulder arthritis is far less common than hip and knee arthritis – there are roughly 10 times more hip and knee replacements used. It can however be very debilitating threatening the patient’s independence.
The common symptoms due to shoulder arthritis is a deep ache or pain, worse on movement but also causing sleep disturbances. The pain may be localised to the back of the shoulder. Movements are often restricted and associated with a crunching sensation from the joint.
A course of non-operative treatment should always be tried: pain killers / anti inflammatory medication, physiotherapy to maintain muscle strength and possibly increase movements. And of cause avoiding painful movements whenever possible!
Injections into the joint with steroid may give a short to medium term relief. Early arthritis may be treated with injections stimulating cartilage regeneration (Hyaluronic Acid).
But if significant joint damage has occurred surgery with a Shoulder Replacement procedure is the treatment of choice.
As with other joint replacements there are a vast number of different implants available, but in general they are as follows:
Total Shoulder Replacements: The head of the Humerus is removed and replaced with a ball made of stainless steel or ceramics. The head is attached to a stem inserted into the canal of the humerus. Traditionally a 12-15 cm-long stem is used but they are now in many cases being replaced by short stem-implants. The socket on the Glenoid is replaced with a plastic (poly-ethylene) component. The components may be inserted with or with-out cement depending on their design.
Hemi-arthroplasties: Only the humeral side of the joint is replaced. This may be appropriate where the glenoid bone is severely eroded and cannot support a replacement or in the case of fractures to the neck of the Humerus. I rarely use hemi-arthroplasties as I believe that the results from Total Shoulder Replacements are better.
Reverse/Inverse Shoulder Replacements: If the rotator cuff muscles have ruptured and the humeral head has moved upwards away from the centre of the socket a standard shoulder replacement may not be appropriate. Instead an implant where the socket is placed on the humeral side and a ball mounted on the glenoid is used. This provides a fulcrum for the Deltoid muscle (the large muscle forming the shoulder rounding) to work on. These patients – apart from pain – often suffer from an inability to elevate the arm actively (a pseudo-paralysis). Following surgery a significant improvement in active movement can be seen.
The Reverse/Inverse shoulder replacement is generally reserved for patients above the age of 70 ys as the long term results are uncertain, especially if strenuous use is attempted.
All Shoulder Replacement surgery is performed in a General Anaesthetic often supplemented with a Nerve Block. Following surgery the arm is rested in a sling until the first post-operative day when excercises are commenced. Initially the arm is elevated passively, i.e. using the other arm as a motor or using a pulley. Once a good range of movement is obtained the arm can be elevated actively under the supervision of a physiotherapist. It is recommended that a sling is used until good muscle control has been obtained; normally for 2-3 weeks.
The patient is normally discharged home from the hospital after 2 or 3 days.
For the first 6 weeks post-surgery the shoulder requires protection to allow the muscles to heal. After six weeks it may be possible to return to driving and to light active use of the arm. Over the following months a gradual return to activities is encouraged, but one must bear in mind that improvement in shoulder function is seen for at least 12 months.
All surgery may be associated with complications. Fortunately complications following shoulder replacements are uncommon but they may be serious. They include fractures, nerve or vascular damage, infection, instability, muscle rupture, late loosening of the implant.
The cause of instability may either be traumatic or atraumatic. The traumatic cases normally follow an extreme event, e.g. a tackle or an awkward fall, where the Humeral head is forced out of the joint. This normally results in an Anterior Dislocation, where the head sits in front of the shoulder blade. Occasionally the dislocation may reduce by simple movements to the arm but often it requires medical involvement with sedation and closed reduction (done as a manipulation). The shoulder only rarely dislocated posteriorly.
Atraumatic dislocations may be the result of muscle imbalance or of soft tissue weakness. These dislocations may be anterior or posterior or both.
If a shoulder has become unstable certain movements may result in the shoulder dislocating or sub-luxating. In the case of Anterior Instability this is typically when the arm is brought into the cock-up or throwing position (abduction and external rotation), whereas the shoulder with Posterior Instability is at risk when pushing the is pointing straight forwards and a posteriorly directed force is applied to it.
If a shoulder remains unstable following a traumatic dislocation surgery should be considered. In Anterior Instability this involves re-attaching the capsule to the front of the joint.
In case of atraumatic instability or abnormal muscle pattern instability prolonged courses of physiotherapy often result in relief of symptoms; surgery is very rarely indicated.
The result of surgical stabilisation following a traumatic dislocation is excellent. It is rare to experience further dislocations unless significant trauma occurs.
Surgery is normally performed in General Anaesthetic often supplemented by a Nerve Block during a 24-hour admission. It can either be done as an open or a key-hole procedure. Most studies indicate that open surgery has a lower risk of further dislocations than key-hole surgery. I perform virtually all my stabilisations via small “bra-strap” incision. It is generally a soft tissue procedure but on rare occasions a bone block may be required.
At discharge the arm is supported by a sling but may be used in front of the body for light activities. The sling should be used until good muscle control of the arm has been obtained (normally one to two weeks post surgery). For the first six weeks the shoulder should be protected and all strenuous use avoided. The patient should not drive or ride a motorcycle or a bike for this period of time. After 6 weeks a return to all activities is encouraged but leisure pursuits such as swimming and racket sports (depending on the handedness of the patient) should be postponed until after 3 months. Contact spots should be avoided until 6 montrhs after surgery.
All surgery may be associated with complications such as infection, nerve-damage, stiffness, pain etc. Recurrence of instability is rare but may occur following further trauma.
The cause of Frozen Shoulder is unknown. It may be seen as a result of trauma but generally there is no specific cause to be found.
Depending on a what stage the patient presents the symptoms are either a severe deep pain of the shoulder or a significantly reduced range of movement ( it may be possible to lift the arm to shoulder height but virtually always impossible to reach behind the neck or the lower back).
It is important to rule out other conditions causing shoulder pain and stiffness such as Arthritis, Rotator Cuff Tear, Dislocations etc. An X-ray or possibly a scan may be indicated.
Pain-relief and an exercise programme often supervised by a physiotherapist should be started asap.
If the symptoms persist surgical treatment in the form of injections of local anaesthetics and steroid drugs into the joint may improve movements. If this should prove unsuccessful a Manipulation under Anaesthesia will in most cases result in a marked improvement to shoulder movements.
All surgery is associated with the risk of complications such as muscle or bony damage and pain. Injections may result in infections. Fortunately complications following the above treatment are rare.