Shoulder Conditions
Rotator Cuff Injuries
The rotator cuff are a series of four tendons that cover the shoulder joint between the humerus (ball) and glenoid (socket). The tendons arise from the corresponding muscles near the shoulder blade (scapula) and insert at the front (subscapularis tendon), top (supraspinatus tendon) and back (infraspinatus and teres minor tendons) of the humerus. The muscles are important in controlling shoulder movements and maintaining stability of the joint whilst the other 'external' muscles like the deltoid, trapezius and pec help power shoulder movements.​​​​​​​​​​​​​​​​​​​​​
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Rotator cuff tears are common as we get older. Tendons thin over time - a process which starts above aged 30 and continues over time. Tears can occur through injury, or just as a process of wear and tear with age. Often there is a combination of a thin, worn tendon and an external force caused by injury. Patients then may present with pain and if the tear is large enough, shoulder movement may be reduced.
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​In high energy injuries with extensive damage of multiple tendons in certain patients, we often manage these with surgery. Smaller tears of gradual onset are usually managed initially by non-operative measures. These can include physio, analgesia, steroid injections in the first instance. Most small 'degenerate tears' do not ever heal, but symptoms often improve without functional compromise and pain settles. In patients where pain and function does not improve or worsen a rotator cuff repair may be beneficial.
Shoulder Arthritis
Shoulder arthritis commonly affects the ball-and-socket (gleno-humeral joint), or the joint between the collarbone (clavicle) and shoulder blade (scapula) - know as the acromoiclavicular (or 'AC') joint. Like most arthritis there are a number of causes. The commonest we see is a gradual process condition over a number of years (related to genetics). It can be caused by failure and tearing of rotator cuff muscles - as the 'ball' (humerus) struggles to centre itself on the hockey (glenoid). It can occur following injury - especially with damage to the cartilage, and also as a result of inflammatory conditions (such as rheumatoid arthritis, or infection).
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Non-operative treatment - such as simple painkillers and physio or targeted injections can be useful in the first instance for the treatment of shoulder arthritis. If the pain and stiffness worsens and becomes disabling, the surgery can be helpful.
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For patients with advanced glenohumeral joint arthritis, a shoulder replacement can be life-changing. The type of replacement often depends on the degree of wear within the joint, to both the surfaces, bone and surrounding rotator cuff tendons. The aim of surgery is to improve pain, range of motion and therefore function.
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For patients with arthritis at the AC joint, arthroscopic (keyhole) surgery to shave away bone at the joint surface can be an effective treatment
Radiographs showing a patient with shoulder (glenohumeral joint) osteoarthritis (a). The main mover of the shoulder is the deltoid with the attachments to the acromion and humerus shown by the orange curved line (D). The white line represents the lever arm between the centre of rotation, which in the normal shoulder goes between the humeral head and the deltoid. Figure (b) showing a radiograph following a reverse shoulder replacement. Note how the lever arm is longer and now lies between a sphere on the socket-side and the deltoid. The deltoid is effectively lengthened. This allows the deltoid to work more efficiently as the shoulder no longer relies on the internal (rotator cuff muscles)
Shoulder dislocations and instability
A dislocated shoulder (glenohumeral joint) is usually caused by a significant injury leading to damage to some of the supporting structures of the shoulder. Structures affected can include the capsule and labrum, (which acts as a 'bumper' between the ball and socket, or the surrounding rotator cuff tendons. Often the bone of the socket (glenoid) or ball (humerus) is fractured (broken) at the time. There can be other factors leading to dislocation or a sensation of instability within the shoulder. Some patients have generalised hyperxlaxity ('double-jointedness') which may contribute. In some patients, the muscles around the shoulder area fail to work in a balanced way, causing instability and a tendency for dislocation. Most cases of true 'dislocation' require reduction by a professional, either pitch side, by ambulance staff, or in the emergency department.​​​​​
​​​​​​​In some cases, after a single episode of dislocation, no further treatment is rehired. Many patients get some benefit from focused physiotherapy. In some patients with persistent symptoms, such as shoulder apprehension on activity, recurrent dislocations, or in cases when fractures are evident on imaging, surgical stabilisation may be appropriate. As in all cases of surgical management, the type (open or arthroscopic (keyhole)) and nature of the procedure depends on a multitude of factors which will be discussed before deciding on the best option for the patient.
Two radiographs following a Latarjet procedure. In this procedure, the coracoid bone is removed and secured to the front of the socket (glenoid) with two screws. This stabilises the shoulder by effectively increasing the distance the humerus has to move to dislocate out of the glenoid. It also moves an important set of strap muscles that arise from the tip of the coracoid. This allows the strap muscles to act as a restraint to dislocation.
Shoulder Impingement
Shoulder impingement occurs when the patient develops pain (often a "catching" sensation) when lifting their arm to the side. It can be caused by a number of different disease processes.
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It may be due to inflammation in the tissue called the bursa that lies between the rotator cuff tendons and the bone at the far edge of the shoulder blade (called the acromion), tearing to the rotator cuff itself, or bone spurs on the undersurface of the acromion or at the joint between the acromion and the clavicle (acromioclavicular "AC" joint).
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Often, non-operative treatment is successful at improving symptoms. Well-directed physio and occasionally steroid injections can be beneficial. If this fails, then surgery to clear the space between the rotator cuff and the acromion often improves symptoms. This surgery is performed arthroscopically (keyhole) - and is often called 'arthroscopic subacromical decompression'. The AC joint can be cleared simultaneously and any rotator cuff tear or other problem within the joint managed at the same surgery.
Frozen Shoulder
Frozen shoulder is a condition that leads to pain and stiffness. It has a number of associations and causes. It usually occurs spontaneously, but can be secondary to an injury, or surgery. It is more common in patients with diabetes.
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Frozen shoulder usually follows a progression of three stages;
1. Freezing phase - pain predominates
2. Frozen phase - stiffness predominates and pain lessens
3. Thawing phase - pain and stiffness gradually improves.
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Frozen shoulder is often a self-limiting condition, and does not usually require surgical treatment. Range of movement however, may not go back to normal and the course of the disease can last 18-24 months. Initial treatment always involves physiotherapy and sometimes steroid injections into the glenohumeral (ball- and socket) joint.
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In cases where significant symptoms remains, patients may benefit from an arthroscopic (keyhole) release of the tight tissues and shoulder manipulation which can lead to a significant improvement in symptoms.