15 February 2018
The winter weather often makes our joints ‘feel older’ than they really are - but despite its name, ‘Frozen Shoulder’ has nothing to do with the frost and snow!
According to Mr Granville-Chapman, a Consultant Orthopaedic Shoulder Specialist at Spire Thames Valley Hospital, you are in fact very unlikely to develop the condition from yomping through the snow-covered countryside!
He explains: “The complex nature of the shoulder means that there is a lot that can go wrong within the joint and the surrounding soft tissues that can lead to pain and loss of function. The shoulder is particularly prone to problems through poor posture, ageing, wear and tear and acute injuries.”
Here he looks at five common problems, how they develop and how they can be treated.
1) Frozen shoulder:
What is it: In frozen shoulder, there is inflammation and thickening of the capsular lining that surrounds your shoulder joint. It usually occurs without any obvious cause, but can be associated with certain medical conditions, or a shoulder injury.
Symptoms: Pain is the initial symptom. It is felt inside your shoulder joint and in the upper arm. The pain is often very severe and frequently interferes with sleep. The shoulder then becomes very stiff and, alongside your pain, this makes simple tasks of daily living very difficult. Frozen shoulder normally improves gradually over time, but this can take two years and 40% of patients will be left with residual stiffness. Patients with severe symptoms therefore seek treatment to accelerate their recovery.
Diagnosis: The combination of your symptoms, your clinical examination and an x-ray will allow this diagnosis to be made.
Treatments: Painkillers and anti-inflammatory medications can reduce your pain. Unfortunately, physiotherapy on its own is often ineffective, but physiotherapy is essential to maintain gains after any treatment for frozen shoulder. Hydrodistension - A guided steroid injection, coupled with salt-water distension of your shoulder joint, often improves the pain and, for many, it also stretches out the tight capsule to improve range of motion. This is a procedure carried out with you awake in the clinic; it takes only a few minutes and has very few risks. Many patients elect to try this minimally invasive option before considering surgery. Keyhole surgery is considered if other treatments fail. Your surgeon inserts a telescope into your shoulder joint and releases the thick and inflamed capsular lining. The shoulder is then carefully manipulated to completely free up the shoulder. This is a very effective operation with the vast majority of patients experiencing profound improvement in both pain and range of motion.
2) Rotator cuff tear
What is it: The rotator cuff is a group of four muscles that wrap closely over the ball of your shoulder joint. These muscles maintain fine control for your shoulder movements and keep the ball centered in the socket. The rotator cuff tendons are prone to degeneration through ageing, wear-and-tear and/or injury. A ‘torn tendon’ describes an area or the tendon that has either partially or fully separated from its insertion onto the humerus bone. A ‘cuff tear’ can range from a tiny partial defect to a massive tear, where the whole two or more tendons of your rotator cuff have detached from the bone.
Symptoms: Pain is typically felt over your upper outer arm and made worse by reaching away from your body. Movements may feel weak, particularly if a large portion of your tendons has torn. It is difficult to raise your arm above shoulder height. Without an acute injury, the majority of rotator cuff problems are degenerative and symptoms tend to come on gradually.
Diagnosis: Your symptoms and clinical examination findings will be suggestive of a cuff problem. Your surgeon will usually get imaging (x-ray plus either Ultrasound or MRI scan) to confirm and quantify your problem.
Treatments: It is important to note that many defects in the rotator cuff do not cause symptoms and that such defects are part of the ageing process for many of us. For example, in 70 year olds with no problems in their shoulders, up to 30% will have some tearing in their rotator cuff. Treatment is required only if you have symptoms of pain or weakness. Painkillers, anti-inflammatories and modifying your activities may help. Physiotherapy helps by correcting poor posture, improving engagement and strengthening of your core, your rotator cuff and your other shoulder muscles. However, if you have an acute tear, or your shoulder does not improve with therapy, then a surgical repair is the best option if your surgeon feels this is feasible based on your scan findings and your age. Rotator cuff repair surgery can be done by keyhole surgery and your torn tendon is secured back onto the bone to allow it to heal. The recovery period involves 4-6 weeks in a sling and a graduated return to normal function. The outcomes are very good in terms of patient satisfaction. The chance of your repaired tendon healing fully depends primarily on your age, but also the nature of your tear. Patients over 70yrs old have limited capacity to heal their degenerate torn tendons; so many patients older than this do not choose to have their tendon repaired.
3) Shoulder arthritis
What is it: Arthritis of the shoulder occurs when the smooth cartilage lining of the ball (humeral head) and socket (glenoid) joint wears out. The worn surfaces can then grind on each other causing pain and stiffness.
Symptoms: Deep-seated constant ache that develops gradually. The pain is made worse by movement, often with a feeling of grinding. The pain can become very severe and interrupt sleep. The combination of pain and stiffness may make it difficult to carry out simple activities of daily living.
Diagnosis: An x-ray will diagnose this problem. If you require surgery, a CT scan may be needed to allow accurate planning of your joint replacement.
Treatments: Painkillers and anti-inflammatories (topical gel or tablets) may help control your pain and most patients have modified their activities already by the time they see a doctor. Steroid (cortisone) injection into the shoulder joint may provide temporary relief, but repeated injections work less well. Physiotherapy may help you maintain function in early degeneration, but it cannot reverse the underlying process and is often painful in advanced arthritis. Shoulder replacement is the definitive solution for patients with arthritis symptoms that cannot be controlled by non-operative treatment. In shoulder replacement surgery your worn-out joint surfaces are removed and replaced by precision-engineered metal and plastic components. The surgery requires a 10-15cm scar over the front of your shoulder and most patients stay in hospital for two or three days. There are two main types of total shoulder replacement – anatomic (ball and socket the normal way round) and reversed (ball and socket are switched). If your rotator cuff is functional, you will probably be offered an anatomic replacement. If your rotator cuff has failed, then you will do better with the reversed option, as this is designed to allow for a deficient rotator cuff. Outcomes for shoulder replacement are very good. 85% of patients will be very satisfied with significantly improved pain and function by six months. 90% of replacements will last more than 10 years.
4) Subascromial Bursitis/rotator cuff tendinopathy/impingement
What is it: The rotator cuff tendons move in a relatively narrow ‘subacromial’ space. The roof of this space is formed by bone and ligament. The space itself contains a very thin, low friction ‘pouch’ called the bursa, which allows smooth gliding of the rotator cuff beneath it. In bursitis, this tissue becomes inflamed and thickened and causes pain. Sometimes, spurs of bone and thickened ligaments exacerbate the rubbing. The problem probably begins with degeneration (tendinopathy) of the rotator cuff tendons, which then causes the inflammation. Bursitis can be aggravated by poor shoulder posture and muscle control in the shoulder.
Symptoms: Pain, usually an aching sensation that comes on gradually and is typically felt over the upper outer arm. It is made worse by reaching away from the body or behind the back. It is common to feel pain at night making it difficult to sleep.
Diagnosis: Your symptoms and clinical examination will be suggestive. Your surgeon may order and x-ray and either an Ultrasound or MRI scan to check that the tendons are intact.
Treatments: Most patients with bursitis can improve with a combination of a cortisone injection and an exercise-based physiotherapy program. If these treatments fail, then keyhole surgery (arthroscopic subacromial decompression) involves removing the inflamed bursal tissue with release of the tight ligament and removal of the thickened bone. Often other structures in the shoulder are also painful and these can be addressed at the same time if required (e.g. Acromioclavicular joint).
5) Shoulder instability
What is it: The shoulder joint comprises a ball and a shallow socket surrounded by soft tissues, which includes the capsule lining the joint, ligaments and the rotator cuff muscles. The shallow joint design allows great flexibility in movement, but renders it vulnerable to dislocation. When the shoulder dislocates it tears tissues attached to the rim of the socket, dents or chips off bone and stretches the ligaments of the joint. The majority of dislocations occur in contact sport (e.g. rugby tackle), but occasionally other problems cause instability.
Symptoms: An acute traumatic dislocation is normally obvious and you should go to your local Emergency department to have your shoulder put back into its socket. A ‘subluxation’ means a partial dislocation and this normally relocates itself. After your shoulder has been relocated you should wear a sling for a week and then begin therapy to regain control and motion in your shoulder. If your shoulder dislocated after an acute injury, then you should be referred to a shoulder surgeon. This is because there is a high risk of recurrence of instability, especially in sports-playing adolescents and young adults (under 25 years old). If you do re-dislocate, each time you will cause more damage to your joint. If you are a little older (over 40), you are likely to have injured your rotator cuff and may need surgery to repair this.
Diagnosis: Acute dislocation is diagnosed with examination and x-rays. You will have another x-ray after your shoulder has been relocated. Later on, your shoulder surgeon may order a special MRI (MRI arthrogram) as this is the best test to assess the structural injuries inside the shoulder to help plan treatment. Occasionally a CT is required if you have suffered bony injury.
Treatments: Physiotherapy is helpful to regain control, mobility and strength of the shoulder. Keyhole surgery (arthroscopic Bankart/labral repair) may be considered after the initial episode of dislocation in those with a high risk of re-dislocation, or if the shoulder repeatedly dislocates. Keyhole Surgery can also be used to treat patients whose shoulders feel unstable but do not fully dislocate. Some patients require a bony reconstruction operation (Latarjet procedure) to address the damage inside their shoulder. This involves a 5-7cm scar over the front of the shoulder. A piece of bone near the shoulder joint is moved to reconstruct the bony defects created by the dislocations. The surgical recovery involves 4-6 weeks in a sling and a graduated therapy-led return full function. Outcomes are very good, with approximately 90% regaining stability.
Don’t suffer with your shoulder! Book an appointment today to discuss your shoulder problems. Simply call us on 01753 665 404 or contact us firstname.lastname@example.org.