Shoulders
Symptoms
Stiffness
Sometimes shoulders are stiff in all directions, but sometimes it’s specific directions. The pattern gives a clue about the underlying cause. Frozen shoulder is the commonest , and shoulder arthritis is relatively uncommon
Pain
This sometimes tells us where the problem is coming from; For example AC joint pain usually hurts accurately at the joint. On the other hand rotator cuff pain usually hurts part way down the arm , as a consequence of the nerve supply to the muscles and tendons
Instability
The fact that the shoulder is so flexible come out with such an enormous range of movement, puts it at risk of dislocation more than any other joint in the body. Shoulders can also feel unstable even if they don’t fully dislocateNeck pain
Pain arising in your neck may produce symptoms you feel in your shoulder
Trauma
Fractures, ligament tears, dislocations, other injuries
Conditions
Rotator cuff disease, from tendonopathy to massive rotator cuff tear
A lot of so called “impingement” is actually due to a problem with the rotator cuff tendons themselves.
Frozen shoulder
A condition which causes pain and stiffness. We don’t really know what causes it but we know how it behaves. I’m going to be on sudden movements is common , as is interruption of sleep. It used to be thought untreatable, but there are options
Dislocation and instability
Some joints slip a little but some dislocate fully. Some have a soft tissue injury, some a bone problem and some have both. Some are constitutional in hypermobile patients, and some are muscle co-ordination issues. Getting the right diagnosis is critical to advising the right treatment
Calcifying tendonitis
The development of little blobs of calcium in the rotator cuff tendons. Most of the time they sit there just causing a mild ache but as they start to breakdown they can cause absolute agony. Treatable
“impingement”
This word is used to describe lateral arm pain, when the sufferer’s arm is roughly horizontal. In fact true impingement is very rare , and the symptom has many other causes
Subacromial Bursitis
Another cause of “impingement” type pain
Acromio-clavicular joint pain
Pain felt very specifically at the end of the collar bone, typically on reaching overhead or lying on the affected side
Biceps tendonitis
Mostly a gym uses disease, with pain at the front of the shoulder
SLAP tears
A tear of the Superior Labrum Anterior to Posterior . Rare
Conservative Treatments
Confirmation of the diagnosis
Knowledge of the diagnosis it is therapeutic itself
Reassurance
Even surgeons do most of their healing work by talking to patients
Physiotherapy
Physiotherapy plays a large part in the treatment of shoulder conditions. A great many things can be treated by physio alone. I don’t think anything can be treated by surgery alone; everyone who’s had a shoulder operation needs physio
Watch and wait
Some conditions require immediate treatment, but often it’s reasonable to wait and see how things play out. The covid pandemic has taught us that even disabling pathology can improve of it’s own accord
Corticosteroid injection
Steroid injections rarely cure anything, but they facilitate physiotherapy. Hydrodistention for a frozen shoulder is a good example of this
Shockwave
Shockwave treatment stimulates an inflammatory response around calcific tendonitis, stimulating your body’s own mechanism to get rid of the deposit
Surgical Operations
Arthroscopic subacromial decompression
This is an operation for “impingement”. It has become very popular, and recent evidence suggests that it’s become over used. A lot of patients with lateral arm pain will recover with physiotherapy and time, and the number of people who need this operation is actually very smallArthroscopic rotator cuff repair
a rotator cuff tear is actually a detachment. It can be reattached to the bone in a number of ways using small dissolving bone anchors. The surgery takes an hour or two, and full sporting recovery is unfortunately long. Patients continue to improve for about a year
Arthroscopic release of frozen shoulder (arthrolysis)
Most frozen shoulders don’t need surgery , but some are so stiff and so painful, and don’t respond adequately to a steroid injection, that it is the way forward. This operation cuts the tight layer inside the joint
Arthroscopic removal of calcific deposits
Some calcium deposits are too crystalline to be aspirated by a needle, and need be removed in a keyhole operation
Arthroscopic stabilisation
The detached labrum can be reattached using small dissolving bone anchors. A defect at the back of the humeral head can be managed by pinning some overlying rotator cuff tendon into it
Revision rotator cuff repair
Torn rotator cuffs can be difficult to repair, especially when they fail slowly, and like all surgery there is a failure rate. A redo is occasionally necessary
Arthroscopic excision of lateral clavicle
For people whose AC joint pain won’t settle with a steroid injection, and in whom activity modification isn’t working, taking out a small piece of bone usually provides the solution
Open rotator cuff repair
Sometimes the rotator cuff is so badly damaged that it is easier to do a good repair using open techniques.
Find patient guidance at the British Elbow and Shoulder Society web pages:
https://bess.ac.uk/patient-resource-subacromial-shoulder-pain/