1. What is the shoulder?
The shoulder is the most mobile and probably the most complex joint in the human body because it is inherently unstable (glenohumeral joint); the complex interaction of the labrum, ligaments and rotator cuff muscles confer stability or resistance to dislocation. It is comprised of 4 separate joints, 3 bones and a total of 4 muscles (Rotator Cuff) are directly involved in its movement; apart from the rotator cuff, 17 other muscles are also secondarily involved in shoulder movement. The articulating surfaces of the humeral head and glenoid as well as that of the distal end of the clavicle and acromion are lined with articular cartilage.
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2. What procedures do I need to undergo to diagnose my shoulder problem?
Establishing the exact cause of shoulder pain starts with obtaining a complete history and physical examination. You will be asked to fill-up an evaluation form to objectively determine your functional disability. We usually request for special x-ray views of the shoulder followed by an MRI or CT Arthrography. Some patients may require an EMG-NCV to rule out cervical radiculopathy or entrapment of the Suprascapular nerve (SSN) as the cause of their pain.
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3. What is the Rotator Cuff?
The Rotator Cuff is a group of 4 muscles (subscapularis, supraspinatus, infraspinatus and teres minor) primarily responsible for the movement of the shoulder. Apart from its role as the prime mover of the shoulder, the integrity and contraction of the rotator cuff muscles keeps the humeral head centered on the glenoid and prevents the upward migration of the humerus (arm bone) when raising the arm.
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4. What is Impingement Syndrome?
It is one of the most common causes of shoulder pain. Its hallmark is pain in the arm that is aggravated by lifting objects or applying resistance to arm elevation. The two most common explanations are: 1.) the acromion develops bone spurs projecting downward and thus decreasing the space for the supraspinatus tendon; 2.) the cumulative trauma sustained by the supraspinatus tendon when it hits the acromion whenever the arm is elevated beyond 90°. Both situations lead to pain and inflammation of the supraspinatus tendon that could further lead to the development of rotator cuff tears.
Treatment:
The initial treatment is nonsurgical; consisting of pain medications and rehabilitation but other causes of shoulder pain like rotator cuff tears should first be ruled out. If patients are not responsive to nonsurgical treatment, your doctor may recommend surgery (Arthroscopic Acromioplasty). The surgical treatment aims to make more space underneath the acromion for the head of the humerus to allow pain-free elevation of the arm possible again.
Click here to view an animation of an Arthroscopic Acromioplasty
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5. What is Frozen Shoulder (Adhesive Capsulitis)?
This self-limiting condition is characterized by slow-onset of pain and stiffness with no preceding traumatic episode. Attempts to mobilize the shoulder in any direction by either the patient or another individual will result in severe pain because of the contracted shoulder capsule. It commonly occurs in individuals who are 40-60 years old and in individuals with Diabetes and Thyroid problems. Although this condition is self-limiting, its clinical duration may last up to 24-36 months unless the patient undergoes some form of treatment. Establishing the diagnosis is not so straightforward since other shoulder conditions may present with similar clinical manifestations.
Treatment:
For true cases of Frozen Shoulder, the treatment is non-surgical consisting of pain medications and rehabilitation. Steroid injections may be of help during its initial stage. Previously, patients who fail to recover their shoulder mobility were treated with shoulder manipulation that is performed under sedation. In developed countries, the practice of shoulder manipulation is being abandoned because of its propensity to produce uncontrolled capsular tears, rotator cuff tears and it could sometimes result in fractures of the humerus.
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6. What are Rotator Cuff Tears?
They are disruptions in the continuity of any of the 4 rotator cuff muscles which maybe traumatic or degenerative (age-related which is increasingly seen in patients 40 y/o and older). The supraspinatus is the most commonly torn muscle and the symptoms felt by patients vary from severe pain and functional disability to no symptoms whatsoever. These tears usually present as avulsion of the tendon from its bony attachment (degenerative) or tears within the tendon substance (traumatic); whichever the patient has, these tears are not known to heal spontaneously.
Treatment:
Pain relief and a reasonable level of functional recovery can be achieved thru physical rehabilitation for patients with rotator cuff tears. The patient should realize however that the natural course of these tears is to grow larger and eventually set the stage for the other rotator cuff muscles to tear as well. The most recent scientific evidence showed that patients with rotator cuff tears who did not undergo surgical repair risk the progression of repairable tears to irreparable tears accompanied by significant degenerative joint changes within 4 years.
The consensus among the leading shoulder experts in Europe and North America is to repair rotator cuff tears utilizing the least invasive means possible. There are 3 possible techniques to attain rotator cuff repair namely: Open, Mini-open and Arthroscopic. Open is the classical technique, Arthroscopic is the minimally-invasive approach while Mini-open is the intermediate approach. Arthroscopic rotator cuff repair is preferred over the older techniques because it allows the surgeon to treat all coexisting pathologies with the same small incisions and lastly, the incidence of post-operative adhesions is significantly less.
Click here to view an
animation of an Arthroscopic Rotator Cuff Repair
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7. What is Biceps Tendon Instability?
Biceps tendon instability is a condition wherein the soft tissue restraint of the long head of the biceps tendon is damaged. They usually present with a painful click and tenderness of the shoulder. It is present in up to 40% of patients with rotator cuff tears and is one of the most common causes of painful clicks in the shoulder.
Treatment:
Patients with biceps tendon instability need to undergo biceps tenodesis and since they usually present with rotator cuff tears, they are simultaneously addressed during rotator cuff repair. Biceps tenodesis involves the transfer of the origin of the biceps tendon from the top of the glenoid to the humeral head.
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8. What is Cuff Tear Arthropathy?
Cuff Tear Arthropathy is a special form of shoulder arthritis. It is the consequence of long standing rotator cuff tears marked by stiff upward migration of the humerus accompanied by changes in the humeral head and acromion. This condition is not amenable to rotator cuff repair; the treatment of choice is Reverse Shoulder Arthroplasty that is not yet available in Asia.
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9. What is Shoulder Dislocation?
Shoulder dislocation is the painful dislodgement of the humeral head from its socket (glenoid) secondary to trauma. As we have mentioned earlier, the shoulder is inherently unstable and the ligaments, labrum and rotator cuff muscles confer stability when the shoulder dislocates, we can expect to see some damage in the stabilizing structures. In young patients, (<30y/o) dislocations tend to produce tears in the ligaments and the labrum while in older patients they tend to produce rotator cuff tears. Most shoulder dislocations are anterior but they could also occur in other directions.
Treatment:
Shoulder dislocation is an orthopaedic emergency and immediate reduction should be performed as soon as it is recognized; patients may have to be sedated to facilitate reduction. After reduction, the patient will wear an arm sling for 2 weeks before resuming their normal daily activities. Current scientific evidence supports the operative treatment of first-time dislocators because dislocations may recur in up to 95% of cases if it happens in patients less than 25 years of age. Arthroscopic treatment is preferred over open techniques because arthroscopy allows the surgeon to thoroughly examine and treat other concomitant shoulder pathologies.
Click here to view an
animation of an Arthroscopic Bankart Repair
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10. What are the long-term consequences of shoulder dislocations?
Patients who have suffered from more than 10 shoulder dislocations are at risk for the ff: 1) attenuated or absent labrum, 2) stretched-out ligaments, 3) deforming their glenoid (shoulder-socket) & humeral head and 4) develop early shoulder osteoarthritis. Patients with severe anatomic abnormalities are not amenable to Arthroscopic Reconstruction; they need to undergo a Latarjet procedure that involves the transfer of the coracoid bone to reinforce the glenoid.
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11. What is a SLAP Tear?
SLAP tears are avulsions of the attachment of the biceps tendon inside the shoulder joint. The exact mechanism why these lesions occur is still unknown but shoulder experts agree that lack of shoulder flexibility plays a big role in its pathogenesis. Patients with SLAP tears present with pain and often complain of their arm just falling-dead after forceful throwing activities. They are common in baseball pitchers, tennis and badminton players.
Treatment:
SLAP tears can only be treated arthroscopically due to their deep anatomical location. SLAP tears were virtually unknown prior to the advent of shoulder arthroscopy.
Click here to view an
animation of an Arthroscopic SLAP Tear Repair
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12. What are the conditions that affect the AC Joint?
The two most common AC Joint conditions are AC Joint Dislocation and AC Joint Arthritis. AC Joint Dislocation is the traumatic separation of the clavicle and the acromion; depending on the severity of the dislocation, some or all of the supporting ligaments of the AC Joint can be torn. AC Joint Arthritis is a degenerative condition of the AC Joint characterized by loss of articular cartilage in the articulating surfaces of the acromion and the clavicle; it is common in heavy manual laborers and in persons who have suffered from an AC Joint dislocation.
Treatment:
Patients with an acute AC Joint Dislocation are treated with an Arthroscopic Weaver-Dunn Procedure. We perform this procedure arthroscopically because we believe that the force that produced the dislocation is also sufficient to cause damage inside the shoulder joint and performing the procedure arthroscopically will enable as to address all the problems secondary to the trauma.
Patients with AC Joint arthritis are treated with AC Joint Resection. Arthroscopic resection is preferred than open because other concomitant pathologies can be easily treated if the procedure is done arthroscopically.SLAP tears can only be treated arthroscopically due to their deep anatomical location.
Click here to view an
animation of an Arthroscopic Distal Clavicle Resection
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13. What causes clicking in the shoulder?
Clicking in the shoulder can be secondary to SLAP tears, biceps tendon instability, cartilage abnormalities, subacromial impingement, scapular dyskinesia and AC Joint arthritis. Shoulder clicks only become significant when it is accompanied by pain. It is not uncommon for patients to suffer from 2 or more shoulder pathologies.
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14. What is Shoulder Osteoarthritis?
Shoulder osteoarthritis is a degenerative condition whose hallmark is the loss of articular cartilage and the formation of osteophytes. Articular cartilage is the substance that facilitates the pain-free motion in joints so more advanced stages of osteoarthritis result in more symptoms of pain and stiffness. Shoulder osteoarthritis occurs less frequently when compared to knee or hip osteoarthritis; they are only common in persons who have a history of humeral head fractures, chronic shoulder dislocators and in persons involved in heavy manual labor.
Treatment:
The treatment for early stages of shoulder osteoarthritis is pain relievers and rehabilitation. More advanced stages are best treated with a Hemiarthroplasty or a Total Shoulder Arthroplasty because they are less responsive to conservative measures.
Click here to view an
animation of a Total Shoulder Replacement
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15. What is Suprascapular Nerve Entrapment?
The Suprascapular nerve (SSN) is responsible for the movement of the supraspinatus and infraspinatus muscles. It can be compressed at the area where it enters the scapula (Suprascapular notch) by thickening or calcification of the transverse scapular ligament. Patients with this condition may suffer from dull pain behind the shoulder, scapular dyskinesia or present with muscle wasting of the supraspinatus and infraspinatus muscles.
Treatment:
Patients suspected of having SSN Entrapment are subjected to EMG-NCV studies to document any conduction abnormality in the nerve. Once the diagnosis is established, the patient is advised to undergo arthroscopic release of the SSN. This procedure involves cutting the transverse scapular ligament to relieve the compression and to prevent further damage of the suprascapular nerve.
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16. What are steroid injections?
Steroids are a group drugs that have analgesic (pain-relieving) and anti-inflammatory (anti-swelling) effects. Steroids were previously routinely injected into the shoulder joint to relieve acute shoulder pain that is not alleviated by oral pain medications. Their routine use in the shoulder has fallen out of favor because steroids have been recently proven to weaken tendons that predispose the tendon to spontaneous ruptures.
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17. What can I expect during surgery?
You will be given antibiotics before you are brought to the operating theatre. A pain catheter is placed prior to your operation to facilitate adequate pain relief after your surgery. Shoulder surgery is usually performed under General Anesthesia (asleep) but we could also perform the surgery under Regional Anesthesia (awake) upon request. Depending on your condition, implants may be necessary to accomplish the surgical repair of your problem.
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18. What can I expect after my shoulder surgery?
After shoulder arthroscopy, you can expect significant swelling on your operated shoulder for the first 24 hours. Rehabilitation is generally started the next day and you will be informed about your activity restrictions for the succeeding weeks. You are required to wear either an arm sling or an abduction pillow for a period of 3 to 6 weeks depending on the type of your operation. If non-absorbable sutures were used, they are usually removed 10-14 days after your surgery. You are strongly advised to seek the recommendation of your surgeon before performing any activity progressions.
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