Shoulder Joint Conditions - Arthroscopy, Dislocation, Fracture, Treatment
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Shoulder Joint Conditions

Dr.Surya Rao Poodipeddi profile Authored by Dr.Surya Rao Poodipeddi on 19 Apr 2014 - 14:48.

Continuing from the article, Shoulder Joint: The most flexible joint, which is actually part I, this article deals with treatment of shoulder joint injuries in part II

Arthroscopy is the next alternative, if conventional treatments with anti-inflammatory drugs, rest and physiotherapy including application of ice and heat have not yielded any substantial relief.

Arthroscopy is both diagnostic and a curative procedure for any injury or tear(s) in the rim of the glenoid cavity or the tendon of the biceps muscle. However, the physician will recommend arthroscopic surgery only after a final diagnosis has been arrived at.

When is a total shoulder joint replacement required?

Total shoulder replacement, also known as total shoulder arthroplasty (TSA), may be required to relieve severe pain occurring due to the stiffness caused by arthritis or degenerative joint disease. A shoulder replacement surgery can not only relieve pain, but also restore motion, strength, function and help patients to restore their daily activities and also get back to their personal fitness programs like yoga, pilates etc.

The surgery involves replacing the damaged humeral head (or joint “ball”) with a metal ball, and putting a new smooth plastic surface on the glenoid (called the “socket”). Metal on plastic surfaces is the hallmark of virtually all shoulder replacement implant systems. At times partial shoulder replacement may also be done with certain severe shoulder fractures of the humeral head. This technique requires the replacement of the ball component only.

During arthroscopy the doctor will first asses the area and extent of involvement. If the injury is confined only to the rim without involving the tendon the shoulder is considered stable. In such cases the surgeon will simply remove the torn flap and correct any other problems associated with the injury.

If the tear extends to the biceps tendon with or without any detachment the result is an unstable joint, in such cases the surgeon repairs the torn structures and reattaches the tendon if detached, using absorbable tacks, wires or sutures.

Tears below the middle of the socket are also associated with shoulder instability. The surgeon has to re-attach the ligament and tighten the shoulder socket by folding over and pleating the tissues.

Post-operative treatment consists of keeping the shoulder in a sling for about 3 to 4 weeks. The surgeon advises gentle and passive pain free range of motion exercises. Once the sling is removed, it is important to start motion flexibility exercises and gradually start to strengthen the biceps muscle. Those who are athletes should follow sports-specific exercises  after six weeks and be prepared  for long rehabilitation since it takes three to four months for complete healing of the shoulder. 

The most common conditions affecting the shoulder joint are:

  • Dislocation of the shoulder
  • Fracture neck of the humerus

Dislocation of the shoulder: The shoulder joint is the body’s most mobile joint with an ability to turn in many directions. However, this advantage makes the joint most vulnerable for dislocations.

If the dislocation is partial we call it as sublaxation where the head of the humerus (upper arm bone) is partially out of the socket (glenoid).

In case of complete dislocation the head of the humerus is all the way out. Whether partial or complete a dislocated shoulder causes pain and unsteadiness in the shoulder. There may be spasm in the muscles which increases the pain. When dislocation happens often we call it as habitual dislocation of the shoulder which might need surgical correction. The main symptoms of a shoulder dislocation include swelling, weakness and bruising. Sometimes the dislocation may tear the ligaments or the tendon in the shoulder. Once in a while there may be injury to the nerves.

The shoulder may dislocate forward (anterior dislocation) backward (posterior dislocation) or downwards (inferior dislocation). Anterior dislocation is the commonest amongst the three where the humerus moves forwards and out of its socket giving a bulge in the front. This occurs when the arm is in a throwing position (like in the sports of throwing a javelin or shot-put).

Treatment: A doctor can often spot the diagnosis. When in doubt an X-ray of the joint confirms the condition. Treatment involves reducing the dislocation when the dislocated head is put back in its position which reduces the pain instantly. After reduction you may need to apply a sling for immobilizing the joint for some time to avoid a relapse.

Fracture of the neck of the Humerus:

The upper arm bone is called the humerus. It has a shaft and two ends. The upper end forms the shoulder joint and has a head which joins the shaft through the neck. The lower end forms the elbow joint with the help of the upper ends of the bones of the forearm.

Fracture of the neck of the humerus is often caused by falling on an outstretched hand or a direct impact on the shoulder. It is often seen in young adults, adolescents and the elderly. The fracture may be simple without any displacement which can be corrected with an arm sling and resting the joint for 2 to 3 weeks.

Sometimes the fractured ends may be displaced. If the displacement is beyond 1 cm or it is also accompanied by a dislocation, surgical correction is done followed by the usual immobilization and rest to the joint for a prolonged period.

What causes shoulder joint pain?

A number of factors and conditions can contribute to shoulder pain. The most prevalent cause is rotator cuff tendinitis characterized by inflamed tendons.

Shoulder pain can also result with some of the instances such as:

  • An injury to another part of your body, usually the neck or bicep. This is known as referred pain. Referred pain generally doesn’t get worse when you move your shoulder.
  • An impingement syndrome is where the rotator cuff gets caught between the acromium (part of the scapula that covers the ball) and humeral head (the ball portion of the humerus).
  • Several forms of arthritis, torn cartilage, or a torn rotator cuff. Swelling of the bursa sacs (which protect the shoulder) or tendons can also cause pain.
  • Development of bone spurs, which are bony projections that develop along the edges of bones.
  • Pinching of a nerve in the neck or shoulder, or breaking a shoulder or arm bone, are also causes of pain.
  • A frozen shoulder caused by stiffness of tendons, ligaments, and muscles making it difficult or impossible to move.
  • Shoulder dislocation caused by injury due to overuse of the shoulder. It happens when the ball of the humerus gets pulled out of the shoulder socket.
  • Serious conditions such as a spinal cord injury or a heart attack may also lead to shoulder pain.

Other conditions affecting the shoulder joint include:

  • Rotator cuff injuries: The shoulder joint is surrounded by four muscles and their tendons. These are collectively called as rotator cuff. Any of the four muscles may get injured leading to a tear, often seen among tennis players, swimmers and weight lifters. Definite diagnosis of this condition is through MRI of the shoulder. Treatment is done by exercising the joint and physiotherapy.
  • Bursitis & tendonitis can occur in the space between the rotator cuff and the bone. Sometimes calcium may get deposited leading to calcific tendonitis. Treatment depends on the cause and severity of the problem.
  • Osteoarthritis, rheumatoid arthritis and arthritis due to trauma are some of the conditions that can affect the shoulder joint. Treatment again depends on the cause and extent of involvement.
  • Acromio-clavicular or AC joint is a part of the shoulder joint which may have a separation leading to AC separation that may cause severe pain and restrict shoulder joint movements.
  • ​Since the clavicle is a part of the shoulder joint any fracture in the clavicle (the collar bone) will indirectly affect the shoulder movements until the fracture is attended to through cuff and collar sling.

Frozen shoulder is a condition in which the shoulder is painful to move and the movement is often completely restricted. There is another condition called Painful Arc in which only certain movements of the shoulder are painful. In Painful arc the patient is able to move the arm away from the body up to a point at which pain starts and continues as the arm is moved further out. As soon as the arm moves out of the painful range the pain disappears and the arm can be moved normally until the arm is above the head. Patients therefore try to move the arm in a different direction to avoid pain.

To begin with, a frozen shoulder starts as a painful shoulder in which a movement is still possible but the range of movements is grossly restricted. Though the pain reduces over a period of 6 to 9 months the stiffness in the joint gradually increases. The characteristic feature of a frozen shoulder is that the pain subsides but the stiffness remains. The main cause for this condition is thought to be due to inflammation of the lining of the shoulder joint. It commonly affects those who have diabetes where there is a deposit of an abnormal protein in the synovial lining of the joint.

Painful arc on the other hand may arise by itself or after a recognized injury to the shoulder. It may also occur as a result of number of underlying problems which include inflammation of the muscles that move the arm away from the body, a tear in the muscle due to injury or as a result of arthritis in the joint between the collar bone and the shoulder blade.

Treatment for both frozen shoulder and painful arc includes pain killers, physiotherapy and shoulder exercises. In cases with severe pain intra-articular (Injection within the joint) injections of steroids gives instant relief but only to recur after some time. If the cause is due to muscle tear use of analgesics followed by exercises and physiotherapy gives good results. Sometimes an anesthetic is injected locally for immediate relief.

Whatever is the cause and extent of involvement, physiotherapy and gradual exercises over a considerable length of time, remains the mainstay of treatment. Surgery is another alternative when other methods fail to give adequate relief.

Sports persons with this problem need a prolonged and graded exercises, physiotherapy, rest and prolonged rehabilitative measures with or without surgery depending on the cause and severity.

Risk factors for developing low back pain:

Besides, the underlying diseases, there may be certain other risk factors raise the risk for low back pain, some of which may including:

Age: Low back pain typically occurs between the ages of 30 and 50, and tends to increase with advancing age, depending on one’s lifestyle. With age, the muscle elasticity and tone decreases, the bone loses its strength   due to bone loss from osteoporosis. This can eventually lead to fractures. The fluid between the vertebrae also decreases with age, thereby reducing the cushion effect between the vertebrae

Weight Gain:Overweight, obesity, or sudden weight gain puts stress on the back and often lead to low back pain.

Low Physical Fitness: Back pain often occurs due to sedentary kind of lifestyle with hardly any physical exercise. This leads to weak back and abdominal muscles that cannot support the spine. A sudden fit of exercises after a long period of inactivity are prone to suffer painful back injuries than people who make moderate physical activity a daily habit. Low-impact aerobic exercises help to maintain the integrity of intervertebral discs.

Pregnancy: During pregnancy, women often complain about low back pain. This is due to the pelvic changes and alterations in weight loading. Back pain normally resolves in the postpartum period.

Occupational hazards: Heavy lifting, pushing, or pulling,  that puts pressure on the spine to twist, can lead to injury and back pain. A poor posture accompanied by inactivity or a desk job that needs sitting all day in a chair with inadequate back support can cause back pain.

Mental stress: Anxiety and depression influences their pain threshold. Stress affects the body in various ways, including causing muscle tension.

Genetic Reasons: ankylosing spondylitis, (fusion of the spinal joints) a form of arthritis that restricts mobility of the spine has a genetic link.

Backpack overload in children: Low back pain is possible in children when using a backpack overloaded with schoolbooks can cause muscle fatigue. The American Academy of Orthopedic Surgeons recommend that a child’s backpack should weigh no more than 15 to 20 percent of the child’s body weight.

 

*Disclaimer: This is not medical advice. The content is for educational purposes only. Please contact your doctor for any health care issues.