The shoulder is the most mobile joint in the body. It has a very wide range of motion due to its anatomy which consists more of muscular restraint versus boney restraint. It functions as a ball and socket joint but has a shallow socket. It relies on multiple muscles around the shoulder for its stability. For this reason, it is the most frequently dislocated joint. Shoulder problems tend to be more common in physical laborers as well as overhead athletes. Shoulder pain can also occur due to overuse injuries such as rotator cuff tears.
The rotator cuff is a major group of tendons in the shoulder joint providing support and enabling a wide range of motion. Major injury to these tendons can result in a tear know as a rotator cuff tear. It is one of the most common causes of shoulder pain in middle aged adults and older individuals. It may occur with repeated use of arm for overhead activities, while playing sports or during motor accidents. Rotator cuff tear causes severe pain, weakness of the arm, and crackling sensation on moving shoulder in certain positions. There may be stiffness, swelling, loss of movements, and tenderness in the front of the shoulder.
Rotator cuff tear is best viewed on magnetic resonance imaging. Symptomatic relief may be obtained with conservative treatments – rest, shoulder sling, pain medications, steroidal injections and certain exercises. However surgery is required to fix the tendon back to the shoulder bone. Rotator cuff repair may be performed by open surgery or arthroscopic procedure. In arthroscopy procedure space for rotator cuff tendons will be increased and the cuff tear is repaired using suture anchors. These anchor sutures help in attaching the tendons to the shoulder bone. Following the surgery you may be advised to practice motion and strengthening exercises.
Shoulder impingement is also called as swimmer’s shoulder, tennis shoulder, or rotator cuff tendinitis. It is the condition of inflammation of the tendons of the shoulder joint caused by motor vehicle accidents, trauma, and while playing sports such as tennis, baseball, swimming and weight lifting.
Individuals with shoulder impingement may experience severe pain at rest and during activities, weakness of the arm and difficulty in raising the hand overhead. X-rays and MRI scans show the injury and inflammation. Shoulder impingement can be treated with rest, ice packs, anti-inflammatory drugs, and avoiding the activities involving the shoulder. Physical therapy may be advised to strengthen the muscles and steroid injections may be given if pain persists. Arthroscopic surgery is recommended if the rotator cuff tendons are torn and to remove the bony spurs.
Frozen shoulder is a condition that limits shoulder movements because of pain and inflammation. It is also called adhesive capsulitis and may progress to where an individual may find it very hard to move the shoulder. It is more common in older adults aged between 40 and 60 years and is more common in women than men.
Frozen shoulder is caused by inflammation of the ligaments holding the shoulder bones to each other. The shoulder capsule becomes thick, tight, and stiff bands of tissue called adhesions may develop. Individuals with shoulder injury, shoulder surgeries, shoulder immobilized for long periods of time, other disease conditions such as diabetes, hypothyroidism, hyperthyroidism, Parkinson’s disease and cardiac diseases are at risk of developing frozen shoulder.
Frozen shoulder may cause pain and stiffness and limit the movements of shoulder. Condition can be diagnosed by the presenting symptoms and radiological diagnostic procedures such as X-rays or MRI scans. Treatment for frozen shoulder includes nonsteroidal anti-inflammatory drugs and steroid injections for pain, treatment of underlying risk factors, and shoulder arthroscopy surgery. During surgery, the scar tissue will be removed and tight ligaments, if any, will be dissected. Following surgery physical therapy will be advised to bring full range of motion and strengthen the muscles.
The surgery is performed under sterile conditions in the operating room under spinal or general anesthesia. An incision is made over the affected shoulder to expose the shoulder joint. The upper arm bone (Humerus) is separated from the glenoid socket of the shoulder blade (Scapula). The humeral head which is arthritic is cut off. The surgeon concentrates on the glenoid (socket). The arthritic part of the socket is removed and prepared to take the glenoid component. The glenoid component is then pressed into the socket. The upper arm bone is prepared to take the new humeral component. The humeral component is then inserted into the upper arm bone. This may be press fit relying on the bone to grow into it or cemented depending on a number of factors such as bone quality and surgeon’s preference. The humeral head component is then placed on the humeral stem. This component is made of metal. The artificial components are fixed in place. The Joint capsule is stitched together. The muscle and tendons are then repaired and the skin is closed.
Shoulder instability is a chronic condition that causes frequent dislocations of the shoulder joint. A dislocation occurs when the end of the humerus (the ball portion) partially or completely dislocates from the glenoid (the socket portion) of the shoulder. A partial dislocation is referred to as a subluxation whereas a complete separation is referred to as a dislocation. The common symptoms of shoulder instability include pain with certain movements of the shoulder; popping or grinding sound may be heard or felt, swelling and bruising of the shoulder may be seen immediately following subluxation or dislocation. Visible deformity and loss of function of the shoulder occurs after subluxation or sensation changes such as numbness or even partial paralysis can occur below the dislocation as a result of pressure on nerves and blood vessels.
The risk factors that increase the chances of developing shoulder instability include:
- Injury or trauma to the shoulder
- Falling on an outstretched hand
- Repetitive overhead sports such as baseball, swimming, volleyball, or weightlifting
- Loose shoulder ligaments or an enlarged capsule
Arthritis comes in several varieties.
Osteoarthritis (Degenerative Joint Disease)
This is an age-related “wear and tear” type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones of the shoulder softens and wears away. The bones then rub against one another. Over time, the shoulder joint slowly becomes stiff and painful.
Unfortunately, there is no way to prevent the development of osteoarthritis. It is a common reason people have shoulder replacement surgery.
This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed “inflammatory arthritis.”
This can follow a serious shoulder injury. Fractures of the bones that make up the shoulder or tears of the shoulder tendons or ligaments may damage the articular cartilage over time. This causes shoulder pain and limits shoulder function.
Rotator Cuff Tear Arthropathy
A patient with a very large, long-standing rotator cuff tear may develop cuff tear arthropathy. In this condition, the changes in the shoulder joint due to the rotator cuff tear may lead to arthritis and destruction of the joint cartilage.
Avascular Necrosis (Osteonecrosis)
Avascular necrosis is a painful condition that occurs when the blood supply to the bone is disrupted. Because bone cells die without a blood supply, osteonecrosis can ultimately cause destruction of the shoulder joint and lead to arthritis. Chronic steroid use, deep sea diving, severe fracture of the shoulder, sickle cell disease, and heavy alcohol use are risk factors for avascular necrosis.
A severe fracture of the shoulder is another common reason people have shoulder replacements. When the head of the upper arm bone is shattered, it may be very difficult for a doctor to put the pieces of bone back in place. In addition, the blood supply to the bone pieces can be interrupted. In this case, a surgeon may recommend a shoulder replacement. Older patients with osteoporosis are most at risk for severe shoulder fractures.
Failed Previous Shoulder Replacement Surgery
Although uncommon, some shoulder replacements fail, most often because of implant loosening, wear, infection, and dislocation. When this occurs, a second joint replacement surgery — called a revision surgery — may be necessary.
Every year, thousands of conventional total shoulder replacements are successfully done in the United States for patients with shoulder arthritis. This type of surgery, however, is not as beneficial for patients with large rotator cuff tears who have developed a complex type of shoulder arthritis called “cuff tear arthropathy.” For these patients, conventional total shoulder replacement may result in pain and limited motion, and reverse total shoulder replacement may be an option.
A conventional shoulder replacement device mimics the normal anatomy of the shoulder: a plastic “cup” is fitted into the shoulder socket (glenoid), and a metal “ball” is attached to the top of the upper arm bone (humerus). In a reverse total shoulder replacement, the socket and metal ball are switched. The metal ball is fixed to the socket and the plastic cup is fixed to the upper end of the humerus.
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Overhand throwing places extremely high stresses on the shoulder, specifically to the anatomy that keeps the shoulder stable. In throwing athletes, these high stresses are repeated many times and can lead to a wide range of overuse injuries.
Although throwing injuries in the shoulder most commonly occur in baseball pitchers, they can be seen in any athlete who participates in sports that require repetitive overhand motions, such as volleyball, tennis, and some track and field events.
SLAP tears are also common amongst athletes. A SLAP tear is an injury to the labrum of the shoulder, which is the ring of cartilage that surrounds the socket of the shoulder joint. The term SLAP stands for Superior Labrum Anterior and Posterior. In a SLAP injury, the top (superior) part of the labrum is injured. This top area is also where the biceps tendon attaches to the labrum. A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. The biceps tendon can be involved in the injury, as well.
A shoulder separation is not truly an injury to the shoulder joint. The injury actually involves the acromioclavicular joint (also called the AC joint). The AC joint is where the collarbone (clavicle) meets the highest point of the shoulder blade (acromion). The most common cause for a separation of the AC joint is from a fall directly onto the shoulder. The fall injures the ligaments that surround and stabilize the AC joint.
If the force is severe enough, the ligaments attaching to the underside of the clavicle are torn. This causes the “separation” of the collarbone and wingbone. The wingbone actually moves downward from the weight of the arm. This creates a “bump” or bulge above the shoulder.
The injury can range from a little change in configuration with mild pain, to quite deforming and very painful. Good pain-free function often returns even with a lot of deformity. The greater the deformity, the longer it takes for pain-free function to return.
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