Table 4
Problem Non-operative Operative Treatment
Instability External rotation splint Surgical stabilisation
Stiffness Wait 2.5 years Arthroscopic capsular release
Impingement Corticosteroid injection Arthroscopic acromioplasty
Rotator cuff tear Surgical repair
AC joint pain Corticosteroid injection Distal clavicle excision
Arthritis NSAIDs Total shoulder replacement

Impingement syndrome, subacromial bursitis.

  • 1. Avoid overhead activities.
  • 2. A single injection of corticosteroid and local anaesthetic into the subacromial space. The position of insertion of the needle is 1 cm medial and 1 cm inferior to the postero-lateral corner of the acromion. The needle should be directed upwards towards the anterior edge of the acromion. Redirect the needle downwards if it hits the bone or upwards if it hits tendon. The solution for injection should include a corticosteroid (eg 1 ml of Depo-Medrol 40 mg/ml) and 5-10 ml of local anaesthetic (eg 1% lidocaine).
  • 3. Once the pain has settled down, usually at 3-4 weeks, institute a rehabilitation exercise regime focussing on external rotation power and endurance.
  • 4. If non-operative measures fail, then referral for arthroscopic acromioplasty. Our experience is that the first injection of corticosteroid is the most helpful, and that the response from subsequent injections reduces by 50% on each further injection. I would not recommend more than three injections of corticosteroid to a given area.

Calcific Tendonitis : If identified early, the calcific material can be aspirated under ultrasound guidance. We have found ultrasound-guided arthroscopic removal of calcific material to be a very effective way of resolving the problem. After anaesthesia we use ultrasound to place a needle within the calcific material. We are able to follow the needle into the calcific material and then suck it out with a shaver. Sometimes there is a small hole in the tendon at the end of the procedure in which case, if it is large enough, we will repair it arthroscopically as per arthroscopic rotator cuff repair. If it is small enough then it usually does not need to be repaired. [Calcific Tendonitis brochure]

Rotator Cuff Tear : Partial thickness tears are initially treated as per impingement with a corticosteroid injection in the subacromial space followed by rehabilitation.Fill thickness tears enlarge with time and I recommend early surgical repair.Arthroscopic repair. Technological advances are making it easier and easier to repair rotator cuffs as half day cases under regional anaesthesia. The tear is repaired through keyholes using sutures and suture anchors (small metal anchors that go into bone and stay there permanently. Sometimes the tear is too big to fix by direct repair, in which chase I bridge the defect with a synthetic patch, again [ Rotator Cuff Tear brochure ]

Cuff Tear Arthropathy : Chronic rotator cuff tears sometimes lead to secondary glenohumeral joint arthritis – a syndrome called “cuff tear arthropathy”. Treatment of “cuff tear arthropathy” is not straightforward; however, replacing the shoulder with a special type of shoulder replacement reverse total shoulder can be helpful in reducing pain and improving hands.

reverse tsr1
biceps rupture

Biceps Rupture : Rupture of the long head of biceps in the bicipital groove can be treated with benign neglect, ie return to full activities as soon as pain persists. The only significant adverse sequelae is the cosmetic deformity of a “pop-eye” sign. Elbow flexion strength is rarely affected, however patients may loose power of supination (eg using a screwdriver). Distal biceps rupture in a young individual is more problematic and early surgical repair should be considered.

Arthritis : The treatment for arthritis is the same as those for other joints. Early on, non-steroidal anti-inflammatory agents are helpful. In the later stages a shoulder replacement is a very effective means of improving pain. As arthritis is less frequent in the shoulder than in the hip or knee, total shoulder replacement is performed less frequently than hip and knee replacements. Most shoulder surgeons would perform between 10 and 20 shoulder replacements a year. Fortunately the rate of revision is very low. The one exception being for cuff deficient shoulders. If a glenoid component is placed in a rotator cuff deficient shoulder the abnormal upward forces placed on the glenoid will induce it to “rock free”. For this reason, reverse total shoulder – are usually used for rotator cuff deficient shoulders

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capsular-release-300x225

Frozen Shoulder : The natural history of idiopathic adhesive capsulitis is that it will resolve on its own over two-and-a-half years. One option is, therefore, to wait it out as it will always get better. Non-interventional modalities including physiotherapy, drugs and injections have not been shown to improve the outcome of frozen shoulder1. An alternative approach is an arthroscopic capsular release. This is a procedure where the thickened capsule is divided under direct vision in a circumferential manner around the glenoid. This effective procedure is performed under interscalene block as a day-case. It restores range of motion and removes pain immediately. It is important to combine the surgery with an aggressive post-operative rehabilitation program to maintain motion2.[ Frozen Shoulder brochure ]

AC Joint : Arthritis of the AC joint can be effectively treated with a single local anaesthetic – corticosteroid injection into the joint, usually under x/ray or ultrasound control. If this works, then recurs, then the current surgical procedure available is a distal clavicle excision.

Instability : The patient presenting in middle age with a shoulder dislocation should be carefully evaluated for a tear or an avulsion fracture of the rotator cuff. Test for supraspinatus weakness, perform an xray and if concerned an ultrasound. If there are no tendon injuries or fractures, patients who are advancing in age, particularly those over 40 should be managed non-operatively as the shoulder becomes tighter in this age group and recurrence rates are low, when treated conservatively.

In younger age groups (17-40 years) recurrence rates are high. A newly identified principle of non-operative treatment of shoulder instability is to avoid using a sling6. Placing the arm in internal rotation will open up the Bankart lesion and increase recurrence rates4. If immobilization is to be considered, then the arm should be placed in external rotation in an external rotation pillow or brace

(http://www.ori.org.au/bonejoint/shoulder/ssfd.htm) as this will force the Bankart lesion to re-appose to the glenoid neck6.

The ease and technology for repairing Bankart lesions has advanced significantly. The detached labrum can be reattached using suture anchors – that lodge in bone with sutures attached that can be passed through the labrum and capsule to reattach it to the anterior and inferior glenoid margins. The procedure can be performed arthroscopically under local anaesthetic as a day case, with minimal morbidity. [ Instability brochure ]

instability repair

Multi-Directional Instability : Multidirectional instability is a problem of capsular laxity, and is particularly prevalent in young girls. The first line management is a rehabilitation program focussing on scapular control and rotator cuff strengthening. The condition does improve with age. Sports that involve repetitive overhead activities (eg swimming) are more difficult for athletes with multidirectional instability. Surgical techniques to reduce the volume of the shoulder capsule are well established, however, the results are not as successful as those for acute traumatic anterior instability.

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