Treatment

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 traumatic 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 as this will force the Bankart lesion to re-appose to the glenoid neck

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.

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. 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.

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 shoulder.

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.

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.

Rotator Cuff Tear

Partial thickness tears are initially treated as per impingement with a corticosteroid injection in the subacromial space followed by rehabilitation. Full thickness tears enlarge with time and I recommend early surgical 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 case I bridge the defect with a synthetic patch.

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 overhead activities.

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.

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.