Treatment

ProblemNon-operativeOperative Treatment
Instability (traumatic)

Instability (multidirectional)

External rotation splint

Watson-Warby program

Surgical stabilisation PDF

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StiffnessWait 2.5 yearsArthroscopic capsular release PDF

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ImpingementCorticosteroid injectionArthroscopic acromioplasty

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Rotator cuff tearSurgical repair PDF

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AC joint pain

AC joint instability

Corticosteroid injection

Wait and see

Distal clavicle excision

AC stabilisation

Arthritis

Cuff Tear Arthropathy

NSAIDsTotal shoulder replacement video

Reverse total shoulder replacement video

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

Fractures

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 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. 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

 

Idiopathic (“cause unknown”) adhesive capsulitis, commonly known as frozen shoulder, typically resolves naturally over approximately two-and-a-half years. One approach is to simply wait, as the condition generally improves over time. However, it’s noteworthy that non-interventional treatments like physiotherapy, medications, and injections haven’t shown significant efficacy in altering the natural course of frozen shoulder.

 

An alternative treatment option is an arthroscopic capsular release. This procedure involves surgically dividing the thickened capsule around the glenoid under direct vision. Performed under interscalene block as a half day case, this method effectively restores range of motion and alleviates pain immediately. Post-operative rehabilitation is crucial to maintain the regained motion and ensure optimal recovery. This approach offers a more proactive solution for those seeking immediate relief from the symptoms of frozen shoulder.

Frozen Shoulder

Impingement syndrome, subacromial bursitis

 

Initially, it’s crucial to avoid overhead activities that can exacerbate the condition.

 

A key treatment is administering a single corticosteroid and local anaesthetic injection into the subacromial space. This injection, carefully positioned near the acromion, can provide significant relief. The solution typically includes a corticosteroid and local anaesthetic.

 

Once pain subsides, usually within 3-4 weeks, it’s important to start a focused rehabilitation exercise regime. This regime should concentrate on enhancing external rotation power and endurance.

 

If these non-operative measures are unsuccessful, the next step may involve a referral for arthroscopic acromioplasty. It’s noted that the first corticosteroid injection tends to be the most effective, with subsequent injections decreasing in efficacy. Generally, it is not recommended to administer more than three corticosteroid injections to the same area.

Calcific Tendonitis

 

Early identification of calcific deposits is key in their management. Under ultrasound guidance, these deposits can be effectively aspirated. At our clinic, we utilise a technique that involves ultrasound-guided arthroscopic removal of calcific material, which has proven to be very effective. During the procedure, after administering anaesthesia, we use ultrasound to accurately position a needle within the calcific deposit. We then follow the needle’s path to the deposit and remove the calcific material using a shaver. In cases where this results in a notable hole in the tendon, we may perform an arthroscopic repair, similar to a rotator cuff repair, if the hole is sufficiently large. Smaller holes typically do not require repair. This method is precise and minimises tissue damage, enhancing the chances of a swift and successful recovery.

Rotator Cuff Tear

 

Treating partial thickness rotator cuff tears initially involves methods similar to impingement syndrome management, beginning with a corticosteroid injection into the subacromial space, followed by a structured rehabilitation program. In contrast, full thickness rotator cuff tears, known for their tendency to worsen over time, often necessitate early surgical intervention. Modern advancements have streamlined rotator cuff surgeries, making them less invasive and often feasible as half-day procedures under regional anaesthesia. These surgeries typically employ minimally invasive techniques, utilising sutures and suture anchors – small, permanent bone fixtures. For more severe cases, where the tear is too extensive for a direct repair, a synthetic patch might be utilised. 

Rotator Cuff Repair

Cuff Tear Arthropathy

 

At George Murrell Shoulders, we specialise in addressing complex shoulder conditions like chronic rotator cuff tears, which can lead to a condition known as ‘cuff tear arthropathy’, a form of glenohumeral joint arthritis. This condition, while challenging, can often be effectively treated with a specialised surgical procedure known as a reverse total shoulder replacement. This innovative treatment, designed to reduce pain and improve functionality in overhead activities, has shown promising results for patients suffering from advanced shoulder arthritis and rotator cuff degeneration. By opting for a reverse total shoulder arthroplasty, patients can experience significant improvements in mobility and pain relief, particularly in scenarios where conventional shoulder surgeries might not suffice.

Cuff Tear Arthropathy

Biceps Rupture

 

When addressing the rupture of the long head of biceps in the bicipital groove, our approach often involves benign neglect, meaning patients are encouraged to resume full activities as soon as the pain subsides. The primary concern with this condition is the cosmetic “pop-eye” sign, while elbow flexion strength typically remains unaffected. However, patients might experience a decrease in supination power, such as when using a screwdriver. Conversely, a distal biceps rupture, particularly in younger individuals, can be more concerning. In these cases, early surgical repair is often advised to ensure optimal recovery and function. This strategy balances the need for minimal intervention in less severe cases with the benefits of surgery in more serious ruptures, focusing on patient-specific treatment and recovery.

Biceps Rupture

Arthritis

 

Arthritis treatment in the shoulder, similar to other joints, starts with non-steroidal anti-inflammatory drugs (NSAIDs) in the early stages. For advanced arthritis, shoulder replacement surgery proves to be a highly effective method for pain relief. While arthritis in the shoulder is less common compared to the hip or knee, total shoulder replacement is still a valuable option for those in need. These surgeries have a low rate of revision, except in cases of cuff deficient shoulders. In such scenarios, abnormal forces on the glenoid component can cause instability, making reverse total shoulder replacements a preferred option. This approach, tailored for rotator cuff deficient shoulders, addresses the unique challenges posed by this condition.

Shoulder Arthritis