Patient Info
At LondonOrtho we provide comprehensive specialist advise, investigation and treatment for all musculoskeletal conditions including sports injuries, fractures, osteoarthritis and rheumatoid arthritis.
At LondonOrtho we provide comprehensive specialist advise, investigation and treatment for all musculoskeletal conditions including sports injuries, fractures, osteoarthritis and rheumatoid arthritis.
CONTACT US
Jackie Barrow
contact@londonortho.co.uk
01494 873252
01494 873252
Isometric Muscle Contraction
This is the contraction of a muscle without movement at the joint. There is no change in length but tension increases.
Isotonic Muscle Contraction
This is the constant loading of a muscle with variable velocity.
Isokinetic Muscle Contraction
A muscle contraction in which a constant joint angular velocity is maintained by accommodating resistance.
Active Assisted Movements
An exercise in which part of the activity is undertaken by a patient and part by the therapist or other equipment eg: walking stick.
Active Movement
A movement performed by a person unaided by any external factor or influence.
Abnormal Movement Pattern
Abnormal movement patterns arise for varied reasons, typically:
Plyometrics
This is an exercise where by eccentric loading of a muscle in a stretch position is followed by powerful concentric shortening. In shoulder rehabilitation this is used months after surgery for active people in the form of throwing/catching/bouncing a ball of increasing weight.
Passive Movement
A movement which is performed by a force, which can be another person or a machine, i.e. continuous passive movement machine (CPM) but does not require voluntary activity of the patients own muscles.
The uses for passive movement are listed below:
Purpose
To decompresss the impingement of the rotator cuff against the coraco-acromial arch ( acromium process, spur, coraco-acromial ligment) and thickened/inflamed bursa.
Indication
Patients with shoulder pan from impingement. Patients may also have an associated acromioclavicular joint degeneration requiring excision. Patients may also have an associated rotator cuff tear, which may or may not, require separate repair.
Skin Incisions
Sagittal: this gives the best cosmetic result
Procedure
The deltoid is detached from the antero-lateral aspect of the acromium and split distally to a maximum of 3 cm. The under surface of this region of the acromium is then removed( a Neer type acromioplasty). A limited or full excision of the bursal sac is caried out, depending on the severity of the condition. The deltoid is carefully repaired ( including sutures through the bone)
Possible Associated Procedures
Arthroscopy of the gleno-humeral joint
Excision of the acromioclavicular joint
Repair of rotator cuff tear
Possible Associated Complications
Infection
Detachment of the repaired deltoid
Nerve injury, e.g suprascapular nerve
Shoulder stiffness
Purpose
To decompress the impingement of the rotator cuff against the coraco acromial arch ( acromium process, spur, coraco- acromial ligament) and thickened /inflamed bursa.
Indications
Patients with shoulder pain from impingement in which the rotator cuff is intact or where there is a tear not suitable forrepair. Rarely, it may be necessary to convert to an open procedure.
Skin Incisions
Posterior- arthroscope
Lateral- arthroscopic instruments and arthroscope
Anterior- used for gleno-humeral joint assessment and as an outflow portal; or should acromioclavicular joint require excision/or chlectomy.
Procedure
Removal of the antero-lateral ,inferior aspect of the acromiu and the acromial attachment of the coracoacromial ligament with arthroscopic power tools and radiofrequency instruments.
Possible Associated Procedures
Arthroscopic assessment of the gleno-humeral joint
Acromioclavicular joint excision
Rotator cuff repair
Biceps stabilisation, or tenodesisMain Possible Complications
Nerve Injury
Failure to completely decompress
After your operation
A sling is applied in theatre and worn for 48 hours. The post operative swelling usually resolves in 24 hours.
The sutures cn be removed after 2 weeks and the physiotherapist will check the range of movement.
4 Weeks post op
Your surgeon will asses the range of passive and active range of movement. If there is no progression in the range of motion from the two week assessment then a referral will be made for increased physiotherapy; an MUA may be considered (or a capsular release) at a later stage.
Neurological function will be assessed.
12 Weeks post op
Assess active and passive range of movement
Assess rotator cuff function
Assess scapulothoracic function
Examine for concurrent pathology
6 Months Post op
Assess active and passive range of motion
Discharge with continuation of physiotherapy or review in 3 monthsprascapular nerve
Shoulder stiffness
Function
The shoulder is an extremely complex joint, designed to provide maximum mobility and 3 dimensional range of motion, more than any other joint in the body.
MULTIDIRECTIONAL INSTABILITY
Its function includes strong power to lift heavy weights even at arm’s length (which requires much more force at the end of a long “lever arm”, than close to the body); the shoulder joint is also responsible for getting the hand in the right position in space for whole range of functions.
When you consider all the different functions and positions we use our hands in, every day, it is easy to understand how hard daily life can be when the shoulder isn’t working well.
The shoulder complex is formed of 3 bones, the scapula, the humerus and the clavicle. There are 2 joints linking the bones.
a) The glenohumeral joint linking the scapula and the humerus.
b) The acromioclavicular joint linking the scapula and clavicle.
The shoulder joint is the most mobile in the body. It allows the arm to be positioned in a range greater than a hemisphere and can be rotated at any point in the hemisphere.
The glenohumeral joint itself is a ball and socket joint, the spherical head of the humerus sits into the concave socket of the glenoid.
The bony glenoid is thickened by a rim of cartilage called the glenoid labrum to increase the stability of the joint.
RC GLENOID LABRUM
The joint is covered by a thick joint capsule which is enforced by several ligaments.
JOINT CAPSULE
Overlying this is a layer of small muscles called the rotator cuff, composed of – supraspinatus, infraspinatus, subscapularis and terres minor. They form a “cuff” anchoring the humerus into the glenoid socket and although anatomically small, play a vital role.
Overlying these muscles are the larger power muscles which move the arm once the rotator cuff muscles have contracted and anchored the joint. They are the biceps (flexes the elbow and shoulder), triceps (extends the elbow and shoulder), pectoralis major ( adducts the arm and moves the body on a fixed arm eg press ups), latissimus dorsi ( extends the arm and raises the body on a fixed arm eg pull ups) and deltoid (abducts the arm).
Sub-Acromial / Sub- Deltoid Bursa
Sandwiched between the rotator cuff muscles and the outer layer of large bulky shoulder muscles are structures known as bursae.
They are present in many parts of the body. They are found wherever two body parts move against one another and there is no joint to reduce the friction. A single bursa is simply a sac between two moving surfaces that contains a small amount of lubricating fluid, which allows the movement to occur with less friction.
There are many instances however when a bursa can become inflamed; this may cause pain, tenderness or the sac to become distended with excessive fluid. The condition is known as a bursitis.
Purpose
To relieve pain and improve rotator cuff function
Indications
Patients with pain or difficulty elevating the arm against gravity or lifting ,from repairable rotator cuff tears, either degenerate or tears resulting from an injury e.g sudden, heavy lifting.
Skin Incisions
Sagittal, superior/lateral aspect of the shoulder. This is designed to give the best cosmetic results.
Approach
The deltoid is divided between its fibers and detached from the front of the acromium to provide access to the torn rotator cuff. An acromioplasty is usually also required(link). This increases the sub acromial space and reduces the possibility of impingement and recurrent tear.
Procedure
The rotator cuff tear is located (most commonly in the supraspinatus tendon). The tendon is carefully released of all adhesions and bought back to its original position. It is then repaired, without tension directly to the bone utilizing small anchors secured within the bone. The bone surface has to be carefully prepared.
Possible Associated Procedures
Arthroscopy
Excision of the acromioclavicular joint
Sub Acromial Decompression
Manipulation Under Anaesthetic
Main Possible Complications
Infection
After the operation
0-2 weeks
An abduction brace (either 15 or 30 degrees ) is applied in theatre.
Avoid all active movements
Seen by physiotherapist to be shown how to safely remove and re-apply brace and to perform passive, controlled shoulder movements.
2 Weeks Post Op
Wound and sutures are reviewed by the hospital or practice nurse.
Pain levels discussed to keep under control
Physiotherapist assesses active and passive range of motion
4 Weeks Post Op
Surgeon reviews deltoid and rotator cuff function, pain levels, active and passive range of motion and neurological function.
Physiotherapist progresses to active assisted exercises.
6 Weeks Post Op
Physiotherapy session to progress to full active exercise and discard brace.
12 Weeks Post Op
Surgeon assesses active and passive range of motion, anterior deltoid function and rotator cuff function.
6 Months Post Op
Final Review
Assess active and passive range of motion
Discharge with continuation of physiotherapy or review in a further 3 months
Continue home strengthening exercise programme and plan return to chosen sports/manual work/heavy lifting.
Magnetic Resonance Imaging is now a widespread imaging modality and has become a preferred tool for diagnosing and monitoring many conditions. It is capable of delivering highly detailed pictures of any part of the human anatomy and unlike x ray , has no known side effects.
MRI are obtained in what I essentially a very large magnet linked to a computerized image acquisition system which measures the body’s distortion of the magnetic field. The best images are obtained from machines in which the patient lies on a couch in the middle of the scanner. There are also open scanners for patients who feel too claustrophophic to tolerate the 20 minute scan. The images obtained from the scanner are however ,( to date ) ,not as high quality or definition as those obtained in a standard “ open at one end “ scanner.
MRI can obtain very detailed images of all tissues of the body: in the case of the shoulder: both bone and all soft tissues.
It can also differentiate between normal and diseased tissues. It is very useful to help diagnose a wide range of shoulder pathologies.
A contrast iodine solution is injected into the shoulder joint area to help highlight the joint structures. Several x ray images of the joint can be viewed on a screen ( the technique is called fluoroscopy).The shoulder is moved during the procedure to take images in various positions. A tingling sensation may be experienced during the procedure.
Arthrography in combination with x ray fluoroscopy, ( or sometimes in combination with MRI scanning ) can be a useful diagnostic tool in certain, selected cases, such as certain types of shoulder instability; or to diagnose a
SLAP TEAR.
An ultrasound gives high frequency waves that echo off the body. This creates a picture image of the structures within the shoulder. It is particularly useful in diagnosing rotator cuff tears. The equipment is similar to that used to scan pregnant women to check the baby.
X-rays or radiographs are the most widely used diagnostic imaging technique.
The shoulder is placed between the x-ray machine and photographic film. Whilst remaining still the machine sends electromagnetic waves through the joint, exposing the film to reflect the internal structure.
Arthroscopy is a minimally invasive surgical procedure used to visualize, diagnose and treat problems inside any joint. It is often referred to as “ keyhole surgery”
The word arthroscopy comes from two Greek words, “arthro” (joint) and “skopein” (to look). The term literally means, to look within the joint. To perform an arthroscopic examination, small (3-5 mm) incisions are made in the patients skin and fine diameter instruments, that contain a lens and fiberoptic lighting systems to magnify and illuminate the structures inside the joint are inserted. By attaching the arthroscope to a miniature television camera, the surgeon is able to visualise the interior of the joint on a monitor screen, and operate using specially designed small diameter instruments,through very small incisions rather than a large incision needed for “open” surgery.
Arthroscopy is useful for diagnosing rotator cuff tears and abrasions, biceps tendon problems, labral tears and instability of the joint, loose bodies and arthritis. The entire shoulder joint, as well as the subacromial bursa, can be examined and visualised in this way. A wide range of corrective surgery can be performed arthroscopically.
Two or three 5mm puncture wounds ( or “portholes”) are often all that are required. One allows for the arthroscope and the others for any arthroscopic instruments needed to correct the problem.
Arthroscopic surgery has the following advantages over open surgery:
If the arthroscopy is purely for diagnosis, you will be encouraged to use your shoulder as much as possible immediately afterwards. There should not normally be any restriction to using the arm and shoulder fully, as normal, the day after surgery (other than keeping the small wounds clean and dry for 10 days). You should be able to return to work within 2 days.
There is generally a single stitch which will require removing ( by your G.P’s practice nurse, or at the hospital) 10 to 12 days later. During this time you will have to take care to keep the wounds covered with a waterproof dressing when showering.After the stitches are removed you will be able to swim/ shower etc.
Assess for scapula dyskinesis and teach scapula setting.
Patient supplied with ultrasling II SAS 15 degree abduction wedge.
Wedge to be worn 24 hours/day for 4 weeks. Rolled towel or similar waterproof wedge to replace abduction wedge when showering.
The most comfortable sleeping position is supine with a pillowbehind elbow supporting arm and brace forwards.
Weeks 1 – 4
Attending physiotherapy sessions will help with pain relief. Particular attention should be paid to reducing trapezius and levator scapulae trigger points/muscle spasm. Gentle caudal traction and glenhumeral joint glides in the plane of the glenoid are especially useful.
Weeks 4 – 6
Weeks 6 +
Weeks 8 +
ACCELERATED PROTOCOL FOR ROTATOR CUFF REPAIR
Assess for scapula dyskinesis and teach scapula setting.
Patient supplied with ultrasling II SAS 15 degree abduction wedge.
Wedge to be worn 24 hours/day for 4 weeks. Rolled towel or similar waterproof wedge to replace abduction wedge when showering.
The most comfortable sleeping position is supine with a pillow behind elbow supporting arm and brace forwards.
Weeks 1 – 4
Attending physiotherapy sessions will help with pain relief. Particular attention should be paid to reducing trapezius and levator scapulae trigger points/muscle spasm. Gentle caudal traction and glenhumeral joint glides in the plane of the glenoid are especially useful.
Weeks 4 – 6
Weeks 6 +
Weeks 8 +
No combined full abduction with external rotation for 12 weeks. Avoid sharp pain throughout.
Weeks 0 – 3
Weeks 4 – 6
Weeks 6 – 12
Weeks 12+
Functional Activities
LIVING WITH A SHOULDER SLING
Washing
Prepare a bowl of water, soap and flannel. If possible get someone else to remove your clothing.
Your helper should then lift your arm slightly away from your side. Let them take the weight of your arm to avoid using your muscles. They may also need to wash your unaffected arm and any areas that you cannot reach with your un-operated arm. If you are having a shower, replace your wedge with towels, protected by plastic bags tied around them.
Be careful at all times not to jar your shoulder and avoid all sudden movements. Do not rush.
Keep the wounds dry.
Getting Dressed
Eating and Drinking
Use your un-operated arm. You may need someone to cut your food into small pieces.
Lift kettles/saucepans etc with your un-operated arm only – do not “assist” with your operated arm.
General Advice
Prepare your home before surgery. You will not be able to reach very far and unable to lift or move anything heavier than you can carry in one hand.
Think of your daily routine. Put anything you are going to need within easy reach.
It may be easier, for a while, to have some plates, mugs etc out on the work surface to be easily accessible
It may be wise to have some ready meals in the freezer.
For comfort, you may find gentle should friction useful. Sit down – allow your arm to fall forwards and very gently tug on your arm. You should feel no sharp pains at all.
Ideal Application
Both versions of the UltraSling II provide immobilization for rotator cuff repairs, capusular shifts, Bankhart repairs, glenohumeral dislocations/subluxation and soft tissue repairs/strains and after some fractures.
Features and Benefits
Ideal Application
This provides support in the ideal position after some (more complex) rotator cuff repairs.
Features and Benefits
This provides support in the ideal position after some anterior stabilizations, capsular shift and Bankart Repair proceedures.
Ideal Application
For use after initial anterior shoulder dislocation or post operatively when external rotation is desired The anterior part of the capsule hangs loosely during internal rotation and the labrum is able to displace medially. In external rotation, the subscapularis tendon tightens thus closing the anterior joint cavity and helping the labrum maintain a good position on the glenoid rim.
Features and Benefits
Deltopectoral or Anterior Surgical Approach
Normally most of subscapularis will have been detached and resutured so this needs protecting by:-
In Patient Protocol
Day 1
Outpatient Protocol
Week 4
Week 5
Weeks 6+
General Guidelines
The outcome achieved will depend on the quality of the soft tissues pre-operatively. If the patient has had pain for months or years there will be a large degree of disuse atrophy of the rotator cuff. Rehabilitation may be slow, but should be followed through with progressive exercises for several months, until maximum potential is reached. Improvement can continue up to 2 years. As far as possible work towards functional goals early on.
Functional Activities
(*RCR)
There is a need to protect the anterior deltoid (detached and repaired). Therefore avoid active flexion/abduction until after end of week 4.
