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:
ARTHROSCOPIC CAPSULAR RELEASE
Purpose
To increase the range of motion of the shoulder ( gleno humeral joint)
Indications
Patients with a restricted range of motion from Adhesive Capsulitis ( Frozen Shoulder )
Skin Incisions
Two 4 mm portals are established, one at the front and one behind the shoulder.
Procedure
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 +
ACROMIOCLAVICULAR JOINT FIXATION/REPAIR
Internal fixation with Kirschner-wires
ACJ reduction, fixation achieved by drilling steel Kirshner wires across the acromion, the AC Joint and into the lateral end of the clavicle.
Unfortunately the reduction of the ACJ is often lost soon after the wires are removed 6-8 weeks post-operatively
Worse this carries the risk of wire loosening and migration, this can be very dangerous.
Bosworth screw fixation(3)
ACJ reduction, fixation achieved by drilling a Bosworth screw through the clavicle, then inferiorly into base of the coracoid process, followed by coraco-clavicular ligament repair with sutures. Aftercare includes gentle mobilisation after 1 week and delaying more forceful mobilisation and lifting until after screw removal at 8 weeks.
Again there is risk of migration of the screw, and frequent loosening of the screw with erosion of bone around the implant.
This has also led to further fracture of the clavicle at the position of the screw.
There is the necessity for a second procedure to remove the screw.
Mumford- Distal clavicular excision
Indicated for chronic, symptomatic, type II subluxations. The acromion is sutured to raw end of the clavicle followed by prompt mobilisation after 1 week.
Variable results and does not address symptoms arising from clavicular instability
Weaver-Dunn -Distal clavicular excision with coraco-clavicular ligament reconstruction(4)
Coraco-acromial ligament is freed from the acromion and sutured to the remaining end of the clavicle through its intramedullary canal to achieve reduction. Patients may mobilise gently after one week in a sling, but delay more forceful mobilisation and lifting until after 6-8 weeks.
This procedure relies on a viable coraco-acromial ligament and can fail to stabilise the clavicle sufficiently, especially for the higher grade injuries (for these it is best combined with some form of coraco-clavicular ligament reconstruction or fixation).
Unavoidably disrupts the coraco-acromial arch.
Coraco-clavicular ligament reconstruction using various soft tissue autografts or allografts
free tendon grafts, e.g. fascial grafts; long head of biceps tendon, etc
These can require harvesting of either local or separate area tissue and the consequent loss of that tissue and either a bigger or a second operation site & wound.
Coraco-clavicular ligament reconstruction with prosthetic ligament
The Nottingham Surgilig:
The implant is made from polyester with braiding technology originally developed to produce the ABC, the ARD and the Soffix ligaments, which have been extensively used in the knee over many years.
Loops are woven into each end of the grafts, which come in a range of lengths. The prosthetic ligament is looped around the base of the coracoid process, then threaded through itself to provide a broad based fixation which will not erode or cut through the bone. A firm, smaller loop, at the clavicular end allowing secure screw fixation to the clavicle. The graft is threaded posteriorly around the circumference of the clavicle, thus allowing the natural rotation (45?) of the clavicle to occur without risk of erosion or fracture (as can occur with many other implants).
Over a period of time, fibrous ingrowth occurs, establishing the formation of a “neo-ligament” with host tissue, but retaining the excellent implant strength.
The strength of the construct exceeds that of the natural ligments thus allowing very early mobilisation, and early return to sporting and strenuous activities.
For those patients who have persistent symptoms following conservative treatment for AC dislocations types I –III, early operative intervention is advocated by many surgeons, especially for manual workers and athletes.
Results of early repair have been reported to be superior to those carried out late 10.
Drawbacks of earlier techniques such as the Weaver-Dunn (otherwise successful for relatively stable injuries) include the delay in recovery to full function and performing resistive shoulder exercises until soft tissue healing is sufficiently advanced at 10-12 weeks; as well as the need for further fixation with higher grade injuries.
Conversely, using an implant such as the Nottingham Surgilig, patients are able to resume normal activities from 2 weeks without the need for medium term protection.
References
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
Introduction
There are two main groups of anti-inflammatory medicines:
Some NSAID’s are combined with analgesics. NSAID’s are usually taken in tablet or capsule form, but are also available as liquids, creams, sprays and suppositories.
Anti-inflammatory painkillers are used to ease pain and swelling in various parts of the body. For example, they are used to relieve painful swelling and inflammation in the joints caused by rheumatoid arthritis or osteoarthritis and overuse or impact injuries such as sprains and strains.
Your doctor may also prescribe NSAID’s for other conditions where there has been swelling, inflammation or pain. You need a prescription to get NSAID’s, apart from lower strength ibuprofen and aspirin which can be bought from your local chemist.
How does it work?
If you have a sprain or strain, or an inflammatory disease such as arthritis, your body releases chemicals called prostaglandins, which travel rapidly to he injured area.
Prostaglandins make the tissue around the injury swell up and become inflamed, causing you to feel pain. NSAID’s prevent the production of prostaglandins, stopping further swelling and relieving pain.
Who can use it?
Pregnant women, or women who are breastfeeding should not use NSAID’s. Young children should only take NSAID’s on the advice of a doctor. Unless your doctor specifically advises it, aspirin should not be taken by children under the age of sixteen.
Elderly people should take extra care when taking NSAID’s as there may be an increased risk of some side effects, including confusion and stomach problems.
You should inform your doctor if you have ever had an allergic reaction to any NSAID, or if you are taking any other medicine that could cause a negative reaction.
These include (but are not restricted to):
Dosage
Before taking NSAID’s, it may be worth trying paracetamol. Paracetamol is a good painkiller and is less likely to cause side effects. However, it does not reduce inflammation. For conditions such as osteoarthritis which have little inflammation, paracetamol is the preferred painkiller.
Ibuprofen and aspirin are NSAID’s that are available over the counter at your chemist. The ibuprofen that you get is a lower dose than the one that you can get on prescription from your doctor.
For NSAID’s, the dose will depend on the type of medicine being used, what form it is being used in and what condition it is being used for. Unless otherwise directed by a doctor, you should always follow the instructions provided in the enclosed PIL, or as stated on the packaging.
Side Effects
Most people who take NSAID’s do not experience any major side effects. However, you should always read the leaflet that comes with the tablets as it will list all the cautions and possible side effects.
The most commonly reported side effect of long term use of NSAID’s is stomach irritation. If taken over long periods of time, NSAID’s can irritate your stomach lining and may cause it to bleed. Sometimes, this can lead to an ulcer developing. If you have to take NSAID’s for a persistent or recurring problem, your doctor may also prescribe anti-ulcer medication to prevent ulcers.
If you are taking NSAID’s and you develop upper abdominal pains, pass blood or black stools, or vomit blood, you should stop taking the medication immediately. Also, you should see your doctor as soon as possible or go to the nearest casualty department.
NSAID’s can worsen the effects of kidney disorders, so are not advised for people with this condition. In rare cases, NSAID’s may cause an allergic reaction, usually resulting in a painless skin rash. If you develop an allergic reaction, take advice from your chemist or visit you doctor as soon as possible
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.
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.
BANKART REPAIR OPEN
Purpose
To repair the detached antero-inferior labrum ( Bankart Lesion) to the glenoid with minimal restriction of external rotation.
Indications
Patients with a Bankart Lesion and recurrent dislocation of the shoulder joint ( glenohumeral joint)
Skin Incisions
Delto pectoral
Approach
Superficial muscles are separated and deep muscles divided. The capsule of the joint is opened. All these structures are repaired at the end of the procedure.
Procedure
The edge of the glenoid is roughened to produce an improved surface for the repair.A number of either Titanium or Bioabsorbable anchors, usually 3, are inserted into the margin of the glenoid. These embedded ‘anchors’ grip the bone and allow the labrum to be tightened against the glenoid via sutures passed through both the labrum and the anchor. In this way the Bankart lesion is repaired, allowing the tissues to heal in this position.
Possible Associated Procedures
After the operation
BANKART REPAIR ARTHROSCOPIC
Purpose
To repair the detatched antero-inferior labrum( Bankart Lesion ) to the glenoid with minimum loss of external rotation.
Indications
The procedure is appropriate for patients with a torn labrum, diagnosed by arthroscopic evaluation or MRI scan. Repair is indicated especially after recurrent dislocation but should be considered after the first dislocation in higher demand sports men and women.
Skin Incisions
Three incision portals are used: anterior ,anterior-superior and posterior.
Procedure
During the operation a full diagnostic evaluation of the glenohumeral joint is made. The labrum, the degree of damage to the head of the humerus ( Hill Sachs Lesion), the degree of laxity in the glenohumeral capsule and ligaments are all assessed. Concurrent pathology is excluded.
The procedure holds the labrum in the repaired position, allowing the tissues to heal.
Possible Associated Procedures
MRI OVERVIEW
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.
MANIPULATION UNDER ANAESTHETIC
Purpose
To increase the range of motion of the shoulder ( gleno- humeral joint)
Indications
Patients with a restricted range of motion from Adhesive Capsulitis ( Frozen Shoulder )
Procedure
Under general anaesthesia the shoulder joint is manipulated into the greatest possible range of motion, thereby releasing adhesions and/or a tight fibrotic capsule ( lining of the joint)
Possible associated procedures
Arthroscopy
Arthroscopic Capsular Release
Interscalene Regional Nerve Block
Main Possible Complications
Humeral Fracture
Pain causing recurrent stiffness
After your operation
Introduction
Analgesic is the medical name for painkiller. An analgesic is any group of medicines used to relieve pain.
Analgesic medicines are split into three groups:
Opioids
Opioids analgesics are also known as narcotic analgesics or opiates. They are used to ease moderate to severe pain and are often prescribed to patiens who are recovering from operations, severe injuries or to ease severe pain. Some opioid analgesics are:
Non-opioids
Non-opioids are also called non-narcotics. They are used to ease mild to moderate pain from headaches, toothache and muscle and joint pains. Many non-opioid analgesics can be bought over the counter at chemists and supermarkets. Non-opioid analgesics are:
Some non-opioids also have anti-inflammatory properties. These are known as non-steroidal anti-inflammatory drugs (NSAIDS). There are over twenty types including:
Combined Analgesics
Some analgesics combine both mild non-opioid drugs such as aspirin or paracetamol, with a small amount of opioid in a single tablet. These combination analgesics are often prescribed to people who are not benefiting from non-opioids, like paracetamol, alone. Combined analgesics are:
Some combination painkillers can be bought over the counter and contain smaller quantities of opioid painkiller than those available on prescription
Painkillers – what are they used for?
Analgesics are used primarily for pain relief. They treat the symptoms of a condition rather than the condition itself.
Some pain relieving medicines have other properties too. For example, aspirin can be used to ease inflammation and is also used to reduce the risk of blood clots forming. Paracetamol is used to reduce a fever or high temperature.
Advantages
Analgesics are a quick and effective way of coping with mild to severe pain. Most analgesics take from thirty to sixty minutes to start working if taken in tablet form, although intravenous or injected painkillers are often much quicker to take effect.
Who can use Painkillers?
It is always best to find out what the problem is before treating the symptoms. In other words, just taking analgesics may relieve pain but it may also hide the cause of the pain eg if you have an underlying condition.
Some painkillers, such a aspirin, should not be used by pregnant or nursing mothers, although other painkillers are considered safe. A GP, pharmacist or midwife should be consulted before taking any kind a medication.
Children under sixteen years should not take aspirin, unless under the guidance of a specialist, as it may increase the risk of Reye’s syndrome, a condition that affects the brain and liver.
You should always consult you doctor before taking analgesics if you are already taking other forms of medication.
Paracetamol can be used by all ages and is most suitable for minor pain and for reducing a high temperature.
Mild non-opioids, like paracetamol, may cause serious health problems if taken in large quantities, so it is best to make sure that your current medication does not contain analgesics or ingredients that may react badly to analgesics.
Opioids may make you feel drowsy and should not be taken with other medicines that have similar effects. You should not drink alcohol while taking analgesics.
You should consult your doctor or pharmacist before taking analgesics, including over the counter painkillers if you have, or have had, any of the following conditions:
It is advised that you speak to your pharmacist before buying any painkillers that have not be prescribed by your doctor or hospital doctor.
Dosage
The dose will depend on the type of analgesic used and the condition it is being use for. Follow the instruction on the packet or enclosed information, unless otherwise directed by your doctor.
Seek medical attention immediately if you suspect an overdose has occurred, either deliberately or by accident.
Side effects
Any possible side effects are listed in the instructions that come with the medicine, although the majority of side effects do not last long and are not a serious risk to health.
It is best to take aspirin and other non-steroidal anti-inflammatory drugs after a meal as they can irritate the stomach and in extreme cases may cause indigestion, ulcers or bleeding. Tinnitus ( ringing in the ears) can indicate that you have taken too much aspirin. Other side effects of aspirin can include nausea, vomiting and acute asthma in people with asthma.
Aspirin interacts with several other medicines so if you experience any difficulty breathing, wheeziness or breathlessness, or develop a rash on any part of your body, stop taking the medicine immediately. Visit your doctor or pharmacist who will advise you about an alternative pain relief medicine.
Paracetamol is a relatively safe, mild analgesic, with few known side effects. However, if taken in very large amounts can have serious side effects including liver damage or failure.
Opioid analgesics may cause severe constipation, nausea or vomiting and drowsiness. Other side effects can include a dry mouth, itching, sweating and in rare cases hallucinations. Opioids are usually proscribed for use over short periods. Some evidence suggests that long term use may increase the risk of addiction as opioid analgesics may give the user feeling of euphoria.
ACCELERATED PROTOCOL FOR ROTATOR CUFF REPAIR
Assess for scapula dyskinesis and teach scapula setting.
Patient supplied with Ultrasling II SAS 15° abduction wedge brace.
Wedge brace to be worn 24 hours/day for 5 weeks. Rolled towel under armpit or similar waterproof
wedge to replace abduction wedge when showering.
The most comfortable sleeping position is supine with a pillow behind elbow and brace, supporting
arm forwards into neutral (ie: avoiding shoulder extension).
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TOTAL SHOULDER REPLACEMENT
Deltopectoral or Anterior Surgical Approach
Normally most of subscapularis will have been detached and resutured so this needs protecting by:-
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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.
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 +
SUB-ACROMIAL DECOMPRESSION – OPEN/MINI OPEN
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
SUB ACROMIAL DECOMPRESSION ARTHROSCOPIC
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
Injections are used regularly to treat shoulder conditions. A mixture of hydrocortisone, which has an anti-inflammatory action, and a local anaesthetic to numb the area are infiltrated.
Glenohumeral Joint
In the case of osteoarthritis, fluid within the joint can be drained to relieve pain and an anaesthetic and steroid injection put into the joint cavity to reduce pain and stiffness.
The most comfortable approach to use is a posterior one.
Acromioclavicular Joint
Joint aspirate can be taken away and local anaesthetic and hydorcortizone put into the joint to relieve pain.
Subacromial Injection
This is used to reduce symptoms of impingement especially when the bursa is inflamed.
Biceps Tendon
Hydrocortizone is injected to reduce symptoms of tendonitis or partial tear.
It is advisable to avoid vigorous activity for one week after the injection.
Glenohumeral joint
Subacromial bursa
Acromioclavicular joint
Bicipital tendinitis
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.
SLAP REPAIR ARTHROSCOPIC
There are three portals, one posteriorly for the arthroscope, one anteriorly for the arthroscope and arthroscopies tools and one below this as an outflow portal.
The purpose is to reattach the detached artero-inferior labrum (Bankart lesion) to the glenoid with minimal restriction of external rotation.
The glenoid socket in the area of the lesion is roughened to produce an improved surface for the repair. Suture anchors are inserted into pre-drilled holes in the margin of the glenoid.
These embedded anchors grip the bone and allow the labrum to be tightened against the glenoid via a suture pressed through both the labrum and anchor.
ANTERIOR/INFERIOR CAPSULAR SHIFT
Purpose
To restore normal volume of the capsule (or lining) of the glenohumeral (or shoulder joint) and restore normal tension and length of the stretched ligaments following recurrent dislocation.
Indications
Patients with recurrent instability and/or dislocation which is caused by multi-directional joint laxity rather than a localized defect (usually as a result of several dislocations)
Skin Incision
Deltopectoral approach.
Approach
Superficial muscles are separated and deep muscles are divided. The capsule of the joint is opened. All these structures are repaired at the end of the procedure.
Procedure
The capsule of the joint is dissected from the muscle anteriorly and inferiorly and divided by an –I incision. The two flaps of capsule are overlapped which shifts the inferior capsule and reduced the overall volume of the joint capsule. Two suture anchors are inserted into the anterior margin of the glenoid bone, allowing the tissues to heal in this position. These embedded ‘anchors ‘ grip the bone and allow the overlapped capsule to be tightened against the glenoid bone.
Possible associated procedures
Main Possible Complications
After your operation
TOTAL SHOULDER REPLACEMENT- ROTATOR CUFF INTACT
Purpose
To replace the damaged articular surfaces of the humeral head and glenoid with prosthetic implants to relieve pain and repair the rotator cuff to restore or improve range of movement and function.
Indications
All patients with pain from arthritis of the glenohumeral joint and a rottor cuff that is intact.
Implants
Two implants are used; a humeral component, composed of a modular metal shaft with separate head components and a glenoid component made of polyethylene with or without a metal surface.
Skin Incision
A Deltopectoral approach is most commonly used.
Possible Associated Procedures
Main Possible Complications
After your operation
The arm will be rested in a controlled position in a sling or brace. The physiotherapist and nursing staff will show you how to adjust and safely remove and re-apply this.(link to living with a sling)
– An x ray will be taken the day after surgery.
– You will be able to return home when your pain is well controlled and you can cope with your arm in a sling, typically 2 days after surgery.
– You can expect to need painkillers for 2 or 3 weeks after surgery to control the background pain. You will also need to take painkillers an hour before each exercise /physiotherapy session ; ideally 3 times a day, for up to 8 weeks or even longer.
– You will be shown specific shoulder and arm exercises by your physiotherapist before you leave the hospital. These exercises are very important and must be carried out accurately after leaving the hospital on a daily basis at home; ideally 3 times a day, for at least 8 weeks. To achieve optimal results, daily exercices should continue for up to a year.
– The stitches must be removed or the wound inspected ( if absorbable sutures are used) at 14 days after surgery: either by your GP’s practice nurse or at the hospital.
– Your surgeon will typically need to see you 4 weeks after surgery.
TOTAL SHOULDER REPLACEMENT WITH ROTATOR CUFF REPAIR
Purpose
To replace the damaged articular surfaces of the humeral head and glenoid with prosthetic implants to relieve pain and repair the rotator cuff to restore or improve range of movement and function.
Indications
Patients with pain from arthrosis or degenerative changes of the glenohumeral (shoulder) joint with an additional, repairable Rotator Cuff tear.
Implants
Two implants are used; a humeral component, composed of a modular metal shaft with separate head components and a glenoid component made of polyethylene with or without a metal surface.
Skin Incision
A superior ( Mc Kenzie) approach is most commonly used.
Possible Associated Procedures
Main Possible Complications
After your operation
-The arm will be rested in a controlled position in a brace.The physiotherapist and nursing staff will show you how to adjust and safely remove this (link to living with a sling)
-An x ray will be taken the day after surgery.
-You will be able to return home when when your pain is well controlled and you can cope with your arm in the sling. This is typically 2 days after surgery.
-You can expect to need painkillers for 2 to 3 weeks after surgery to control any background pain. You will also need to take painkillers an hour before each exercise / physiotherapy session. You will need to do exercises for at least 8 weeks after surgery.
-You will be shown specific shoulder and arm exercises by your physiotherapist before you leave the hospital. These exercises are evry important and must be carried out accurately after leaving hospital on a daily basis at home: ideally 3 times a day, for at least 3 month. To achieve optimal results, daily exercices should continue for up to a year.
-The stitches must be removed or the wound inspected ( if absorbable sutures are used) at 14 days after surgery: either by your GP’s practice nurse or at the hospital.
-Your surgeon will typically need to see you 4 weeks after surgery.
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.
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.
ULTRA SLING II
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
ULTRA SLING II AB
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
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.
