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IMPINGEMENT SYNDROME

This occurs when the rotator cuff tendons collide or strike against the roof of the shoulder (Acromion) formed by a part of the shoulder blade bone (Scapula).

A small space between the roof of the shoulder and the top of the arm bone contains the rotator cuff tendons. This space is further reduced during overhead activities such as painting, swimming, tennis and other overhead activities. This can lead to damage to the rotator cuff tendon in the form tendinosis (damage of tendons at a cellular level) or even a tear. This will cause the bursa (a normal tissue between the rotator cuff and the roof of the shoulder to prevent friction) to become inflamed and cause pain. Hence people who do a lot of overhead related activities are prone to develop this condition.
It can also be a result of wear and tear of the acromioclavicular joint (the joint at the roof of the shoulder and the collar bone) which can cause bony spurs to form and reduce the space for the rotator cuff tendons to glide. It can also be seen in people who have a slightly curved acromion, which is a common condition, which again reduces the space between the top of the arm bone and the roof of the shoulder.

SYMPTOMS

Pain in the shoulder is the main symptom, particularly on overhead activities. This pain can also cause disturbed sleep, particularly when lying on the affected shoulder. Weakness and inability to lift the arm may indicate a tear of the rotator cuff tendons. Limitation of shoulder movement due to pain may further lead to stiffness.
Investigation
•    X-rays can reveal bony spurs and degeneration of the acromioclavicular joint. Sometimes changes due to chronic impingement syndrome can also be seen in the bones.
•    An MRI can be done to rule out a tear of the rotator cuff tendons
•    A simple test wherein a local anaesthetic is injected into the sub-acromial space can be done to confirm that the pain is arising from the sub-acromial space

TREATMENT PROCEDURE:

Non- Surgical:
Initial treatment is with anti-inflammatory medications and physiotherapy. Physiotherapy helps stretch out the shoulder to improve movements and also improves the strength of the muscles around the shoulder. Rest and ice therapy may also be indicated in acute cases. Your doctor may also recommend a pain-killer injection into the sub-acromial space to reduce inflammation and pain.
Surgical:
If pain is unrelenting, then you may be recommended surgery for removal of the swelling bursa and also the bone spurs. A little bit of the under surface of the acromion is also shaved away to make more space for the rotator cuff tendons and is called an acromioplasty.
If the acromioclavicular joint is degenerated and has spurs and is also the source of pain then an excision of this joint is performed by excising about 10mm of the outer end of the clavicle (Collar bone) to prevent rubbing between the 2 joint surfaces to reduce the pain. This does not cause any functional impairment. The acromioclavicular joint or the AC joint excision can be performed either arthroscopically (minimal invasive surgical procedure) or as an open procedure.

ROTATOR CUFF TEARS

The rotator cuff consists of muscles and tendons in the shoulders which connect the upper arm to the shoulder blade and hold the ball of the upper arm into the shoulder socket allowing for smooth and rotational movement of the arms.

These tendons can be damaged as a result of an injury or also get inflamed and torn as a result of wear and tear, as is more common in older individuals. In younger individuals, inflammation can also occur as a result of overuse or repeated overhead activities such as swimming, painting or playing tennis. Depending on the damage to these tendons and muscles, arm movement is impaired. Damage to any of these muscles and tendons is termed rotator cuff tears.

Symptoms

The main feature of a rotator cuff tear is a weakness. Only certain movements of the shoulder may be weak depending on which tendon is torn. The supraspinatus tendon (the muscular tendon that runs over the shoulder bones) is the most common tendon to sustain tears and leads to weakness of lateral elevation. In certain individuals, there may be a complete loss of lateral elevation of the arm and gives the appearance of a pseudoparalysis. Here, passive elevation is possible although the patient is not able to perform the movement on his/her own. Certain people with a tear of the rotator cuff may compensate for the loss of a particular tendon with other surrounding muscles and tendons, thereby allowing a normal range of movement.
Investigation
•    X-rays are helpful if the tear is a chronic one whereby there is upward migration of the humeral head. Sometime degenerative changes may also be seen which can also lead to pain eventually if left alone.
•    Ultrasound scan by an experienced musculoskeletal radiologist can provide useful information about the tear.
•    An MRI scan is very useful is diagnosing tears of the rotator cuff and to determine the extent of the tear.

Treatment Procedures

Treatment depends on the age of the patient and the mode of injury. Younger patients are generally given the choice of surgery straightaway if the rotator cuff is torn. Older individuals can be given a trial of nonsurgical treatment.
Nonsurgical treatment includes pain-killer medications with physical therapy to improve shoulder movements and strengthen the shoulder muscles. An injection into the subacromial space or the space between the roof of the shoulder joint and the ball joint of the arm may also be recommended to patients who find it difficult to cope with the pain.
If nonsurgical treatment is unsuccessful, patients are recommended to undergo surgery to shave some bone spurs off from the under the surface of the roof of the shoulder joint to make space for the rotator cuff repair. The rotator cuff can then be repaired by minimal open surgery.

Following repair, the shoulder is usually immobilized for a few weeks in a sling to be followed by light movements for about 6 weeks. Active movements are started after this. Strength training of the muscle is usually started after about 2-3 months. Patients are advised to keep the minimal movement for proper healing.
Massive cuff tears may sometimes require the transfer of another tendon from elsewhere to cover the defect if the tear cannot be repaired. The results of this surgery are not always satisfactory and only recommended in exceptional cases.

Certain elderly individuals with rotator cuff tears may surprisingly have good movement of the shoulder and may only complain of pain. In these patients, the rest of the shoulder muscles have compensated for the torn tendon to provide normal shoulder movements. Repairing the cuff tear in these patients may possibly make their post-operative function worse. Depending on several factors, your surgeon may only recommend a subacromial decompression, a process to shave off the upper part of the shoulder socket, to help you take care of the pain. Following this procedure, the shoulder movements can be started immediately to prevent stiffness.
Chronic rotator cuff tears in elderly individuals can cause the humeral head (the upper end of the arm bone) to rub against the acromion (the roof of the shoulder socket) causing arthritis called as rotator cuff arthropathy. Treatment for this is usually surgical and replacement of the humeral head only (hemiarthroplasty) may be considered. In fairly active individuals a reverse shoulder replacement may be recommended which is a fairly recent procedure. Here, the traditional ball and socket joint are 'reversed' and parts of the shoulder joints are replaced to control pain and allow limited movements. Results of this treatment vary and long term results are awaited.

LABRAL TEARS

The shoulder joint is a ball (Humeral head) and socket (Glenoid) type of joint. The glenoid (socket) is quite shallow and cannot maintain the humeral head (ball) in place on its own. The glenoid is surrounded by the labrum which deepens the glenoid providing for the stability of the shoulder joint. Several ligaments are also attached to the labrum, hence injury to the labrum affects the overall stability of the shoulder joint.
This labrum can be torn as a result of an injury such as a shoulder dislocation or by wear and tear (due to overuse). The anterior labrum is torn in an anterior dislocation and the posterior labrum is torn in posterior dislocation. Posterior dislocations are more common in electrocution and epileptic seizures.
This can lead to instability of the shoulder where you can feel as if your shoulder is loose and popping out of place. These symptoms are more common in younger individuals who are more active particularly with regard to sports. Repeated dislocation can lead to erosion of the anterior aspect of the glenoid and the posterolateral part of the humeral head (Hill-Sach's lesion) and increases the tendency of the shoulder to dislocate.
Diagnosis
A good history and physical examination usually provide a clear cut diagnosis. An apprehension test will be performed whereby the shoulder is placed in a position which causes it to dislocate. A patient who has experience of recurrent dislocations will be apprehensive with this maneuver and tries to resist the position. There can also be increased translation of the humeral head in relation to the glenoid.
Most of the times, the cause is unknown, but it can happen in rheumatoid arthritis, hypothyroidism, pregnancy, previous wrist fractures, tumors or cysts within the wrist, infection or burns. It can also occur in diabetics which may be due to problems with the nerve as a part of peripheral neuropathy rather than compression of the nerve.
Xrays are of little value in diagnosing this condition unless the labral tear is associated with a small avulsion fracture of the glenoid. An MRI or MR arthrogram can reveal the position and extent of the tear. It can also reveal any other concomitant injuries within the shoulder.

Treatment

Initial treatment following a shoulder dislocation is to immobilize the shoulder for 3-4 weeks to rest the shoulder and allow the soft tissue to heal. This is then followed by physical therapy to regain shoulder movements and also to strengthen the shoulder musculature.
If in spite of this treatment, the shoulder continues to dislocate, then your doctor will advise you to undergo surgery to help improve the stability of the shoulder. This is in the form a repair of the labrum to the glenoid. This is commonly done nowadays as an arthroscopic procedure, however, can also be done by an open technique through a longer incision. The open technique is associated with longer recovery time. The labrum is repaired using an implant called a suture anchor which is inserted into the bone. The other end contains sutures which are passed through the torn labrum and aids repair. Usually, 3 such suture anchors are necessary for a satisfactory repair.
However, if there are significant glenoid erosion and humeral head defect due to recurrent dislocations, then your doctor may recommend an open procedure such as a Latarjet procedure instead. Results of the Latarjet procedure are equally good. Here the coracoid process (another part of the scapula or shoulder blade bone) is detached and reattached to the anterior part of the glenoid using screws. This increases the width of the glenoid and resists the humeral head from slipping out.
Rehabilitation is an extremely important part of treatment, especially after surgery. These surgeries are usually followed by a period in a sling with only passive range of motion allowed initially for about 4-6 weeks. Active motion is then allowed after this followed by strengthening.

SLAP TEARS

SLAP is an abbreviation for Superior Labral tear from Anterior to Posterior and a tear of the superior labrum which is the ring of cartilage that surrounds the socket of the shoulder joint.
These are commonly seen in sports people particularly involved in overhead motion like in tennis, squash, badminton players and swimmers as well.
Symptoms
Symptoms have been described as a sharp popping or catching sensation which can be brought about by certain shoulder movements and generally causes vague aching that lingers afterwards.
Investigation
MRI scans helps diagnose this condition. Occasionally, a hole in the tendon, which is normal, can sometimes be misdiagnosed as a SLAP tear. Repairing the 'tear' in this case can cause restriction of shoulder movements and hence all these tears should be evaluated thoroughly at the time of arthroscopic surgery to confirm traumatic changes.

Treatment Procedures
The literature on conservative treatment of SLAP tears is minimal. SLAP tears are treated by arthroscopic debridement or repair using suture anchors (a device used to fix tendons) depending on the extent of the tear. If the tear also involves the biceps tendon (tendons that run along the upper arm bone), depending on the condition of the tendon, it may either be debrided or separated from the attachment to the top part of the labrum and reattached to the humerus.This can cause the shoulder to feel 'tight' thereby restricting movements. Physical therapy is extremely important to help regain shoulder movements. Only passive range of movements is allowed for about 3 weeks, followed by active movements afterward. Return to normal activities normally takes at least 3 months.

BICEPS TENDINOPATHY

Biceps Tendinopathy is described as pain and tenderness in the bicep tendon. It can sometimes be inflamed due to overuse activities which can cause painful movements. It can also occasionally result from direct injury. Biceps Tendinopathy is usually associated with other shoulder pathologies like impingement syndrome, rotator cuff tears or instability.

Symptoms
Pain is more of a dull ache on the top of the shoulder. It usually worsens on overhead activities and on twisting movements of the forearm. This pain can also make the arm feel weak.

Investigation


A thorough clinical exam is extremely important in diagnosis. X-rays are can sometimes show bony spurs or small bony outgrowths that form along the edge of a bone, in the region of the biceps tendon, however, they also help rule out other pathology which can cause similar symptoms.
MRI scan is useful to help diagnose this condition.

Treatment Procedures

Non-Surgical:
Treatment is usually conservative with painkillers and physical therapy. This treatment can be quite prolonged and may cause the patient to get frustrated. The pain may come and go depending on the patient's activities. Avoiding those activities which cause pain and resting the shoulder can help control the pain. Concomitant pathology like impingement syndrome can also be treated at the same time with physiotherapy. In certain cases, your doctor may advise a pain-killer injection into the tendon sheath to help control the inflammation and pain.

Surgical:
Surgical treatment is usually in the form of biceps tenotomy or tenodesis. In biceps tenotomy, the tendon is detached from its attachment on the superior labrum and released. This is usually reserved for elderly individuals. This treatment can cause slight weakness of outward twisting of the forearm. It can also cause a lot of cramping and bunching up of the biceps tendon distally towards the elbow causing a 'popeye' appearance.
Younger patients are usually advised a biceps tenodesis where the tendon is detached from its attachment on the superior labrum and reattached to the proximal humerus. This can be performed either by an arthroscopic technique or open technique as is usually called since it involves a small incision. Usually the tendon can be attached to the soft tissue in the proximal humerus (the upper part of the arm bone that joins to the shoulder socket) directly to the bone by drilling a socket and attaching it with a bioabsorbable screw. This procedure avoids the 'popeye' appearance and cramping is less. There is only about 10-15% loss of straight movement compared to the opposite shoulder.
Physical therapy in case of a tenotomy can be started immediately to help regain movements in the shoulder. To stabilize the joint by anchoring the tendons, light physical therapy is started after a short period of rest in a sling. Active movements are started after about 3 weeks.

Shoulder Surgery:
Shoulder Pain:
SHOULDER PAIN
The most complex yet largest joint of the human bodycomprises thehumerus that is fitted into the scapula as a ball fits in a socket joint. Althogh shoulders are subjected to a lot of movement, the majority of injuries that occur in a shoulder may be treated without performing any surgeries.

Why Do I Get?

Shoulder pain could be due to an injury in the ligaments or tendons. Some common reasons which cause shoulder pain include:
•    Breakdown of soft tissues As one gets older, doing strenuous shoulder activities can lead to a faster breakdown of the soft tissues.
•    Strain Overexertion can affect your shoulder and lead to shoulder pain.
•    Tendonitis The soft tissues around the muscles become inflamed with overuse. This inflamed condition is known as tendonitis.
•    Dislocation An unnerving pain could be experienced with a dislocated shoulder.
•    Arm Bone Fracture Cancer or meningitis, fibromyalgia are some other reasons for neck pain.A fractured upper or collar arm bone can give one an upsetting shoulder pain.
Other factors include frozen shoulder and pinched nerves.
Shoulder Fracture(s)
 Pain can also occur in the shoulder from diseases or conditions that involve the shoulder joint, the soft tissues and bones surrounding the shoulder, or the nerves that supply sensation to the shoulder area. The clavicle and shoulder joint are the two common forms of shoulder fractures. to completely diagnose the precise cause of the shoulder pain. These include: A physical exam followed by appropriate tests recommended by the doctor will be required
•    X-Ray of the neck
•    MRI of the neck
•    CT Scan of the head or neck
•    Blood tests
•    EMG or NCV
Diagnosis:
A physical exam followed by appropriate tests recommended by the doctor will be required to completely diagnose the precise cause of the neck pain. These include:
•    X-Ray of the neck
•    MRI of the neck
•    CT Scan of the head or neck
•    Blood tests
Treatment:
Location of the fracture actually impacts the treatment that is provided to the patient with a fractured shoulder. Generally, shoulder pains can be treated with RICE!
•    (R) Rest Give your shoulder rest for about a day.
•    (I) Ice Pamper your shoulder with an ice-pack. Place it on your shoulder for about 20 minutes for about 4-8 times a day.
•    (C) Compression Bandage your shoulder tightly or compress the area where there is swelling.
•    (E) Elevation Keep the injured shoulder elevated above the heart's level; using a pillow could be helpful.
After a thorough diagnosis of the source of pain, generally, anti-inflammatory medication, antidepressants, pain relievers, pain relieving injections and so on may be provided to relieve shoulder pain.

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