Shoulder Dislocation / Instability

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Shoulder instability is a problem that occurs when the structures that surround the glenohumeral (shoulder) joint do not work to maintain the ball within its socket. If the joint is too loose, is may slide partially out of place, a condition called shoulder subluxation. If the joint comes completely out of place, this is called a shoulder dislocation. Patients with shoulder instability often complain of an uncomfortable sensation that their shoulder may be about to slide out of place–this is what physicians call apprehension.
Shoulder instability tends to occur in three groups of people:

  • Prior Shoulder Dislocators. Patients who have sustained a prior shoulder dislocation often develop chronic instability. In these patients, the ligaments that support the shoulder are torn when the dislocation occurs. If these ligaments heal too loosely, then the shoulder will be prone to repeat dislocation and episodes of instability. When younger patients (less than about 35 years old) sustain a traumatic dislocation, shoulder instability will follow in about 80% of patients.
  • Young Athletes. Athletes who compete in sports that involve overhead activities may have a loose shoulder or multidirectional instability (MDI). These athletes, such as volleyball players, swimmers, and baseball pitchers, stretch out the shoulder capsule and ligaments, and may develop chronic shoulder instability. While they may not completely dislocate the joint, the apprehension, or feeling of being about to dislocate, may prevent their ability to play these sports.
  • “Double-Jointed” Patients. Patients with some connective tissue disorders may have loose shoulder joints. In patients who have a condition that causes joint laxity, or double-jointedness, their joints may be too loose throughout their body. This can lead to shoulder instability and even dislocations.

What is the treatment of shoulder instability?
Treatment of shoulder instability depends on several factors, and almost always begins with physical therapy and rehab. If patients complain of a feeling that their shoulder is loose or about to dislocate, physical therapy with specific strengthening exercises will often help maintain the shoulder in proper position. Shoulder strengthening is most likely to help the second group of patients athletes with multi-directional shoulder instability. Other treatments sometimes used to treat shoulder instability include injections and anti-inflammatory medications.

Will I need surgery for shoulder instability?
If therapy fails, there are surgical options that can be considered. Depending on the cause of the instability, the surgical treatments may be quite different.

If the cause of the shoulder instability is a loose shoulder joint capsule, then a procedure to tighten the capsule of the shoulder may be considered. This can be done with an arthroscope in a procedure called athermal capsular shrinkage. In this surgery, a heated probe shrinks the shoulder capsule to tighten the tissue. The more standard method of this procedure is called an open capsular shift. In this surgery, the shoulder joint is opened through a larger incision, and the capsule is tightened with sutures. The advantage of the open capsular shift is that the results are more predictable. The advantage of the arthroscopic procedure is that the recovery is faster and the incision is smaller. Sometimes a particular problem is better suited to one procedure or the other, discuss this with our surgeon.

If the problem is due to a tearing of the ligaments around the shoulder, called the labrum, then a procedure called a Bankart repair can be performed to fix this ligament. A Bankart repair can also be done either through an incision or an arthroscope. Again, the results of the open procedure are more predictable (more patients get better), but the arthroscopic procedure does not leave as large an incision.

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Shoulder Arthritis

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Osteoarthritis is the most common type of shoulder arthritis. Also called wear-and-tear arthritis or degenerative joint disease, osteoarthritis is characterized by progressive wearing away of the cartilage of the joint. As the protective cartilage surface of the joint is worn away by shoulder arthritis, bare bone is exposed within the shoulder.

The other common type of shoulder arthritis is rheumatoid arthritis. Rheumatoid arthritis is a systemic condition that causes inflammation of the lining of the joints. This inflammation can, over time, invade and destroy the cartilage and bone.

Who develops Shoulder Arthritis?

Shoulder arthritis typically affects patients over 50 years of age. It is more common in patients who have a history of prior shoulder injury. There is also a genetic predisposition of this condition, meaning shoulder arthritis tends to run in families.

What are the common symptoms of Shoulder Arthritis?

Shoulder arthritis symptoms tend to progress as the condition worsens. What is interesting about shoulder arthritis is that symptoms do not always progress steadily with time. Often patients report good months and bad months, or symptom changes associated with weather changes. This is important to understand because comparing the symptoms of arthritis on one particular day may not accurately represent the overall progression of the condition.

The most common symptoms of shoulder arthritis are:

  • Shoulder Pain with activities
  • Limited range of motion
  • Stiffness of the shoulder
  • Swelling of the joint
  • Tenderness around the joint
  • A feeling of grinding or catching within the joint

Evaluation of a patient with shoulder arthritis should begin with a physical examination and x-rays. These can serve as a baseline to evaluate later examinations and determine progression of the condition.

What is the treatment for Shoulder Arthritis?

Treatment of shoulder arthritis should begin with the most basic steps, and progress to the more involved, possibly including surgery. Not all treatments are appropriate in every patient, and you should have a discussion with your doctor to determine which treatments are appropriate for your shoulder arthritis.

  • Shoulder Exercises
  • Physical Therapy
  • Anti-Inflammatory Medicines
  • Anti-Inflammatory Injections
  • Joint Supplement (Glucosamine)
  • Shoulder Arthroscopy
  • Shoulder Replacement Surgery

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Frozen Shoulder (Adhesive Capsulitis)

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Definition of frozen shoulder:

Frozen shoulder, or adhesive capsulitis, is a condition that causes restriction of motion in the shoulder joint. The cause of a frozen shoulder is not well understood, but it often occurs for no known reason. Frozen shoulder causes the capsule surrounding the shoulder joint to contract and form scar tissue.

What causes frozen shoulder?

Most often, frozen shoulder occurs with no associated injury or discernible cause. There are patients who develop a frozen shoulder after a traumatic injury to the shoulder, but this is not the usual cause. Some risk factors for developing a frozen shoulder include:
  • Age & Gender
    Frozen shoulder most commonly affects patients between the ages of 40 to 60 years old, and it is twice as common in women than in men.
  • Endocrine Disorders
    Patients with diabetes are at particular risk for developing a frozen shoulder. Other endocrine abnormalities, such as thyroid problems, can also lead to this condition.
  • Shoulder Trauma or Surgery
    Patients who sustain a shoulder injury, or undergo surgery on the shoulder can develop a frozen shoulder joint. When injury or surgery is followed by prolonged joint immobilization, the risk of developing a frozen shoulder is highest.
  • Other Systemic Conditions
    Several systemic conditions such as heart disease and Parkinson’s disease have also been associated with an increased risk for developing a frozen shoulder.

What happens with a frozen shoulder?

No one really understands why some people develop a frozen shoulder. For some reason, the shoulder joint becomes stiff and scarred. The shoulder joint is a ball and socket joint. The ball is the top of the arm bone (the humeral head), and the socket is part of the shoulder blade (the glenoid). Surrounding this ball-and-socket joint is a capsule of tissue that envelops the joint.
Normally, the shoulder joint allows more motion than any other joint in the body. When a patient develops a frozen shoulder, the capsule that surrounds the shoulder joint becomes contracted. The patients form bands of scar tissue called adhesions. The contraction of the capsule and the formation of the adhesions cause the frozen shoulder to become stiff and cause movement to become painful.
A frozen shoulder causes a typical set of symptoms that can be identified by your doctor. The most important finding is restricted movement. Other shoulder conditions can cause difficulty with movement of the shoulder, such as a rotator cuff tear; therefore it is important to have an examiner familiar with this condition for a proper diagnosis.

What are the typical symptoms of frozen shoulder?

  • Shoulder pain; usually a dull, aching pain
  • Limited movement of the shoulder
  • Difficulty with activities such as brushing hair, putting on shirts/bras
  • Pain when trying to sleep on the affected shoulder

What are the stages of frozen shoulder?

  • Painful/Freezing Stage
    This is the most painful stage of a frozen shoulder. Motion is restricted, but the shoulder is not as stiff as the frozen stage. This painful stage typically lasts 6-12 weeks.
  • Frozen Stage
    During the frozen stage, the pain usually eases up, but the stiffness worsens. The frozen stage can last 4-6 months.
  • Thawing Stage
    The thawing stage is gradual, and motion steadily improves over a lengthy period of time. The thawing stage can last more than a year.

What test are needed to diagnose frozen shoulder?

Most often, a frozen shoulder can be diagnosed on examination, and no special tests are needed. An x-ray is usually obtained to ensure the shoulder joint appears normal, and there is not evidence of traumatic injury or arthritic changes to the joint. An MRI is sometimes performed if the diagnosis is in question, but this test is better at looking for other problems, rather than looking for frozen shoulder. If an MRI is done, it is best performed with an injection of contrast fluid into the shoulder joint prior to the MRI. This will help show if the capsule of the shoulder is scarred down, as would be expected in patients with a frozen shoulder.

What are the treatment options available for frozen shoulder?

Frozen shoulder treatment primarily consists of pain relief and physical therapy. Most patients find relief with these simple steps, although the entire treatment process can take several months or longer.
  • Exercises and Stretching
    Stretching exercises for frozen shoulder serves two functions:

    • First, to increase the motion in the joint
    • Second, to minimize the loss of muscle on the affected arm (muscle atrophy)
    The importance of stretching and exercises cannot be overemphasized as these are the key to successful frozen shoulder treatment. Patients cannot expect to have successful frozen shoulder treatment if they perform exercises only when working with a therapist. These exercises and stretches must be performed several times daily.
  • Moist Heat
    Applications of moist heat to the shoulder can help to loosen the joint and provide relief of pain. Patients can apply moist heat to the shoulder, then perform their stretching exercises–this should be done at least three times daily. Moist heat can be applied by using a hot-soaked washcloth on the joint for 10 minutes before stretching.
  • Physical Therapy
    Physical therapists can help a patient develop a stretching and exercise program, and also incorporate ultrasound, ice, heat, and other modalities into the rehabilitation for frozen shoulder. As said previously, it is important that patients perform their stretches and exercise several times daily–not only when working with the therapist.
  • Anti-inflammatory Medications
    Anti-inflammatory medications have not been shown to significantly alter the course of a frozen shoulder, but these medications can be helpful in offering relief from the painful symptoms.
  • Anti-Inflammatory Injections
    Anti-Inflammatory  injections are also commonly used to decrease the inflammation in the frozen shoulder joint. This can help to decrease pain, and in turn allow for more stretching and physical therapy.

Will i need surgery for frozen shoulder?

If the above treatments do not resolve the frozen shoulder, occasionally a patient will need to have surgery. If this is the case, the surgeon may perform a manipulation under anesthesia. A manipulation is performed with the patient sedated under anesthesia, and the doctor moves the arm to break up adhesions caused by frozen shoulder. There is no actual surgery involved, meaning incisions are not made when a manipulation is performed. Manipulation under Anaesthesia has very good result in treating frozen shoulder to whom that priorly only diagnosed with Frozen Shoulder without other shoulder problem. This procedure is very simple to do and only need 30 minutes to perform. This procedure is usually to be done under daycase. Patient will experience the improvement almost immediately after the procedure.

Alternatively, an arthroscope can be inserted into the joint to cut through adhesion. This procedure is called an arthroscopic capsular release. Surgical capsular release of a frozen shoulder is rarely necessary, but it is extremely useful in cases of frozen shoulder that do not respond to therapy and rehab. If surgery is performed, immediate physical therapy following the capsular release is of utmost importance.

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Calcific Tendonitis

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What is Calcific Tendonitis?

Calcific tendonitis is a condition that causes the formation of a small, usually about 1-2 centimeter size, calcium deposit within the tendons of the rotator cuff. These deposits are usually found in patients at least 30-40 years old, and have a higher incidence in diabetics. The calcium deposits are not always painful, and even when painful they will often spontaneously resolve after a period of 1-4 weeks.

What is the causes of Calcific Tendontis?

The cause of calcium deposits within the rotator cuff tendon is not entirely understood. Different ideas have been suggested, including blood supply and aging of the tendon, but the evidence to support these conclusions is not clear.

How does Calcific Tendonitis Progress?

Calcific tendonitis usually progresses predictably, and almost always resolves eventually without surgery. The typical course is:

  • Precalcification Stage
    Patients usually do not have any symptoms in this stage. At this point in time, the site where the calcifications tend to develop undergo cellular changes that predispose the tissues to developing calcium deposits.
  • Calcific Stage
    During this stage, the calcium is excreted from cells and then coalesces into calcium deposits. When seen, the calcium looks chalky, it is not a solid piece of bone. Once the calcification has formed, a so-called resting phase begins, this is not a painful period and may last a varied length of time. After the resting phase, a resorptive phase begins–this is the most painful phase of calcific tendonitis. During this resorptive phase, the calcium deposit looks something like toothpaste.
  • Postcalcific Stage
    This is usually a painless stage as the calcium deposit disappears and is replaced by more normal appearing rotator cuff tendon.

What are the treatment options available for Calcific Tendonitis?

Patients usually seek treatment during the painful resorptive phase of the calcific stage, but some patients have the deposits found incidentally as part of their evaluation impingement syndrome.

Nonoperative treatment is nearly always the first line of treatment for calcific tendonitis. The treatment protocol is similar to the treatment for impingement syndrome of the shoulder. This includes:

  • Physical Therapy/Exercises
    Exercises and stretching can help prevent a stiff shoulder. One of the most difficult problems associated with calcific tendonitis is the development of a frozen shoulder because of pain. Exercises can help prevent this problem from occurring.
  • Anti-Inflammatory Medications
    Anti-inflammatory medications can help treat the pain associated with the calcific tendonitis. No studies have shown a significant change in the time course of symptoms with these medications, but patients certainly have lessened symptoms.

When is surgery necessary?

Surgery is recommended in the following situations:

  • When symptoms continue to progress despite treatment
  • When constant pain interferes with routine activities (dressing, combing hair)
  • When symptoms do not respond to conservative care

Available treatment options include needling and aspiration of the calcium deposit and excision of the calcium deposit.

Needling is a procedure that is done under sedation or general anesthesia. Our surgeon will direct a large needle into the calcium deposit and attempt to aspirate, or suck out, as much of the calcium deposit as possible. Injections of saline, novocaine, is then performed into the calcium deposit. Patients can resume activity shortly after the procedure.

Excision of the deposit is a larger procedure, but may be necessary, especially is cases of chronic calcific tendonitis. Either through a small incision or through the use of shoulder arthroscopy, the calcium deposit is identified and removed. Physical therapy is usually necessary after this procedure to help regain strength and motion in the affected shoulder.

Are other treatments available for Calcific Tendonitis?

Over the last decade, several reports have shown successful treatment of chronic calcific tendonitis with the use of shockwave therapy. Shockwave therapy is thought to work by inducing so-called ‘microtrauma’ and stimulates blood flow to the affected area. Most reports on this method of treatment of calcific tendonitis show guarded success–perhaps 50-70% of patients improving after one or two high-energy shockwave treatments.

This treatment of calcific tendonitis can be painful, and usually requires anesthesia in order for it to be tolerated by the patient. The good news is that there is a very low complication rate from shockwave therapy. Most patients will develop a hematoma (bruising) from the treatment, but otherwise there are very few complications.

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Biceps Tendon Rupture

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What is a biceps tendon rupture?

A biceps tendon rupture is an injury that occurs to the biceps tendon causing the attachment to separate from the bone. A normal biceps tendon is connected strongly to the bone. When the biceps tendon ruptures, this tendon is detached. Following a biceps tendon rupture, the muscle cannot pull on the bone, and certain movements may be weakened and painful.

There are two types of biceps tendon ruptures:

  • Proximal Biceps Tendon Ruptures
    A proximal biceps tendon rupture is an injury to the biceps tendon at the shoulder joint. This injury type is the most common type of biceps tendon injury. It is most common in patients over 60 years of age, and often causes minimal symptoms.
  • Distal Biceps Tendon Ruptures
    The distal biceps tendon is injured around the elbow joint. This is usually an injury that occurs with heavy lifting or sports in middle-aged men. Most patients with a distal biceps rupture will have surgery to repair the torn tendon.
  • Rupture of the proximal head of the biceps tendon involves one of two heads of the biceps tendon. This condition usually occurs in older individuals and is caused by degenerative changes within the biceps tendon leading to failure of the structure. Most patients have preceding shoulder pain consistent with impingement syndrome or a rotator cuff tear. The proximal biceps tendon rupture may then occur during a trivial activity, and some patients may experience some pain relief once the damaged tendon ruptures.The proximal biceps tendon can rupture in a younger patient with activities such as weight-lifting or throwing sports, but this is quite unusual.

What are the causes of Biceps Tendon Rupture?

Biceps ruptures generally occur in people who are between 40 and 60 years old. People in this age group who’ve had shoulder problems for a long time are at most risk. Often the biceps ruptures after a long history of shoulder pain from tendonitis (inflammation of the tendon) or problems with shoulder impingement. Shoulder impingement is a condition where the soft tissues between the ball of the upper arm and the top of the shoulder blade (acromion) get squeezed with arm motion.

Years of shoulder wear and tear begin to fray the biceps tendon. Eventually, the long head of the biceps weakens and becomes prone to tears or ruptures. Examination of the tissues within most torn or ruptured biceps tendons commonly shows signs of degeneration. Degeneration in a tendon causes a loss of the normal arrangement of the collagen fibers that join together to form the tendon. Some of the individual strands of the tendon become jumbled due to the degeneration, other fibers break, and the tendon loses strength.

A rupture of the biceps tendon can happen from a seemingly minor injury. When it happens for no apparent reason, the rupture is called nontraumatic.

Aging adults with rotator cuff tears also commonly have a biceps tendon rupture. When the rotator cuff is torn, the ball of the humerus is free to move too far up and forward in the shoulder socket and can impact the biceps tendon. The damage may begin to weaken the biceps tendon and cause it to eventually rupture.

What are the symptoms of a proximal biceps tendon rupture?
Usually patients will have sudden pain associated with an audible snap in the area of their shoulder. The pain is usually not significant, and, as mentioned previously, some patients may experience pain relief after the rupture. After the ruptured tendon retracts, patients may notice a bulge in their arm at the biceps muscle. This is the retracted muscle bunched up in the arm, and is sometime referred to as a “Popeye Muscle,” because the muscle is more pronounced than normal.

What is the treatment for a proximal biceps tendon rupture?
Patients usually do not notice any loss of arm or shoulder function following a proximal biceps tendon rupture. A slight bulge in the arm, and some twitching of the retracted muscle are usually the most significant symptoms. Surgical repair of the proximal biceps tendon is usually only considered in the case of a younger patient who is more active.

The reason there is little functional loss following a proximal biceps tendon rupture is that there are actually two tendinous attachments of the biceps at the shoulder joint (that is why the muscle is named “bi-ceps,” meaning two heads). When the rupture occurs at the distal biceps tendon at the elbow, where there is only one attachment, surgical repair is much more commonly needed.

If pain persists following a proximal biceps tendon rupture, other causes of shoulder pain should be considered. These include impingement syndrome (rotator cuff bursitis), rotator cuff tears, or fractures around the shoulder.

Rupture of the distal biceps tendon at the elbow joint is much less common and accounts for less than 5% of biceps tendon ruptures. This injury is also usually found in middle-aged patients, although not always. There is usually some degree of tendinosus, or degenerative changes within the tendon, that predisposes the patient to rupture of the tendon.

The significance of a distal biceps tendon rupture is that without surgical repair, patients who experience complete rupture of the distal biceps tendon will notice loss of strength at the elbow. The strength will affect both the ability to bend the elbow against resistance, and the ability to turn the forearm to the palm-up position against resistance (for example, turning a doorknob or screwdriver).

What are the symptoms of distal biceps tendon rupture?
Distal biceps tendon rupture is characterized by sudden pain over the front of the elbow after a forceful effort against a flexed elbow. Usually the patient will hear a snap and have pain where the tendon rupture occurs. Swelling and bruising around the elbow are also common symptoms of distal biceps tendon rupture.

What is the treatment of distal biceps tendon rupture?
Most patients will experience benefit if the biceps tendon is repaired surgically. If the tear is incomplete, or if the patient is very low-demand (not active), then surgery may not be needed. However, most patients who want more normal use of their arm will benefit from surgery to repair the ruptured tendon to the bone.

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Shoulder pain

Dr Ambrose Yung Knee, Sports and Orthopaedic Centre Knee, Sports and Orthopaedic Clinic

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Shoulder pain are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. The injuries to the shoulder can, and do, cause a lot of pain. Usually the pain is related to a particular function or task but often times the pain becomes more prevalent throughout the day.

What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion in the arm from scratching your back to throwing the perfect pitch.

Mobility has its price, however. It may lead to increasing problems with instability or impingement of the soft tissue or bony structures in your shoulder, resulting in pain. You may feel pain only when you move your shoulder, or all of the time. The pain may be temporary or it may continue and require medical diagnosis and treatment.

This article explains some of the common causes of shoulder pain, as well as some general treatment options. Our doctor can give you more detailed information about your shoulder pain.

Some common Shoulder Pain conditions include:

  • BURSITIS / ROTATOR CUFF TENDONITIS – Rotator cuff tendonitis is an inflammation (irritation and swelling) of the tendons of the shoulder.
  • ROTATOR CUFF TEAR – The rotator cuff is made up of four muscles that help move and stabilize the shoulder joint. Damage to any one of the four muscles or their ligaments that attach the muscle to bone can occur because of acute injury, chronic overuse, or gradual aging.
  • FROZEN SHOULDER – is a condition that causes restriction of motion in the shoulder joint. The cause of a frozen shoulder is not well understood, but it often occurs for no known reason.
  • CALCIFIC TENDONITIS – Calcific tendonitis is a condition that causes the formation of a small, usually about 1-2 centimeter size, calcium deposit within the tendons of the rotator cuff.
  • SHOULDER INSTABILITY / DISLOCATION – Shoulder instability is a problem that occurs when the structures that surround the glenohumeral (shoulder) joint do not work to maintain the ball within its socket.
  • LABRAL TEAR – The shoulder joint is a ball and socket joint, similar to the hip; however, the socket of the shoulder joint is extremely shallow, and thus inherently unstable.
  • SLAP LESION – A SLAP tear is an injury to a part of the shoulder joint called the labrum. The shoulder joint is a ball and socket joint, similar to the hip; however, the socket of the shoulder joint is extremely shallow, and thus inherently unstable.
  • ARTHRITIS – Osteoarthritis is the most common type of shoulder arthritis. Also called wear-and-tear arthritis or degenerative joint disease, osteoarthritis is characterized by progressive wearing away of the cartilage of the joint.
  • BICEPS TENDON RUPTURE – A biceps tendon rupture is an injury that occurs to the biceps tendon causing the attachment to separate from the bone. A normal biceps tendon is connected strongly to the bone.

When do you need to call us about your shoulder pain?
If you are unsure of the cause of your shoulder pain, or if you do not know the specific treatment recommendations for your condition, you should seek medical attention. Treatment of these conditions must be directed at the specific cause of your problem. Some signs that you should be seen by a doctor include:

  • Inability to carry objects or use the arm
  • Injury that causes deformity of the joint
  • Shoulder pain that occurs at night or while resting
  • Shoulder pain that persists beyond a few days
  • Inability to raise the arm
  • Swelling or significant bruising around the joint or arm
  • Signs of an infection, including fever, redness, warmth
  • Any other unusual symptom

What are the best treatments for shoulder pain?
The treatment of shoulder pain depends entirely on the cause of the problem. Therefore, it is of utmost importance that you understand the cause of your symptoms before embarking on a treatment program. If you are unsure of your diagnosis, or the severity of your condition, you should seek medical advice before beginning any treatment.

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