The Shoulder is the commonest joint to dislocate. Once it dislocates, subsequent dislocations easily occur when the arm is brought into the vulnerable position. Usually, the first dislocation occurs due to a violent injury like a fall and in a few patients the dislocation is predisposed by the looseness of the joint.

Most often, the shoulder comes out in the front, and this is called anterior dislocation. Posterior dislocation is when the shoulder comes out in the back, but this is quite rare. In some cases, the shoulder does not come out of the joint completely, and this partial dislocation is called subluxation.

The type and duration of immobilization or strapping following first dislocation does not play a significant role in prevention of recurrence. Hence once dislocated, the patient is prone for more dislocations. A patient with shoulder instability has to live with the constant fear of shoulder dislocation. With each dislocation, the bone of the cup (glenoid) is eroded. In late cases up to 50 % of the bone may be found eroded.

Investigations : X-rays - special views, MRI (not required in all).

Arthroscopy of the shoulder is a great boon to the treatment of shoulder dislocation. In Arthroscopy, three small holes are created in the front and back of shoulder, through which delicate instruments and telescopes are passed into the joint. The inside of the joint is visualized in the TV monitor. During dislocation, the labrum along with ligaments is pulled off from the glenoid rim (Bankart's lesion). By arthroscopy, the torn labrum along with the displaced ligaments are brought into their original position over the glenoid rim and fixed using implants called suture anchors. A suture anchor is a tiny screw with a thread attached to it. The screw part goes into the bone and the sutures hold on to the labrum. The repair requires the use of delicate instruments and knot management techniques. In addition, any looseness of the joint, if present, is treated by reducing the volume of the joint by a procedure called capsular plication.

All shoulder dislocations can be treated arthroscopically, but in a small percentage that present very late with bony deficiency, additional open procedure for a bone transfer becomes essential. People whose shoulder instability is mainly due to looseness of the capsule (joint laxity), may need an open procedure (Capsular Shift) to tighten the joint.

A torn rotator cuff seen arthroscopically

Rotator cuff refers to a group of 4 muscles that surround the head of the humerus (arm bone). The muscles constituting rotator cuff are supraspinatus, subscapularis, infraspinatus and teres minor. The functions of these muscles include elevation of the arm, rotation of the arm and stabilization of shoulder. Most of the tears in the cuff are due to degeneration of the tissue because of advancing age. However traumatic events like falls could also cause the tear. The supraspinatus is the commonest muscle to tear followed by infraspinatus and subscapularis.

The supraspinatus passes under a bony part of the shoulder blade called acromion. For smooth movement between the bone and the muscle, there is a lubricating fluid filled sac called bursa. When this is inflamed (Bursitis), it could result in pain. The tendon itself could be inflamed (Tendonitis) partially torn (Partial tear) or completely torn (Full thickness tear). The term impingement refers to the pain produced by the abnormal rubbing of the muscle under the bone. It is non-specific and it can indicate tendonitis as well as partial tears.

Patients with a torn rotator cuff have localized pain in the shoulder, which increases while elevating the shoulder and while lying on the same side. If the partial tear is significant, the patient may also have weakness in elevating the shoulder. In case of complete tear, the patient has profound weakness in elevating the shoulder and cannot maintain the elevated position of the arm (Drop Arm sign).

Many partial tears progressively enlarge with time. The initial treatment for tendonitis and small partial tears is conservative, with activity modification, physiotherapy and subacromial injections. If patient does not get any relief, arthroscopy is carried out.

Full thickness tears are to be treated immediately as delay in treatment leads to retraction of the torn edges, making the treatment difficult. They are repaired arthroscopically or by mini-open method.

In cases of chronic rotator cuff deficiency, the head of humerus migrates superiorly, due to the absence of stabilizing action of the cuff muscles. The head rubs against the acromion bone, resulting in severe erosive arthritis of the humeral head, causing a condition called rotator cuff arthropathy. At that stage, only prosthetic replacement of the shoulder joint will give relief.

Rotator Cuff Problems in Sportspersons

Sportspersons develop rotator cuff problems quite frequently. But the causative factors are different from those of the elderly. The rotator cuff damage mostly occurs in the inner side of the joint and is commonly due to tightness of the back portion of the joint capsule and an excessive outward rotation of the joint. The mainline of treatment is physiotherapy consists of exercises. Arthroscopy is done only if the course of physiotherapy is unsuccessful.

Investigations: X-rays - AP view, Outlet views, Ultrasound, MRI.

Arthroscopic Management of Rotator Cuff Tear:

The rotator cuff is visualized arthroscopically, both from above and from below. The torn area is identified. The inflamed bursa is excised (subacromian decompression) and the bony surface of the undersurface of the acromion is smoothened (acromioplasty). The Rotator cuff is evaluated, partial tears less than 50 % thickness are debrided and those more than 50 % thickness are repaired, as they are likely to progress to complete tears. The torn edges of the cuff tendon are mobilized and brought back to their place of insertion and repaired with suture anchors.

A torn rotator cuff seen arthroscopically

Stiffness of shoulder is common in elderly patients. It is called periarthritis or adhesive capsulitis or frozen shoulder. The exact reason for the occurrence of this problem is not known. This condition is characterized by the thickening and contracture of the joint capsule. It is commonly seen in diabetics, patients undergoing cardiac procedures, hypo or hyperthyroidism. Minor injury or immobilization could also result in the development of this condition. Patients may have severe disability in doing day-to-day work and have difficulty lying on the same side.

This disorder runs a protracted course and settles down on its own after 12 to 24 months.

Stage I: The first three to six months is characterized by pain and development of progressive stiffness.

Stage II: The second three to six months is characterized by lessening of pain but stiffness persists.

Stage III: The stiffness gradually decreases over the ensuing 6 to 12 months. Some may take up to 26 months to improve. In many the recovery may not be fully complete.

Treatment of Stiff Shoulder

Non-operative treatment: The primary goal in treatment is reduction of pain by rest, ice, analgesics and modified activity. Next, the stiffness is improved by an exercise program.

Intra-articular injections: Injection of saline with or without steroids into the joint may give temporary relief in some patients.

Manipulation under anaesthesia: In this procedure, the patient is put to sleep and the shoulder is moved in all directions with force. The tight capsule is torn and the shoulder regains movements. If not done properly it could result in fracture of the arm bone. We do not practice this technique currently.

Arthroscopy is indicated when the pain and stiffness is intolerable and does not respond to standard physiotherapy measures. Surgery consists of removing the diseased tissues and releasing the tight portions of the capsule. The shoulder is gently moved at the end of the procedure to regain movement. Surgery is followed by physiotherapy.

Shoulder pain is a common complaint among patients seeking medical care. It could be caused by many factors. Most of the time, a clear diagnosis can be made after clinical examination, but occasionally investigations like X-ray, CT or MRI are required to arrive at the diagnosis. Some of the causes of shoulder pain are:

Tendinitis: A tendon is a cord-like tissue that connects muscles with the bone. Inflammation of rotator cuff tendons and biceps tendon due to repetitive activity or overuse is a common cause of shoulder pain.

Bursitis: A bursa is a fluid filled sac, which lubricates the movements between the tendons and bones around the shoulder. Any inflammation of this bursal tissue could also result in pain.

Rotator cuff tear: A torn rotator cuff could produce pain on elevation of shoulder and by lying on the same side. An ultrasound scan or an MRI will clearly define the tear.

Labral tear: A labral tear occurring in the front part of the shoulder is called Bankart's lesion, which is found in dislocating shoulders. It gives rise to pain as well as fear of impending dislocation in certain arm positions. A torn labrum in the superior portion of labrum (SLAP lesion) is also a significant cause of pain in sportspersons participating in throwing activities. It results in pain in certain positions of arm and clicking sounds.

Frozen shoulder: Pain along with stiffness is characteristic of this condition. The age group affected is above 40 years.

AC joint arthritis: The joint between the outer end of the collar bone and the tip of the shoulder blade (acromio-clavicular joint) could get damaged due to injury or arthritis and give raise to pain.

Biceps tendonitis: Biceps is a powerful muscle present in the front of the arm. Its tendon originates from inside the joint. If the tendon is damaged by repetitive use of the arm, it can lead to pain in the shoulder.

Referred pains: Many a times, shoulder pain originates from compression of nerves in the spinal cord in the neck region due to a disc prolapse or cervical spondylosis. Clinical examination and investigations will differentiate between these two. Intra-thoracic and Intra-abdominal conditions also produce shoulder pain due to overlapping nerve supply.

The term SLAP stands for Superior Labrum Anterior Posterior. This refers to the damage or tear of labrum of the superior part of the shoulder joint. Its diagnosis and treatment is by arthroscopy only. Even MRI can miss the diagnosis. This lesion is commonly seen in sportspersons involved in throwing and overhead sports (volleyball, baseball). It is also seen in people who have sustained a fall, landing on their hand. Many types of lesions in the superior labrum have been described and treatments vary according to the type. Tightness of the posterior part of the shoulder capsule is observed often in these shoulders. It is important to correct this tightness by physiotherapy before surgery.

Treatment: Minor frayings of the labrum are smoothened. A detached labrum is reattached to the bone by means of suture anchors. Unstable segments are removed. The surgery is followed by a program of exercises. Return to sports is possible after 5 to 6 months from surgery.