Dr Gautam Tawari is one the best arthroscopist and has performed more than 2000 Shoulder arthroscopies. He has also proficiently performed primary Shoulder Replacements (Anatomic & Reverse) and more complex procedures like Revision Shoulder Replacements.
Shoulder Arthroscopy is a surgical technique to visualise, diagnose and treat problems inside the shoulder joint. Small incisions on the skin allow a pencil-sized camera and instruments to address the shoulder pain. Arthroscopic surgery allows for early rehabilitation, faster recovery and lesser pain.
Dr Tawari is a ex-UK consultant and is fellowship trained in sports surgery, Shoulder surgery, Elbow & Hand Surgery from the top & best surgeon from best centres in the UK.
Common Shoulder Problems and Related Information
Rotator Cuff Tear
The rotator cuff is a group of four muscles that comes together to form a large tendon called the “cuff” which allows the shoulder to move normally. Tears of the rotator cuff disrupts shoulder balance and causes dysfunctional movement, weakness, and pain.
Tears of the rotator cuff occurs from a traumatic shoulder injury (such as a fall), or due to gradual (chronic) breakdown over time.
The most common symptom of a rotator cuff tear is shoulder pain that is associated with weakness. The pain often radiate to the neck and upper arm, but rarely travels below the elbow. Patients often have significant pain at night and difficulty in sleeping.
Most rotator cuff tears will progress over time and lead to worsening shoulder function and arthritis requiring surgical repair. Non-surgical treatment of a rotator cuff tear or tendon inflammation usually consists of a short period of rest, anti-inflammatory medications and a short course of physiotherapy.
Surgical management of rotator cuff injuries, is most often done through a minimally invasive (arthroscopic) technique. Arthroscopy provides a full diagnostic tour of the joint, and allows for treatment of any other abnormalities seen. The torn rotator cuff is repaired back to bone using suture anchors and varying stitching techniques.
Full recovery (return to normal activities) can be expected by 4-6 months. Patients are required to wear a sling for 3 weeks after surgery. After the first 3 weeks, the sling is discontinued and physiotherapy is started. This progresses over 3 phases, and takes approximately 2-3 months. A gradual return to full activity is encouraged, and by six months, the shoulder is nearly back to normal except during strenuous sporting activity.
Frozen shoulder, also called adhesive capsulitis, occurs when shoulder capsule thickens and becomes tight. Stiff bands of tissue called adhesions develop in the shoulder.
The causes of frozen shoulder are not fully understood. Associated factors include – Diabetes, hypothyroidism, hyperthyroidism, Parkinson’s disease, cardiac disease and immobilisation for a significant period of time due to surgery or fracture or injury.
Dull or aching pain which is typically worse on movement of the arm and at night. The pain is usually located over the outer shoulder area and also sometimes the upper arm. There is reduced movement of the shoulder often causing significant disability.
Frozen shoulder eventually gets better over time, although it may take 2 years to 6 years
Non operative treatment consists of non-steroidal anti inflammatory drugs (NSAIDS) & physiotherapy. Steroid injection can aide pain and improve physiotherapy compliance.
Operative treatment consists of shoulder arthroscopy and release of the tight tissues around the joint. Most patients have very good outcomes with these procedures.
After surgery, physiotherapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 3 weeks to 9 weeks. Commitment to therapy is the most important factor in returning to all the activities you enjoy.
Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and greatly improved range of motion. In some cases, however, the motion does not return completely and a small amount of stiffness remains.
Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is present.
Shoulder instability is a problem that occurs when the structures that surround the shoulder joint do not work to maintain the ball within its socket.
Shoulder instability occurs when the head of the Humerus (arm bone) in forced out of the socket. This can happen as a result of a sudden injury or from overuse.
A severe injury cause the shoulder to become unstable by stretching or tearing the ligaments of the shoulder. When the ligaments of the shoulder are pulled away from the bone, this injury is called a “Bankart lesion.”
Common symptoms of shoulder instability include:
- Pain caused by shoulder injury
- Repeated shoulder dislocations
- Repeated instances of the shoulder giving way.
- A persistent sensation of the shoulder feeling loose, slipping in and out of the joint.
- Athletes with instability will have a feeling that the shoulder wants to “come out of socket”.
Physiotherapy with specific strengthening exercises helps to strength the shoulder and maintain the joint in proper position. This most likely helps patients with multi-directional instability.
Shoulder arthroscopy is necessary to stabalise the shoulder. Torn ligament can be repaired using anchors and loose capsule can also be tightened.
After surgery, arm is kept in a sling to avoid use 3 weeks. Full healing takes 3 – 4 months. Physiotherapy is carried out in 3-4 phases from 3 weeks onwards upto 3 months.
Surgical repair provides pain relief, improvement in strength and function, and patient satisfaction, however surgeons expertise is more important in achieving satisfactory results.
Acromioclavicular Joint (ACJ)
The acromioclavicular joint (ACJ) is a small joint between your collar bone (clavicle) and the part of your shoulder blade (scapula) known as the acromion.
The causes for pain in the ACJ are as follows:
- Trauma: Sports injuries and a fall on the shoulder.
- Osteoarthritis: Mostly seen in adults over the age of 30.
- Repetitive strain that may be due to sudden increases in activity.
- Bone injuries of the clavicle.
Pain over the top of the shoulder reproducible with pressure on the top of the shoulder joint. Pain present on lying on the side and increasing with overhead movements. Pain may also increase by lifting or carrying or trying to touch opposite shoulder. A small bump at the end of the collar bone can be felt.
- Rest in case of pain from injuries.
- Activity Modification.
- Simple pain killers and anti-inflammatories.
- Physiotherapy may help to maintain and improve your muscle strength to prevent further problems.
- A steroid injection into the AC joint may help to reduce inflammation and pain.
- Surgery is considered if other treatments do not provide benefit. The surgical technique most commonly used is arthroscopic excision of lateral end of clavicle (keyhole surgery).
After surgery, the arm is rested in a sling for 1-2 weeks. A phased exercise programme starts at 2 weeks and continues for 4-6 weeks. Full recovery is generally acquired by 3 months.
Any abnormality resulting in dysfunctioning of the rotator cuff causes it to rub against the Acromion (upper bone arch) resulting in inflammation of the bursa causing pain. This occurs each time the shoulder is moved and is called impingement.
Pathologies affecting the rotator cuff are :-
- Rotator cuff strain
- Partial or full thickness tear
- Calcific tendonitis
- A tendonopathy due to chronic overuse.
- Glenohumeral instability
- Labral tears, in particular SLAP tears
- Abnormal muscle patterning problems of the shoulder.
Pain that is sharp in nature and associated with movement of the shoulder. Pain can also affect sleep. Shoulder moves fully but with pain.
- Painkillers and anti-inflammatory medications
- Physiotherapy – Strengthening of the weakened rotator cuff muscles
- Injections – reduces inflammation and control the pain, allows the rotator cuff muscles a chance to recover and improve with the exercises
- Surgery – Increasing the amount of space between the acromion and the rotator cuff tendons, which will then allow for easier movement and less pain and inflammation. The operation performed is called Arthroscopic Subacromial Decompression (ASD)
After surgery, a sling is provided for 2-3 weeks only for comfort and the shoulder joint is allowed to be moved. Physiotherapy goes through 3 phases and full recovery generally takes 6 weeks to 12 weeks.
Calcific tendinitis (or tendonitis) occurs when calcium deposits builds up in the rotator cuff tendon. Calcific tendonitis is one of the most common causes of shoulder pain. Associated with performance of a lot of overhead motions, such as heavy lifting, or play sports like basketball or tennis.
It’s thought that calcium buildup may stem from:
- genetic predisposition
- abnormal cell growth
- abnormal thyroid gland activity
- bodily production of anti-inflammatory agents
- metabolic diseases, such as diabetes
Although it’s more common in people who play sports or routinely raise their arms up and down for work, calcific tendonitis can affect anyone.
The most common complaint is pain. The pain worsens with activities, especially with any activities that require the arms to reach over the head, and often affects sleep. Pain is sharp and unbearable. Restricted movements associated with pain is also present.
Non-steroidal anti-inflammatory medication form the mainstay of treatment. Physiotherapy helps to maintain movement and strengthen of shoulder.
Steroid injections provide relief, but this is often temporary.
Ultrasound guided needling of the tendon undertaken by experienced surgeon can provide relief of symptoms and may prevent surgery.
Surgery is recommended if the pain is intractable and not relieved with pain killers. The surgical technique most commonly used is shoulder arthroscopy with removal of calcium deposit carefully from within the tendon.
After surgery, the arm is rested in a sling for 1-2 weeks. A Phased exercise programme starts at 2 weeks and continues for 4-6 weeks. Full recovery is generally acquired by 3 months.
The biceps is a muscle in the upper arm that helps bend the elbow. It has a tendon in the shoulder joint.
This is caused by mechanical injury to the tendon heavy lifting and different types of sporting activities. Biceps tendon subluxation results in the setting of a subscapularis tear where the biceps actually dislocates from its normal position in the shoulder.
The most common complaint is pain in front of the shoulder; however, symptoms can be consistent with rotator cuff tears or arthritis of shoulder. These include pain with activity/overhead motion, weakness, and night pain. Motions such as bending the elbow, carrying heavy weights, and throwing movements can cause pain. On rare occasion, patients may feel a “pop” in the shoulder that is followed by severe pain.
Initial treatment is non-operative management. This includes anti-inflammatory medications & activity modification. If pain continues surgery may be required to alleviate pain.
Arthroscopic surgery involves either biceps tenotomy (cutting the tendon and letting it retract) or biceps tenodesis (cutting the tendon and pinning it to the arm bone). The downside of biceps tenotomy is appearance of a “popeye” deformity as the cut tendon retracts down the arm. Biceps tenodesis avoids the popeye deformity but the surgery may require an open incision. Recovery is prolonged after a tenodesis in comparison to a tenotomy.
A sling is required for the first 3 weeks, similar to a rotator cuff repair. In contrast, patients who have undergone a biceps tenotomy can return to activities as soon as they feel comfortable.
A dislocating biceps tendon in addition also requires repair of the torn subscapularis tendon.
The shoulder joint has a ring of labral tissue around the shoulder socket that stabilizes the head of the upper arm bone. A SLAP tear occurs when there is damage to the top of the labrum, or where the biceps tendon connects to the labrum.
SLAP is an acronym and stands for Superior (topmost) Labral tear from Anterior (front) to Posterior (back).
Injuries to the superior labrum can be caused by acute trauma or by repetitive shoulder motion. An acute SLAP injury may also result from :
- A motor vehicle accident
- A fall onto an outstretched arm
- Forceful pulling on the arm, such as when trying to catch a heavy object
- Rapid or forceful movement of the arm when it is above the level of the shoulder
- Shoulder dislocation
People who participate in repetitive overhead sports, such as throwing athletes or weightlifters, can also experience labrum tears as a result of repeated shoulder motion.
The most common symptoms of a SLAP tear include:
- A sensation of locking, popping, catching, or grinding
- Pain with movement of the shoulder or with holding the shoulder in specific positions
- Pain with lifting objects, especially overhead
- Decrease in shoulder strength
- A feeling that the shoulder is going to “pop out of joint”
- Decreased range of motion
- Athletes may also notice a decrease in their throw velocity, or the feeling of having a “dead arm” after repeated throws.
The initial treatment for a SLAP injury includes:
Non-steroidal anti-inflammatory medication. Physiotherapy with specific exercises that helps to restore movement and strengthen of shoulder.This exercise program is continued anywhere upto 3 months. Surgery is recommended if the pain does not improve.
The surgical technique most commonly used for repairing a SLAP injury is arthroscopy. An anchor is used to repair the torn tissue.
After surgery the arm is kept in a sling for 3-4 weeks to protected the repair while the labrum heals. A tailored physiotherapy program is then introduced which last for 4-6 weeks. Return to sports is generally at 4 – 6 months.
Osteoarthritis, or “degenerative joint disease,” is the commonest type of arthritis in the shoulder. Less commonly seen types of arthritis in the shoulder are Rheumatoid (inflammatory) arthritis and secondary arthritis after shoulder trauma. Shoulder arthritis occurs more commonly with advancing age.
In Osteoarthritis, the smooth cartilage that covers the ends of the bones gets worn away, causing the rough bone ends to rub against each that results in pain and loss of motion in the shoulder.
The most common complaint of someone with shoulder arthritis is pain. The pain worsens with activities, especially with any activities that require the arms to reach over the head, and decreases with rest. The next most common complaint is loss of motion, the motion of the shoulder can sometimes feel like grinding as the bones rub on one another.
Some people with severe joint destruction can also have very few symptoms.
As with most other arthritic conditions, initial treatment consists of:
- Activity modifications
- Exercises and physiotherapy
- Non-steroidal anti-inflammatory medications
Steroid injections are sometimes used as well. If these treatments do not work then surgery is helpful.
Surgery usually involves a joint replacement operation where the arthritic surfaces of the ball and socket are replaced. Based on the state of the muscles and tendons, replacement is undertaken either in the form of Anatomic Shoulder Replacement (where ball and socket are exchanged with like for like) or Reverse Shoulder Replacement (where ball is replaced to become socket & socket is replaced to act as a ball)