Shoulder

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Rotator Cuff Injury

The rotator cuff is a group of 4 muscles which helps to stabilise and move the shoulder joint. Rotator cuff injuries can range from shoulder impingement/tendinitis to partial or complete tears.

Rotator cuff injuries can occur due to degeneration (wear and tear) or trauma (fall/dislocation).

Risk factors for developing rotator cuff injuries include increasing age (due to a reduced blood supply) and repetitive overhead activities (due to impingement from bone spurs).

Occasionally, a rotator cuff tear can also occur from a traumatic injury to the shoulder or a shoulder dislocation.

Rotator Cuff Injury

  • Patients with rotator cuff injuries may present with the following symptoms:

    Shoulder pain

    Usually made worse by overhead activities

    Shoulder weakness

    Difficulty sleeping on the affected side

    Difficulty in returning to sports/work

  • Clinical assessment will include taking a detailed history and a thorough examination of your shoulder.

    Further imaging tests like X-rays, MRI scans and ultrasound scans may occasionally be required.

  • If you have any of the symptoms above, it is advisable to see an orthopaedic specialist for further assessment.

    The appropriate treatment is decided after assessment and a collaborative discussion based on your needs.

    They can be broadly divided into conservative (non-surgical) and surgical options.

  • Non-surgical measures will usually be recommended first if you have not had any prior treatment for your rotator cuff injury.

    These may include a combination or all of the following measures:

    Rest
    reduce overhead activities to minimise further impingement

    Cold packs
    to reduce swelling

    Medications
    anti-inflammatory drugs to reduce pain and swelling

    Physiotherapy
    to strengthen the shoulder muscles and improve range of motion

    Cortisone injection
    this may sometimes be required if the pain is persistent

  • If your shoulder pain and weakness is persistent despite all the above measures, surgery may sometimes be required.

    The appropriate surgical treatment will depend on the nature of the tear (size, duration) as well as your needs (age, functional demands).

    The surgery is typically performed in a minimally-invasive fashion (keyhole) and involves re-attaching the tendon to the bone (if reparable) or a superior capsular reconstruction (if not repairable).

    Occasionally, a shoulder replacement (reverse shoulder arthroplasty) may be required if shoulder arthritis has already developed.

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Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is a condition where the shoulder joint has a loss of motion
(ie ‘frozen’). This occurs when there is thickening of the capsule surrounding the shoulder joint. 

A classical frozen shoulder follows the following stages: 
Freezing — starts with a significant amount of pain but has an acceptable amount of shoulder movement
Frozen — develops more stiffness and restriction in movement, but pain reduces
Thawing — gradual return of movement

This condition can be prolonged, and it can take up to 2-3 years for full recovery.
Frozen shoulder can be classified into two categories:

Primary frozen shoulder (idiopathic)
The primary cause of the frozen shoulder is unknown. However, research has shown people with diabetes are more prone to develop frozen shoulders. It most commonly affects people between the ages of 40 and 60, and occurs in women more often than men.

Secondary frozen shoulder
Clear evidence of trauma and usually involves structural changes within or adjacent to the joint, such as fractures and tendon injuries.

Frozen Shoulder

  • Symptoms of frozen shoulder depend on the stage of the condition:

    Persistent, severe shoulder pain (especially in the early, freezing stage)

    Loss of normal ability to move in all directions, especially in outward rotation

    Difficulty in performing activities of daily living

    “Grinding” when moving your shoulder

  • Clinical assessment will include taking a detailed history and a thorough examination of your shoulder.

    Further imaging tests like X-rays, MRI scans and ultrasound scans may occasionally be required.

  • If you have any of the symptoms above, it is advisable to see an orthopaedic specialist for further assessment.

    The appropriate treatment is decided after assessment and a collaborative discussion based on your needs.

    They can be broadly divided into conservative (non-surgical) and surgical options.

  • Non-surgical measures will usually be recommended first if you have not had any prior treatment for your frozen shoulder.

    These may include a combination or all of the following measures:

    Medications
    anti-inflammatory drugs to reduce pain and swelling

    Physiotherapy
    release the adhesions and improve the range of movement

    Cortisone injection
    this may sometimes be required if the pain is persistent

  • If your shoulder pain and stiffness is persistent despite all the above measures, surgery may sometimes be required to aid your recovery.

    The appropriate surgical treatment will depend on the severity of the frozen shoulder and whether there are any associated conditions (ie rotator cuff tears) that need to be addressed.

    The surgery is typically performed in a minimally-invasive fashion (keyhole) and involves releasing the thickened capsule (capsular release). This is often combined with a manipulation of the shoulder to break down all remaining adhesions.

    Any other associated conditions (ie rotator cuff tears) can also be addressed at the same time.

    To prevent recurrence, it is important to start intensive rehabilitation after the surgery to prevent the adhesions from forming again.

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Shoulder Dislocation

The shoulder is a ball-and-socket joint that is very mobile, which makes it susceptible to dislocations.

Stability of the shoulder is increased by the presence of structures such as the labrum which helps deepen the socket.

A dislocation occurs when the head of the humerus (ball) pops out of the socket.

This typically occurs during contact sports but can also occur from a traumatic injury to the shoulder.

Risk factors for shoulder dislocation include those who participate in contact sports (rugby, ice hockey) or overhead activities (bouldering, racket sports). You may also be predisposed to shoulder dislocations if you have generalised ligamentous laxity.

Shoulder Dislocation

  • Patients with a shoulder dislocation may present with the following symptoms:

    Shoulder pain

    Deformity of the shoulder

    Swelling or bruising around the shoulder

    Difficulty in moving the arm

    Numbness in the shoulder

    In addition, you may find that you are prone to developing recurrent dislocations once you have had a previous episode.

  • Clinical assessment will include taking a detailed history and a thorough examination of your shoulder.

    Further imaging tests like X-rays, MRI scans and ultrasound scans may occasionally be required.

  • If you have any of the symptoms above, it is advisable to see an orthopaedic specialist for further assessment.

    The appropriate treatment is decided after assessment and a collaborative discussion based on your needs.

    They can be broadly divided into conservative (non-surgical) and surgical options.

  • In an acute shoulder dislocation, a closed reduction should be performed early.

    A closed reduction involves special manoeuvres, usually with the aid of sedation, to help reduce the ball into the joint socket.

    You will then be provided an arm sling for support and immobilisation to allow the shoulder to rest for about a week. You may then be referred to a physiotherapist for shoulder exercises to regain your range of motion and strength.

  • If you have recurrent shoulder dislocations or are at an increased risk due to your work or sporting demands, you may be a candidate for surgery.

    The surgery is typically performed in a minimally-invasive fashion (keyhole) and involves re-attaching the torn labrum to your joint socket.

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Acromioclavicular Joint Injury

The shoulder is the most mobile joint in the body and as such, a complex arrangement of structures are required to stabilise the shoulder during movement. 

The clavicle (collar bone) forms a joint with part of the scapula called the acromion. This joint is termed the acromioclavicular joint (ACJ) and permits very small movements between the scapula and clavicle during normal shoulder movement. 

To stabilise the ACJ, there is a complex arrangement of ligaments. These can be divided into two groups; the acromioclavicular capsular ligaments and the coracoclavicular ligaments. When these ligaments are damaged, an ACJ dislocation/separation can occur.

An ACJ dislocation occurs when the outer end of the clavicle dislocates from the acromion. This usually occurs as a result of a direct impact onto the shoulder. The grade of injury can range from I to VI depending on the severity of the injury.

Acromioclavicular Joint Injury

  • Patients with an acromioclavicular joint dislocation may present with the following symptoms:

    Shoulder pain

    Shoulder deformity with a prominent/dislocated collar bone

    Bruising over the shoulder

    Drooping of the shoulder

    Clicking of the ACJ during movements

    Decreased shoulder function in chronic cases

  • Clinical assessment will include taking a detailed history and a thorough examination of your shoulder.

    Further imaging tests like X-rays, MRI scans and ultrasound scans may occasionally be required.

  • If you have any of the symptoms above, it is advisable to see an orthopaedic specialist for further assessment.

    The appropriate treatment is decided after assessment and a collaborative discussion based on your needs.

    They can be broadly divided into conservative (non-surgical) and surgical options.

    The treatment of ACJ dislocation is dependent on the grade of injury (Grade I to VI) and your functional requirements. The higher the grade of injury, the more prominent the dislocated clavicle becomes.

  • Grade I to III injuries generally do not require surgical intervention and can be managed nonoperatively. Sometimes, Grade III injuries may require surgical intervention depending on your symptoms and functional requirements.

    Nonoperative treatment may include a combination or all of the following measures:

    Immobilisation in an arm sling
    reduce pain and movement at the ACJ

    Cold packs
    to reduce swelling

    Medications
    anti-inflammatory drugs to reduce pain and swelling

    Physiotherapy
    to strengthen the shoulder muscles and improve range of motion

  • The aim of surgery is to stabilise the AC joint. This can be done in a variety of ways and is dependent on the nature of the injury as well as the time elapsed following the injury.

    In acute injuries, mechanical stabilisation of the AC joint can be performed in an arthroscopic (keyhole) fashion. In more chronic cases, apart from mechanical stabilisation, biological augmentation through the use of a graft may be necessary.

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Shoulder Arthritis

Shoulder arthritis is inflammation in your shoulder joint that occurs as a result of cartilage loss. The inflammation causes pain, stiffness and difficulty in performing your daily activities. 

The shoulder is a “ball and socket” joint. It is where the “ball” of your upper arm (humerus) rests against the “socket,” or hollowed-out cup, on the edge of your shoulder blade (scapula). This joint is called the glenohumeral joint.

Shoulder arthritis can also happen at a second joint in your shoulder where your collar bone (clavicle) meets the acromion on your shoulder blade. This joint is called the acromioclavicular joint.

Over time, arthritis leads to cartilage loss. Cartilage is the tissue that covers the humeral head and the “socket” of your shoulder joint. Cartilage allows the bone surfaces to glide within the joint. It also cushions your bones against impact.

In the end-stage of shoulder arthritis, bones in the joint rub directly against each other without the protective coverage of the cartilage.

There are different causes of shoulder arthritis, but the most common causes in this part of the world are shoulder arthritis that develops as a result of rotator cuff tear (rotator cuff arthropathy), degeneration (primary glenohumeral osteoarthritis) and post-traumatic (following previous injury or surgery).

Shoulder Arthritis

  • Patients with shoulder arthritis may present with the following symptoms:

    Shoulder pain with movement

    Shoulder pain at rest (with increasing severity)

    Shoulder weakness

    Stiffness

    Difficulty in performing daily activities

    Grinding of the shoulder

  • Clinical assessment will include taking a detailed history and a thorough examination of your shoulder.

    Further imaging tests like X-rays, MRI and CT scans may occasionally be required.

  • If you have any of the symptoms above, it is advisable to see an orthopaedic specialist for further assessment.

    The appropriate treatment is decided after assessment and a collaborative discussion based on your needs.

    They can be broadly divided into conservative (non-surgical) and surgical options.

  • Non-surgical measures will usually be recommended first if you have not had any prior treatment for your shoulder arthritis and your symptoms are mild or manageable.

    These may include a combination or all of the following measures:

    Rest
    reduce inflammation within the shoulder joint

    Cold packs
    to reduce swelling

    Medications
    anti-inflammatory drugs to reduce pain and swelling

    Physiotherapy
    to strengthen the shoulder muscles and improve range of motion

    Cortisone injection
    this may sometimes be required if the pain is persistent

  • If your shoulder pain and weakness is persistent despite all the above measures, surgery may sometimes be required.

    The appropriate surgical treatment will depend on your age and functional demands, and also the underlying cause of the shoulder arthritis.

    This can include the following:

    Total shoulder replacement
    In this surgery, plastic and metal replace the diseased sections of bones in your shoulder joint. Part of the “ball” of your humerus head is replaced with a new metal head that attaches to a metal stem that goes inside your humerus bone. A smooth plastic socket covers your shoulder socket. This is typically performed for primary glenohumeral osteoarthritis.

    Reverse shoulder replacement
    In this surgery, we reverse the location of the ball and socket to improve the biomechanics of the shoulder when the rotator cuff is dificient. A metal head attaches to your shoulder blade and a socket attaches to your humerus. This is typically performed for rotator cuff arthropathy.

    Arthroscopic shoulder debridement
    In this surgery, small tools and a camera are inserted through small incisions in your shoulder. This is to remove loose fragments of damaged cartilage in your shoulder joint and file down any bone spurs if present. This may be an option if you have early arthritis with some cartilage left. Although this procedure does not reverse arthritis, pain relief may last up to 24 months.

Shoulder Fractures

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A shoulder fracture refers to a break or crack in one or more of the bones that make up the shoulder joint. The shoulder is a complex joint composed of the humerus (upper arm bone), scapula (shoulder blade), and clavicle (collarbone). Fractures in any of these bones can result from various causes, including falls, accidents, direct impact, or high-energy trauma. Here's an overview of shoulder fracture injuries:

Types of Shoulder Fractures:

  1. Humerus Fracture: This involves a fracture of the upper arm bone (humerus). Fractures can occur in different parts of the humerus, such as the head, neck, shaft, or surgical neck.

  2. Scapula Fracture: This type of fracture occurs in the shoulder blade (scapula) and can involve different parts of the scapula, such as the body, neck, or glenoid (socket) region.

  3. Clavicle Fracture: A clavicle fracture refers to a break in the collarbone. It's a common type of shoulder fracture and can occur due to falls onto the shoulder or outstretched arm.

Shoulder Fractures

  • Pain, swelling, and tenderness around the shoulder area.

    Limited or complete loss of movement in the shoulder joint.

    Visible deformity or abnormal positioning of the shoulder.

    Bruising and discoloration of the skin.

    Numbness, tingling, or loss of sensation in the arm, hand, or fingers due to potential nerve involvement.

  • Dr Bryan will conduct a physical examination and order of X-rays to confirm the diagnosis, assess the type of fracture, and determine if there are any associated injuries.

  • If you have any of the symptoms above, it is advisable to see an orthopaedic specialist for further assessment.

    The appropriate treatment is decided after assessment and a collaborative discussion based on your needs.

    They can be broadly divided into conservative (non-surgical) and surgical options.

  • Some fractures may be able to manage non surgical way such as immobilisation with an arm sling to allow healing, depending on the type and severity of the fracture.

  • Some shoulder fractures, especially complex or displaced fractures, may require surgical intervention. Surgery involves realigning the bone fragments and using plates, screws, or other hardware to stabilise them.