Mr. Kirti Moholkar, Knee and Shoulder Surgeon
One of the common and painful shoulder condition seen in primary care is subacromial impingement (and related conditions). Impingement refers to a condition where the head of the humerus with the surrounding bursa and tendon is pinched under the acromion. This condition results due to curved or hooked acromion which reduces the free space for the tendon/bursa to glide. Impingement ranges from mild pain on overhead activities to pain that can affect daily activities and work. Degenerative tendon/rotator cuff tears are commonly seen beyond 45 years of age and in patients with long-standing impingement. Impingement can sometimes cause extreme pain pushing the shoulder into a frozen shoulder mode which results in a stiff and painful shoulder forcing patients towards surgery.
It is very important to diagnose and treat these conditions in their infancy. Examination of the shoulder, range of motion and impingement tests are diagnostic of this condition. Physiotherapy and steroid injection in early stages are of diagnostic and therapeutic value. Mild impingement related conditions may not be curable following steroid injection and physiotherapy however if the pain completely subsides and comes back again, it vital to assess the state of the tendons. Ultrasound scan/MRI scans are recommended. The old practice of multiple steroid injections on a six weekly interval is a thing of the past. In the author’s opinion one or maximum 2 injections to establish the diagnosis and provide some help with reference to physiotherapy is recommended. Steroid injection as a time buying tactic is not practised in modern shoulder surgery practice.
If conservative line of management fails to relieve the symptoms, timely referral is recommended. With advanced arthroscopic techniques, impingement related surgery or sub acromial decompression is an operation which is carried out as a day case procedure. Pain usually subsides within 1-2 weeks and 95% of patients are doing most of the daily activities by 4-6 weeks. If tendons are torn, the recovery takes a few weeks longer but with enhanced recovery and double row repair techniques, 85 to 90% patients are back to their daily activities within two months. Physiotherapy in the postoperative phase is immensely important (first 3-6 weeks) which decides the outcome of the operation.
Tendon tear in elderly patients is a challenging and interesting area to treat. Tendon tears in asymptomatic shoulders are treated conservatively. Painful shoulders with tendon damage detected early (before infiltration of the muscles with fat) can be treated quite successfully with surgery. Tendon repairs and superior capsular reconstruction provide good results in elderly patients without arthritis
Arthroscopic shoulder surgery- Kirti Moholkar, Knee and Shoulder Surgeon
Modern arthroscopic shoulder techniques have massively changed the results of shoulder conditions. Most of the shoulder problems are now dealt with arthroscopic modalities thereby reducing the morbidity and improving outcomes. Shoulder surgeons finish their training by arthroscopic fellowships and bring their skill set to their patients and local communities.
Diagnostic shoulder operations are not indicated any more due to modern investigations when required by means of x-ray, ultrasound and MRI scans. Intra-articular shoulder conditions may need contrast injection followed by MRI scans referred as MRI Arthrogram.
Sub-acromial decompression is a simple operation which usually takes 20 minutes and requires assessment of the sub-acromial space to shave the hooked or curved part of the acromion which causes impingement of the tendons.
Open Rotator cuff tendons repair is quite rarely seen these days in modern shoulder practice. Morbidity as well as a recovery time and outcomes are significantly improved by minimally invasive techniques. The author uses arthroscopic enhanced recovery techniques by means of double row repair of tendons which allows shoulder rehabilitation to start as early as one week after operation. Arm sling is retained for 1-3 weeks and physiotherapy is initiated soon based upon the state of the tendons at the time of surgery.
Acromioclavicular joint arthritis is commonly seen in patients who do regular overhead activities like window cleaners. Injection is diagnostic and operation is required in resistant cases. Arthroscopic procedure (excision of lateral end of clavicle) is done to excise about 1 -1.5 cm of the lateral end of the clavicle which reduces pain.
Shoulder stabilisation is an operation to reconstruct the soft tissue structures in the anterior capsular region of the Gleno-humeral joint. Bankarts tear or meniscal tear of the shoulder results due to significant trauma. Traumatic instability is successfully treated by arthroscopic stabilisation operation. Failure rate of arthroscopic shoulder stabilisation has reduced significantly in modern arthroscopic techniques. Multidirectional instability is treated by physiotherapy.
SLAP or Superior Lateral Anterior Posterior meniscal lesions result due to trauma and are detected by MRI Arthrograms rather than plain MRI. These conditions are usually seen in young patients and surgery is the treatment of choice in symptomatic conditions. Rehabilitation is usually slow but timely exercises are rewarding.