Shoulder

Shoulder of our body really consists of several joints that combine with tendons and muscles to allow a wide range of motion to the arm. Mobility has its price, however. It may lead to increasing problems with instability or impingement of soft tissue resulting in pain. You may feel pain only when the shoulder is moved, or all of the time. The pain may be temporary and disappear in a short time, or it may continue and require medical diagnosis and treatment. Most shoulder problems involve the soft tissues, muscles, ligaments, and tendons, rather than bones. Apart from dislocations most of the shoulder problems lead to stiffness of the shoulder in addition to pain. In young people, the common problem is dislocation of the shoulder joint, often repeatedly. It may have started after an initial injury.

 

Some people may even dislocate their shoulders in their sleep. With appropriate surgery, these youngsters can go back to their sports and enjoy life without the constant fear of their shoulders coming out. From middle age onwards the problems of the shoulder leading to stiffness are due to inflammation of tissue ultimately leading to tears of tendons (part of muscle). Sometimes patients develop frozen shoulders with completely stiff shoulders which is more common in diabetic patients. This can be treated with simple medications and appropriate physiotherapy. Sometimes patients may need surgery to get good shoulder function back. For further information

 

SPORTS INJURIES

Sports injuries are injuries that occur to athletes in major sporting events. In many cases, these types of injuries are due to overuse of a part of the body when participating in a certain activity. For example, runner’s knee is a painful condition generally associated with running, while tennis elbow is a form of repetitive stress injury at the elbow, although it does often occur with tennis players. Other types of injuries can be caused by a hard contact with something. This can often cause a broken bone or torn ligament or tendon.

 

Injuries are a common occurrence in professional sports and most teams have a staff of Athletic Trainers and close connections to the medical community. Controversy has arisen at times when teams have made decisions that could threaten a player’s long-term health for short-term gain.

 

Sports injuries can be broadly classified as either traumatic or overuse injuries. Traumatic injuries account for most injuries in contact sports such as Football, Rugby, Australian rules football, Gaelic football and American football because of the dynamic and high collision nature of these sports. These injuries range from bruises and muscle strains to fractures and head injuries.

 

A bruise or contusion is damage to small blood vessels which causes bleeding within the tissues. A muscle strain is a small tear of muscle fibers and a ligament sprain is a small tear of ligament tissue. The body’s response to these sports injuries is the same in the initial five day period immediately following the traumatic incident – inflammation.

 

Common Sports injuries:
Head and neck injury – loss of consciousness, paralysis or even death
Concussion – loss of consciousness or even death
Fractures – a hairline fracture to a crushing injury
Ligament sprains/tears – ACL tears, ankle sprains
Muscle strains/tears – hamstring pull, quadriceps tear
Bruises and abrasions – open wounds on the skin, blunt injuries
Overuse injuries – tennis elbow, runner’s knee, iliotibial band friction syndromeBurnout, and fatigue – due to overtraining also leads to injuries

Coming Soon

STIFF SHOULDER-FROZEN SHOULDER

The shoulder has three bones (shoulder blade, upper arm bone, and the collarbone) and the tendons of four muscles. The tendons of these muscles, which connect to the bones help to move your arm.

 

Frozen shoulder is where the joint gets stiff with restriction of motion. The upper arm bone does not move in the socket of the shoulder blade. The soft tissue connecting these two bones (ligaments and surrounding capsule) becomes inflamed causing shoulder pain along with stiffness. The cause of a frozen shoulder is not well understood, but it often occurs for no known reason.

 

Most people with frozen shoulder have difficulty reaching overhead and reaching to the low back. The stiffening is the body’s natural response to inflammation that develops in or near the shoulder. Stiffening is a protective reflex that protects the shoulder from further injury.

 

In 95 percent of cases, frozen shoulder is totally reversible, although full recovery may take several months. Stiffness and pain do not develop all of sudden but evolve slowly over a period. In the initial stages (Painful/Freezing Stage) this is most painful. The movement starts getting restricted slowly. This painful stage typically lasts 6-12 weeks. Then in the second stage (Frozen Stage) the pain usually eases up as there may not be any movement with the total stiffness of the joint. This frozen stage can last 4-6 months. Then finally as the recovery starts (Thawing Stage) motion steadily improves over a lengthy period of time. The thawing stage can last more than a year.

 

The symptoms of a stiff shoulder:

Shoulder pain; usually a dull, aching pain.
Limited movement of the shoulder
The difficulty with activities such as brushing hair, putting on shirts/bras
Pain when trying to sleep on the affected shoulder. It can even be more problematic if the second shoulder also develops the same problem which can happen with some interval.

 

Causes:
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:

1. Age & Sex – Frozen shoulder most commonly affects patients between the ages of 40 to 60 years old, and it is twice as common in women as in men.

2. 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.

3. 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. Here in addition to the inflammation of soft tissue around the shoulder described above, there is damage to the muscles and bones around the shoulder with bleeding leading to scarring which further restricts movements. In these cases, recovery may take even longer and may not be complete.

4. Other Systemic Conditions – Several systemic conditions such as heart disease and Parkinson’s disease have also been associated with an increased risk of developing a frozen shoulder.

 

Treatment Options:

Treatment of frozen shoulder is intended to minimize the patients suffering and to reduce the duration of the suffering. It is not possible to completely cure at once after the diagnosis is made. Frozen shoulder treatment primarily consists of treatment to control pain and to regain movement. Most patients find relief with these simple steps, although the entire treatment process can take several months or longer.

 

Drugs to reduce the pain and inflammation can be taken. Local creams may also help. Steroid injections can be extremely effective in some cases when given in to the actual area of the problem in the shoulder.

 

Physiotherapy should be started to prevent loss of movement and to regain the lost movement. Stretching exercises are the treatments of choice for frozen shoulder. Massage and heat are used to increase blood flow. Heat lamps and hot water bottles are the most effective way to increase blood flow which carries oxygen and nutrients to the part. The other benefit of massage is that it helps to reduce the amount of scar tissue which is associated with all muscle, tendon and joint injuries.

 

If the above treatments do not resolve the frozen shoulder, occasionally a patient will need to have surgery. As a first attempt, orthopedic surgeons may try a gentle manipulation of the shoulder under anesthesia. This may help loosen the stiff tissue. If patient subsequently continues to maintain the regained movement with physiotherapy – though initially may be very painful- no further intervention may be necessary. However, if the tissue is very stiff, undue force may damage the bones while manipulating. In these cases, the surgeon may decide to surgically release all the tight tissue carefully.

 

Healthy Joint Club says:

The stiff shoulder is quite a common condition associated with significant pain. The doctors may not be able to offer 100% cure for the condition, but certainly, the treatment is going to reduce the suffering and perhaps reduce the duration of suffering. So do not hesitate to seek help but have a realistic expectation of the treatment and then one doesn’t get disappointed

Coming Soon

ROTATOR CUFF PROBLEMS
A rotator cuff is a group of muscles which work together to provide the shoulder joint with dynamic stability, helping to control the joint during rotation. The rotator cuff muscles are Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis. Supraspinatus and Infraspinatus are the most commonly injured rotator cuff muscles. The tendons run between two bones (the acromion & head of the humerus) where they are very vulnerable to being damaged. This can lead to a tear resulting in a painful, weak shoulder. A tear may result suddenly from a single traumatic event or develop gradually. When the tendons or muscles of the rotator cuff tear, the patient is no longer able to lift or rotate the arm with the same range of motion as before the injury and/or has significant pain associated with shoulder motion. Due to the function of these muscles, sports which involve a lot of shoulder rotation – for example, bowling in cricket, swimming – often put the rotator cuff muscles under a lot of stress.

 

Problems with the rotator cuff muscles can be classed into two categories – Tears of the tendons/muscles, and inflammation of the tendons (often called tendinopathy or tendonitis).

 

Rotator cuff injury signs and symptoms may include:
Pain and tenderness in your shoulder, especially when reaching overhead, reaching behind your back, lifting, pulling or sleeping on the affected side
Shoulder weakness
Loss of shoulder range of motion
The inclination to keep your shoulder inactive
The most common symptom is a pain.

 

Causes:

A rotator cuff injury involves any type of irritation or damage to the rotator cuff muscles or tendons, including:

Tendinitis: Tendons in rotator cuff can become inflamed due to overuse or overload, especially if you’re an athlete who performs a lot of overhead activities, such as in tennis or racquetball.
Bursitis: The fluid-filled sac (bursa) between the shoulder joint and rotator cuff tendons can become irritated and inflamed.
Strain or tear: Left untreated, tendinitis can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear. Stress from overuse also can cause a shoulder tendon or muscle to tear.

 

Common causes of rotator cuff injuries include:

Normal wear and tear: Increasingly after age 40, normal wear and tear on your rotator cuff can cause a breakdown of fibrous protein (collagen) in the cuff’s tendons and muscles. This makes them more prone to degeneration and injury. With age, patients also develop calcium deposits within the cuff or arthritic bone spurs that can pinch or irritate the rotator cuff.

Poor posture: When you slouch your neck and shoulders forward, space, where the rotator cuff muscles reside, can become smaller. This can allow a muscle or tendon to become pinched under your shoulder bones (including under collarbone), especially during overhead activities, such as throwing.
Falling: Using arm to break a fall or falling on the arm can bruise or tear a rotator cuff tendon or muscle.

Lifting or pulling: Lifting an object that’s too heavy or doing so improperly — especially overhead — can strain or tear tendons or muscles. Likewise, pulling something very heavy may cause an injury.

Repetitive stress: Repetitive overhead movement of arms can stress rotator cuff muscles and tendons, causing inflammation and eventually tearing. This occurs often in athletes, especially, swimmers and tennis players. It’s also common among people in the building trades, such as painters and carpenters.

Diagnosis:
Physical examination generally gives a good idea about the problem and diagnostic imaging tests like X-rays, MRI scan or ultrasound scan can aid in the diagnosis with a better delineation of the shoulder joint, muscles and tendons.

 

Treatment Principles:

Control pain – Local heat & gels, Tablets, local steroid infiltrations
Prevent stiffness and regain lost movement
Prevent muscle weakness and strengthen muscles (rotators)
Avoiding the causative movement /work
Professional physiotherapy advise modifying / correct sporting action
Surgery to remove the offending structure damaging the rotator cuff muscle and to give enough space for them to move freely without getting abraded
Surgery to repair the torn muscle and to re-attach the tendon to the bone
Treatment recommendations vary from rehabilitation to surgical repair of the torn tendon(s). The best method of treatment is different for every patient.

Nonsurgical treatment: Activity modification (avoidance of activities that cause symptoms), Tablets and creams to reduce pain and swelling, Physiotherapy.

Surgical treatment: The tendons of the rotator cuff muscles usually get torn from their attachment to the bone (head of the arm bone) due to degeneration and repeated rubbing against adjacent bony structures. They get retracted back due to elasticity. Hence during surgery, we need to bring the torn and retracted tendon back to its original place of attachment. The ends of the tendon and the bone surface need to be prepared to create a raw area so that they can stick together. We need to use some screws and stitches to hold the bone and tendon together while they are healing which may take a few weeks. The repair can be done again through arthroscopic techniques, but if the tears are bigger usually we make a small opening to tie them together. In the same way, I described in the ‘pinching shoulder’ section we need to remove any associated bony and soft tissue overgrowths.

 

Care after surgery:

The shoulder is rested for a few days to control pain and swelling. After an interval physiotherapy is started. But during this time only guarded physiotherapy is advised to prevent the repair undone.

OSTEOARTHRITIS OF THE SHOULDER
Osteoarthritis is the most common type of shoulder arthritis. Also called wear-and-tear arthritis, 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 to the shoulder. The shoulder can also get arthritis due to rheumatoid arthritis which may affect many other joints of the body. This inflammation can, over time, invade and destroy the cartilage and bone.

 

Arthritis of the shoulder progresses slowly. It is often due to an injury sustained years earlier, leading to an abnormal wearing down of the cartilage. Injuries include bony fracture, dislocation, or heavy blow to the outer shoulder. Some people may be genetically more prone to develop arthritis. Treatment focuses on reducing inflammation, physiotherapy stretching exercises to preserve motion, and avoidance of activities to prevent further wear and arthritic flare-ups.

 

Symptoms:
Pain is the main symptom especially while moving the shoulder as well as after moving the shoulder. The pain may disturb sleep. There may also be a loss of motion. This may limit your ability to reach objects around you and you may notice a clicking or creaking noise.

 

Diagnosis:
After examination, simple blood tests and x-rays are adequate for the diagnosis. Occasionally MRI scans may also be necessary to exclude any associated damage to the ligaments and rotator tendons.

 

Treatment Options:
The first treatments for osteoarthritis, including osteoarthritis of the shoulder, do not involve surgery. These treatments include:

Resting the shoulder joint. This could mean that the person with arthritis has to change the way he or she moves his or her arm while performing the activities of daily living. For example, the person might wear clothing that zips up the front instead of clothing that goes over the head. Or the person might prop up hairdryers instead of holding them up for long periods of time.
Local pain relief gels and tablets
Physiotherapy to prevent stiffness of the joint and muscle wasting due to disuse
Local injections of corticosteroids or hyaluronic acid into the joint.
Dietary supplements like glucosamine and chondroitin. You can read in details about these drugs in ‘Osteoarthritis’ topic. Diabetics need to be careful as glucosamine might raise blood sugar levels.
If nonsurgical treatments do not work effectively, there are surgical treatments available. As with any surgery, there are certain risks and potential complications, including infection or problems with anesthesia. Surgical treatments include:

Shoulder joint replacement (total shoulder arthroplasty). Replacing the whole shoulder with an artificial joint is usually done to treat arthritis of the glenohumeral joint.
Replacement of the head of the humerus, or upper arm bone (hemiarthroplasty). This option, too, is used to treat arthritis of the glenohumeral joint.
Removal of a small piece of the end of the collarbone (resection arthroplasty). This option is the most common surgery for treating arthritis of the AC joint. After the removal of the end of the bone, space fills with scar tissue.

 

Healthy Joint Club says:

Arthritic conditions involving upper limbs are not as disabling as those of lower limbs. They are less common too. However, they do cause significant suffering and loss of function. But people tend to neglect as they can ‘get away’ without realizing how much they are depending on others for their basic needs. However much ‘Stability’ is important in the leg, ‘Mobility’ is equally important for the hand (upper limb). Since there are ways of improving function and relieve pain, it is up to the sufferer to seek treatment, be it is a problem of the upper limb.

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