The commonest causes of shoulder pain (70%) result from problems with the rotator cuff.

What is the “Rotator Cuff”?

The rotator cuff refers to the deep muscles and their tendons found around the ball and socket joint of the shoulder. They merge to form a “cuff” of tissue around the joint and are involved in the stabilization and movement (including “rotation”) of the joint. Over the top of the shoulder joint is a bone called the acromion. In between the shoulder joint and the acromion is a narrow gap called the subacromial space. This is where the rotator cuff tendons pass through. In this space is a fluid-filled sac called the subacromial bursa, which cushions the tendons allowing them to glide under the acromion as the shoulder is moved.

What can go wrong with the rotator cuff?

Rotator cuff problems can include inflammation (swelling and soreness) of the tendons and bursa (see Impingement) and also damage or tearing of the tendons (see Rotator cuff tears)

Subacromial impingement

There are many names for this type of problem e.g. tendinits, supraspinatus tendinopathy, subacromial bursitis, impingement etc, but they all amount to the same thing i.e. a painful, inflamed rotator cuff.

This condition arises when the tendons of the rotator cuff rub against the roof of the narrow “tunnel” through which they pass with movements of the shoulder. Over the top of the shoulder joint is a bone called the acromion. In between the shoulder joint and the acromion is a narrow gap called the subacromial space. This is (the tunnel) where the rotator cuff tendons pass through. In this space there is also a fluid-filled sack called the subacromial bursa, which cushions the tendons allowing them to glide under the acromion as the shoulder is moved. When the tendons no longer glide smoothly, but rub, impingement occurs.

Symptoms

Impingement problems are usually felt as pain in the upper outer arm particularly when lifting the arm up from the side or when lying on the arm at night. The arm is usually reasonably comfortable when down by the side or tucked in against the body. Usually there is nothing much to feel if you press the area which is perceived as being sore. The symptoms can come on rapidly e.g. after an acute injury such as a fall; over a day or two e.g. after a game of tennis or unaccustomed activity such as cutting a hedge or painting a ceiling; or much more gradually. Often patients describe feeling what they thought was a pulled muscle, which despite time failed to get better.

Treatments

Common treatments include avoiding provocative activities, taking anti-inflammatory tablets, physical therapy, steroid injections and sometimes surgery.

Physical therapy

This focuses on improving posture, shoulder blade control and rotator cuff muscle strength. When the rotator cuff muscles are working well they protect themselves from further damage. This is because their main function is to stabilise the ball in the socket of the shoulder whilst even bigger muscles move the shoulder joint. If the rotator cuff fails to do this adequately, the ball slides around abnormally with shoulder movements which causes the rotator cuff tendons to get pinched and damaged (impingement) even further, making the whole situation worse. One of the aims of physiotherapy is to break this vicious circle.

Steroid injections

The use of steroid, which is a powerful anti-inflammatory, is a very widely used treatment for this condition. It reduces inflammation and swelling in the tendons thereby reducing pain. This has benefits in that it can facilitate the rehabilitation provided by a physical therapist, allowing better strengthening of the rotator cuff. It is also thought that by reducing swelling in the tendons, this give the tendons more room and thus may reduce the chance of the tendons rubbing and the problem recurring. Steroid injections can be considered very safe if used within guidelines and if administered by a trained practitioner.

Surgery

Surgery involves an arthroscopic (keyhole) procedure to remove any inflamed bursal tissue and to remove any spurs of bone from the undersurface of the acromion to take the pressure off the tendons and stop them rubbing. This is known as an arthroscopic subacromial decompression. It is normally performed under General Anaesthetic with a nerve block (to minimise discomfort after the procedure). The surgery can usually be performed as a day-case procedure or, if desired, with a single
night stay in hospital afterwards. You will be in a sling for three or four days for comfort. There are usually two small stitches that are removed about 8 to 12 days after the procedure. It is very important to obtain the appropriate rehabilitation with an experienced physiotherapist and this can all be arranged for you before you return home.

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Rotator cuff tears

The rotator cuff refers to the deep muscles and their tendons found around the ball and socket joint of the shoulder. They merge around the shoulder to form a cuff of tissue and are involved in stabilising and rotating the shoulder joint. Rotator cuff problems are a frequent cause of shoulder pain and dysfunction. The main problems include inflammation due to impingement and tearing of the tendon. Tendon tears can occurs in two ways:

Firstly tears can occur as a progression of impingement where the tendons are pinched or rubbed over a long period causing them to weaken and eventually tear. This is thus a process of degeneration over time.

The second mechanism is a more acute tear occurring as a result of trauma such as falling on the side of the shoulder.

In reality, many tears often occur as a result of both mechanisms acting together i.e. the tendon can become weakened due to impingement problems and then may tear as the result of an often trivial injury.

There are many theories as to why rotator cuff tendons tear, but it is probably connected to age related degeneration in the tendons. Thus it is not surprising that degenerate tears are rare before the age of 35. Traumatic tears can occur at any age, given a big enough injury. However tears from more minor trauma are also much more common in middle and older age than in younger patients.

Symptoms of a rotator cuff tear

Often the symptoms are very similar to that of impingement i.e. pain is usually felt in the upper outer part of the arm, particularly when lifting the arm up from the side and when lying on the arm at night. The arm is often reasonably comfortable when at rest by the side. In addition, with a tear, there may be weakness in lifting the arm up from the side. With larger tears, the patient may not be able to lift the arm up from the side at all and may need to use the opposite arm to lift the injured arm overhead.

Treatment of rotator cuff tears

Rotator cuff tears do not always need to be fixed. We know that many people can have tears in these tendons without ever having any problems at all in their shoulders. It seems to be that for some individuals tendon tears are part of the natural ageing process. Thus if the tear is not associated with any symptoms whatsoever, it can essentially be observed without any active intervention.

However, generally speaking, if a patient has a tear which is causing significant symptoms which cannot be resolved with non operative measures and they are medically fit for surgery, a repair may be considered. Sometimes the tear may have progressed too far for a conventional repair to be performed and other option are available in such circumstances.

Non-operative treatment

In some cases a surgical repair may not be feasible either because the tendon damage is too severe or because the patient is not medically fit to undergo an operation. Treatment options in such instances include physiotherapy, steroid injections and supra scapular nerve blocks.

Surgery

Surgery for rotator cuff tears usually involves a keyhole procedure to repair the tendons back to the bone of the humerus from where it has torn. This is done with anchors which are like tiny corkscrews which are drilled into the bone. The anchors have stitches attached which are passed through the torn tendon. Knots are then tied to bring the tendon back to the bone allowing it to heal back into its correct place. Sometimes the tendons cannot be repaired directly to the bone without undue tension in the repair and in these instances, a graft may be used to assist the repair.

Following this type of surgery, the arm will need to be rested in a sling for four to six weeks to allow healing of the tendon to the bone. Physiotherapy will be commenced in the first week or so, to try and prevent the shoulder from becoming to stiff. Next, the priority will be to achieve good posture and control of the shoulder blade whilst shoulder movements are undertaken. Later the physiotherapist will start to assist in the strengthening of the muscles around the shoulder.

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Shoulder arthritis

Arthritis is a common condition which can affect any joint. It can affect the two main joints in the shoulder. The first site is the main joint i.e. the ball and socket joint(the gleno-humeral joint). This is what most people are referring to when they talk about shoulder arthritis and is the focus of this description. The smaller joint (the acromioclavicular joint) where the top of your shoulder blade meets your collarbone is the second site and is discussed elsewhere. Arthritis actually means “joint inflammation” and there are two main types:

Osteoarthritis

This is the “wear and tear” or degenerative type of arthritis and may be primary i.e. no particular cause; or secondary to another previous problem such as an injury or infection within a joint.
The cartilage which normally covers the joint surfaces (providing smooth gliding surface) becomes thinner and spurs of extra bone (osteophytes) may form which alter the shape of the joint and make it stiff. Eventually the bones start to rub together

Inflammatory arthritis

The most well known type of inflammatory arthritis is Rheumatoid arthritis, but most other types affect the joint in a similar way. The shoulder joint is covered with a lining (synovium) — responsible for producing the lubricating joint fluid . Rheumatoid arthritis causes the lining to swell, causing pain and stiffness in the joint. In Rheumatoid arthritis some of the defences that normally protect the body from infection instead damage normal tissue and soften bone. These give slightly different appearances on an X-ray to those seen with osteoarthritis. Sometimes, however, osteoarthritis can then also occur secondarily to an inflammatory arthritis, in which case a mixed picture will be seen on X-ray.

Symptoms of arthritis

The cardinal symptoms are pain and stiffness, often with creaking and grating arising form the joint with attempted movement. The symptoms usually come on relatively slowly and gradually get worse, but may fluctuate to a degree on a day to day basis. There may be only a dull background ache with the worst pain coming on at the extremes of movement.

Treatment

Simple painkillers and anti-inflammatory medications can be helpful particularly in the early stages of arthritis. Physiotherapy may be of benefit. Steroid injections can be used to good effect. If these measures do not work, or become ineffective with time, surgery may be considered. Occasionally keyhole surgery may be appropriate, but for more advanced disease often joint replacements surgery is indicated.

Shoulder joint replacement

Broadly speaking, there are two types of shoulder replacement. The first involves replacing the ball side of the joint alone (a hemiarthroplasty, or ‘half shoulder replacement’). The second involves replacing both sides of the joint (a total shoulder replacement). Generally speaking, the latter option is preferred as it results in more reliable pain relief and better movement, but certain conditions need to exist in order for the full replacement to be safely performed. Essentially the tendons must be in good condition and there needs to be enough remaining bone in the socket to accommodate a total shoulder replacement. Within these two main categories of shoulder replacement there are a number of further different options and the decision on the best implant will be individualised to the patient. Shoulder replacement surgery usually involves a one or two night stay in hospital after the procedure. After surgery you can expect to be in a sling, with some restrictions on use of the arm, for up to six weeks. Physiotherapy will start within a few days of the operation.

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Rotator cuff arthropathy

This is essentially a type of degenerative shoulder arthritis which arises as a result of a longstanding tear of the rotator cuff. When the rotator cuff fails to work, its stabilising effect which normally keeps the ball (humeral head) centred in the socket (glenoid) is lost. This means that the remaining intact muscles (deltoid) no longer produce a smooth rotation of the humeral head, but instead lead to a shearing (sliding) movement of the humeral head on the glenoid. This results in wearing of the joint. This effect usually happens over years and this condition tends to occur in the older population.

Symptoms

A patient with rotator cuff arthropathy usually has a long history of shoulder problems. They often have history of shoulder pain felt predominantly on the outside of the upper arm and may have had difficulty lifting the arm up from the side. As the arthritis develops, the shoulder may become increasingly stiff and painful. The patient may have already had previous treatments for their shoulder problems, but it is by no means unusual for the patient with rotator cuff arthropathy to first seek help with the disease already established. The typical patient with rotator cuff arthropathy will tend to shrug the shoulder as they attempt to lift the arm up from the side. Effective movement may be very limited. The pain is usually made worse with attempts to move the shoulder.

Treatment

Initial treatment may involve the administration of a steroid injection to reduce discomfort, along with specialised physiotherapy to try and improve movement. This type of physiotherapy is known as an anterior deltoid strengthening program. The idea is to strengthen the deltoid to take over some of the work of the torn rotator cuff and to restore the balance between the remaining muscles around the shoulder. If this approach fails to provide adequate symptomatic improvement, a suprascapular nerve block may be considered, particularly if the patient is not suitable for surgery. Administration of a suprascapular nerve block does not preclude progression to any other the of the other existing treatment options if required.

Surgery

Appropriate surgical options for the treatment of rotator cuff arthropathy include both arthroscopic operations and more significant open surgeries.

Arthroscopic surgery often involves the performance of a debridement, release of the tightness at the front of the shoulder and release (tenotomy) of the biceps tendon. Such a procedure has been shown to be of worthwhile benefit to the patient in 70% of cases. After this type of surgery, the arm is kept in a sling for a few days only and then physiotherapy is commenced (again an anterior deltoid programme as above).

Open surgery for rotator cuff arthropathy is more significant and involves a special type of joint replacement known as a reverse total shoulder replacement. This type of shoulder replacement basically involves using a replacement which reverses the orientation of the ball and socket in the shoulder. This makes the remaining muscles (specifically the deltoid) much more efficient. This usually results in improved range of movement as well as less pain. Reverse shoulder replacements tend to be reserved for the over 70 age group. There are other options which may be more appropriate for the younger patient suffering with rotator cuff arthropathy. After this type of surgery the arm is usually kept in a sling for about four weeks but gentle physiotherapy will begin in the first week.

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Frozen shoulder

Frozen shoulder is a condition that leads to pain and progressively worsening stiffness of the shoulder. It's also known as adhesive capsulitis or shoulder contracture. The symptoms tend to gradually get worse over a number of months. They may start as a mild “niggle” with pain felt in the upper outer arm.The pain then gradually increases and is often worse when reaching behind or when reaching out suddenly or jolting the arm. The condition may improve with time, but this can sometimes take several years. Traditionally, the process of frozen shoulder has been described in three stages:

Stages of frozen shoulder

There are three separate stages to the condition, but sometimes these stages may be difficult to distinguish. The duration and severity of the symptoms vary greatly between individuals.

Stage one

During the "freezing" phase, the upper arm starts to ache and becomes painful when reaching out for things. The pain is often worse at night and when you lie on the affected side. This stage can last anywhere from two to nine months.

Stage two

This is known as the "frozen" phase. The shoulder becomes increasingly stiff. Fortunately the pain is either at a similar level or sometimes less. This stage usually lasts 4-12 months.

Stage three

The "thawing" phase. Finally the situation improves with less pain and a gradual improvement in movement. Usually there is a slight permanent residual restriction in range of movement.

What causes frozen shoulder?

It is not clearly understood what causes frozen shoulder but we do know what happens in the shoulder during the process and that certain groups of people are particularly prone to acquiring the condition:

In frozen shoulder, the lining of the ball and socket joint (known as the capsule) becomes inflamed and thickened. It then also contracts, resulting in a stiff joint that is painful to move.

Frozen shoulder can come on secondary to many other problems in the shoulder (e.g. after an injury or surgery), but most often comes on “out of the blue”. The commonest group to get this type of “spontaneous” frozen shoulder are women in their forties and fifties. Diabetics are another group of people that are commonly affected. That being said, frozen shoulder can occur in adults of any age.

Diagnosing frozen shoulder

Establishing a correct diagnosis is important and unfortunately frozen shoulder diagnosis is often delayed or made incorrectly. This can have implications as it is believed that if treatment is instigated early in the disease process, the more likely a long term problem can be avoided.

Treatment of frozen shoulder

Once the diagnosis is established, the initial treatment is usually a steroid injection. It is important that the injection is given into exactly the right spot and the sooner the better. Usually physiotherapy is recommended after the injection (this has been shown to be more effective than physiotherapy alone). The patient is usually reassessed a few weeks after the injection and on occasions the injection may be repeated. If there is an inadequate response to the injection and physiotherapy, surgical intervention may be considered. This is a keyhole operation known as an arthroscopic frozen shoulder release.

Arthroscopic frozen shoulder release (capsular release)

This keyhole operation is appropriate for people who have failed to respond to non-operative treatments of their frozen shoulder and have persistent and limiting pain and stiffness in their shoulder. The operation is carried out under general anaesthetic. The shoulder and arm is usually numbed before the operation starts by the injection of local anaesthetic in the form of a nerve block. The operation is performed through two very small incisions (about 8mm long) and involves releasing the tight structures in the capsule of the ball and socket joint of the shoulder thereby reducing pain and restoring movement. The patient is encouraged to move the arm as soon as possible after the surgery and there are no major restrictions. The key to success is to maintain range of movement with regular exercise under the supervision of an experienced physiotherapist. The sling can be discarded within a day or two of leaving hospital and the patient should be able to drive within two weeks. It is important to keep going with the exercises for about three months after the operation to reduce the risk of recurrent stiffness. To see an example of this operation click here

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Fractures around the shoulder

By far the commonest bone around the shoulder (and one of the commonest in the whole body) to fracture (break) is the collar bone (or clavicle). The next commonest area in the shoulder to fracture is the upper section of the upper arm bone (known as the proximal humerus). Both bones can break in many different patterns, and thus the appropriate treatment can vary greatly.

Clavicle Fractures

The clavicle is effectively a strut which connects the shoulder and arm to the breast bone (sternum).  During a fall onto the side of the shoulder, significant force is transmitted along the bone and this can result in a fracture. These breaks often occur in the middle of the bone as this is the thinnest part. Clavicle fractures are more common in the younger age group but can occur throughout life.

Treatment

If the break occurs in the middle of the bone and the two parts of the bone do not move relative to one another i.e. an undisplaced fracture, then there is reasonable consensus that such an injury should be treated non operatively. However, if the bone fragments  overlap significantly (by more than about two centimetres), then operative treatment may be indicated. Breaks which occur at the outer end of the collar bone, particularly if displaced, are more likely to need surgery for treatment. The decision to operate depends on many factors and it is often prudent to seek an expert opinion as to the best management of these type of fractures.

For both non operative and operative management, the time needed for the break to heal will depend on a number of factors including patient age, fracture displacement, the configuration and number of the breaks. Certain activities are known to slow the rate of healing including smoking and the frequent use of some anti-inflammatory pain killers such as Diclofenac and Ibuprofen.

Whether or not an operation is performed, it will be necessary to be treated in a sling for a period. Return to non-contact activities e.g. swimming, will be possible sooner than “contact” activities such as rugby, horse riding and cycling.

Proximal Humeral Fractures

These fractures may involve the part of the upper arm bone (humerus) just below the ball of the shoulder (at the humeral neck) but sometimes also involve the ball itself (the humeral head). They are a common fracture in the older patient and are associated with osteoporosis (reduced bone density) but can occur at any age. They usually occur following a fall onto the shoulder and are thus commonly happen during many sporting activities such as cycling and skiing.

Treatment

Treatment again depends on many factors including age, activity levels, displacement and configuration of the fracture. 

Non operative treatment would typically involve resting in a sling for about three weeks, followed by progressive movement with significant physiotherapy input to regain as much movement and strength as possible.

The exact nature of any operative treatment is quite variable and could range from a simple manipulation all the way up to a shoulder replacement in more severe injuries. Probably the commonest type of operation for the moderately severe injury is a plate fixation. A typical recovery after such an operation would involve about three weeks in a sling, followed by regular physiotherapy. 

Acromioclavicular joint pain

The acromioclavicular (AC) joint is formed where the flat part of the shoulder blade which projects forward over the shoulder (known as the acromion) meets the collar bone (or clavicle). This joint can become degenerate or worn (arthritic) over time and become painful. Sometimes, after trauma, the joint may become unstable.

Symptoms of AC pain

AC pain is usually felt at the top of the shoulder overlying the joint itself and can sometimes radiate up the side of the neck. The pain is often worse during activities where the bones either side of the joint are forced together. This includes activities such as reaching overhead, reaching in front of the body across the other shoulder (such as when pulling a seatbelt on), and during activities such as press ups. AC pain is often seen in people who do a lot of repetitive overhead activity. AC pain can occur at any age but in older patients frequently occurs in conjunction with other shoulder problems such as impingement.

Treatment

Initial treatment usually involves a steroid injection into the joint (particularly if the patient has already tried simple painkillers / anti-inflammatory medications). Sometimes this is performed in conjunction with physiotherapy. If the steroid injection(s) only give short lived benefit and the pain cannot be adequately controlled with the above measures, surgery may be considered.

Surgery

This involves a keyhole procedure to remove the damaged joint surfaces and some bone from the end of the collarbone, thereby restoring the space in the joint. The aim of this is to stop the bones rubbing together (the space between them becomes smaller with arthritis) and hence eliminate the pain. This is a relatively small operation but it still takes about two to three months for the ache in the joint to completely settle after surgery. After such an operation (which can be performed as a daycase procedure), the arm is usually kept in a sling for three or four days and then movement is encouraged with the help of a physiotherapist.

Acromioclavicular joint dislocations and instability

The joint is normally stabilised by a number of strong ligaments. These ligaments can be damaged with significant trauma to the shoulder. The commonest mechanism is a fall onto the side of the shoulder. As a result, the AC joint can become unstable and even dislocate. Injuries to to AC joint are classified as Types 1 to 6, being of increasing severity.

In types 1 and 2, the strongest ligaments remain intact and instability is mild. Such an injury is very likely to settle naturally without significant intervention. In types 3 to 6, the ligament damage and hence resultant instability is more severe. These type of injuries are more likely to need surgical intervention to address the symptoms. The need for surgery should be considered on an individual basis and will depend on a number of factors including symptoms, severity of damage, the patients’ age, the patient’s working and recreational/ sporting activities etc.

Treatment

Non-operative treatment of AC instability

In less severe injuries, often the best treatment is a period of rest in a sling, to hopefully allow the damaged ligaments to scar and heal. During this time anti-inflammatory pain killers may be given to reduce discomfort. This is often followed by a course of physiotherapy to regain range of movement and strength around the shoulder. A return to full activities at a pre-injury level would be expected.

Surgery for AC joint instability

Surgery may be recommended for more severe injuries, or in some cases for less severe injuries which have failed to settle despite an adequate course of non-operative treatment.

Surgery can be performed arthroscopically in the early phases (within two to three weeks) of the injury. If the injury is more chronic, a slightly different procedure will be required which will involve open surgery. The arm will need to be rested in a sling for four weeks after the operation to allow adequate healing, but physiotherapy will be started straight away. It is usually advised to avoid contact sports for three months after such an injury. A further modification can be performed in elite athletes to facilitate a faster rehabilitation, but this is not necessarily the best option for the general population. Again, the options for the type of surgery would be discussed on an individual basis.

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Biceps tendon problems

The biceps is the upper arm muscle so named from the Latin for “two heads”. It is effectively formed from two muscles which during evolution have partly merged into one. Thus at the top (proximal) end of the muscle there are two tendons, whereas at the bottom, where the muscles have merged, there is one. The two upper tendons attach to different parts of the shoulder and the single tendon at the bottom (distal tendon) attaches to one of the forearm bones (the radius)

The biceps tendons can become inflamed (tendinitis) and sometimes can tear (tendon rupture)

Biceps tendinitis

Inflammation of the tendon (tendinitis) occurs most commonly in one of the tendons which attaches to the top of the shoulder socket. This is known as the “long head of biceps”

Isolated or primary biceps tendonitis is actually relatively uncommon (less than 10% of cases). In 90% of cases, the biceps tendonitis is associated with other shoulder problems such as impingement and SLAP tears.

Biceps tendinitis can occur as a result of repetitive (often overhead) activity such as in swimmers, tennis players and throwing athletes. In other cases an isolated significant injury can set off the problem.

Biceps tendinitis can often be treated non-operatively with rest, anti-inflammatories, physiotherapy and occasionally with ultrasound guided steroid injection. If these measures fail, surgery may be indicated. This will often involve removing the damaged portion of tendon, refixing it further down (known as a tenodesis).

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An alternative is to release the tendon at the upper end without refixing it. This is acceptable as the muscle is still attached by the remaining upper tendon. This is called a tenotomy.

Biceps tendon rupture

Rupture or tear of the tendon may occur following a period of inflammation and weakening of the tendon or as the result of a single injury. Of the two upper biceps tendons, it is again the “long head of biceps” which is almost invariably involved. The distal tendon (at the lower end) can also have problems with tendonitis and can rupture.

Distal tendon rupture- This injury is best treated with an operation as the rupture results in the muscle no longer being attached at the lower end (where there is one tendon only).

Proximal tendon rupture- This injury is not so serious as the biceps muscle is still attached to the the shoulder (where there are two tendons to start with). If a rupture at the top end has already occurred, non operative treatment is usually recommended as there is usually a very mild, often unnoticeable functional deficit as a result. There may be some exceptions to this rule e.g. overhead athletes.

Pectoralis major ruptures

The pectoralis muscle is a large fan shaped muscle found on the front of the chest wall. It originates both from the chest wall and the clavicle (collar bone). It then forms a tendon which has a complex insertion on the upper part of the humerus (upper arm bone). It is the main muscular contribution to the shape of the front of the chest. 

Tears of the muscle itself do occur, but much more commonly, it is the tendon which ruptures at, or near, the attachment to the upper arm.

This type of injury is commonest in males under about 50 years of age, frequently in weight lifters and contact sportsmen e.g. rugby players.

The rupture is usually sustained whilst engaging in vigorous activities such as bench press. There is usually immediate pain in the upper arm and chest. Deformity (indentation) of the area above the arm pit may be noted. Bruising may develop over a few hours / days. Weakness may be noted when trying to repeat activities such as bench press and the muscle may be seen to bunch up whilst attempting to do so.

Treatment

Surgical repair is usually recommended, particularly in higher demand patients. Ideally this is performed within the first few weeks of injury as it has been shown that the outcomes of early surgery are superior to operations performed at a later date. However good results can still be obtained in the situation where the rupture is long-standing, but a slightly different surgical technique may be needed,

After surgery, the arm will need to be rested in a sling  for three or more weeks and an individualised rehabilitation programme will be provided.

SLAP tears

What is a SLAP tear?

“S.L.A.P tear” stands for Superior Labrum Anterior to Posterior tear.
The labrum is the lip of tissue (cartilage) which surrounds the socket (glenoid) of the shoulder. The labrum is important for the stability of the shoulder and also provides the site of attachment of one of the tendons of the biceps muscle. “Superior” describes the upper part of the labrum and “Anterior to Posterior” describes the direction of tearing i.e. from front to back. In other words a SLAP tear is a tear of the upper part of the labrum from front to back.

Types of SLAP tear

There are four main types of SLAP tear, each with slightly differing treatments:
Type 1 represents fraying , but not detachment of the labrum.
Type 2 represents detachment of the labrum
Type 3 is a “bucket handle” tear. This is when the labrum splits and part of it hangs into the joint
Type 4 is where the damage extends into the biceps tendon itself

Causes

One of the tendons of the biceps muscle attaches to the upper part of the labrum and it is forcible contraction of this tendon which causes damage to the underlying labrum. This can occur as part of a single injury, such as a during a dislocation of the shoulder or forceful pull on the arm or, secondly, as part of repetitive trauma, such as in overhead sports activities. Throwing athletes, tennis players, etc. are at particular risk of this repetitive mechanism of injury.

Symptoms

The symptoms associated with SLAP injuries can be difficult to describe and are sometimes confused with other problems such as AC pain . However, patients often describe pain felt over the top of the shoulder associated with clicking and popping. Sometimes the pain can radiate into the area of the biceps muscle.

Diagnosis

The type of symptoms described by the patient will often give rise to a suspicion of a SLAP tear. A number of clinical tests on examination have been described to try to diagnose SLAP tears, but none of these is wholly reliable. The definitive diagnosis is usually made by performing a special MRI scan where some dye is placed into the shoulder joint prior to the investigation. This is known as an MRI Arthrogram (MRA) and is the ideal investigation for assessing damage to the labrum of the shoulder joint. The dye tracks into any abnormal spaces or clefts between the tissues and shows up clearly on the scan, thereby delineating any tears very clearly.

Treatment

If the SLAP tear is not particularly symptomatic, simple measures such as anti-inflammatories may be sufficient. If the symptoms are more significant, surgery may be required. The surgery is performed with a keyhole (arthrosocpic) approach.

• For type 1 problems, an debridement may be performed. This is simply a tidying up of the frayed edge of the labrum. Recovery after this type of surgery is very quick and the shoulder will be mobilised immediately after surgery.
• For type 2 problems (the commonest type) the labrum may be repaired back down to the edge of the socket (glenoid). This is done with small “anchors” in a similar fashion to that performed in instability surgery, with full recovery taking eight to twelve weeks.
• Type 3 problems- here the “bucket handle” segment is usually removed and the remainder of the labrum is reattached (as with a type 2 problem)
• Type 4 problems are more rare. The labrum is repaired as in type 2 and 3, but the damage to the biceps also needs to be addressed. This is usually done by fixing the biceps down to a slightly different site in the shoulder (a tenodesis). Full recovery after this will be about ten to twelve weeks.

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Shoulder dislocations and instability

The shoulder is one of the most mobile joints in the body and thus it is not surprising that it is prone to dislocations. A number of factors help the shoulder to stay in joint. Very little stability is afforded by the shapes of the involved bones as the shoulder is essentially composed of a ball (the humeral head) perched on a very flat socket (the glenoid). The socket is deepened somewhat by the presence of a lip of soft tissue (cartilage) found around the periphery of the glenoid. This tissue, which is vital to stability, is called the labrum. The labrum is attached to the capsule of the joint which itself has a number of thickenings (ligaments) which are also important for stability. The other important structures assisting stability are the muscles around the joint itself.

Shoulder instability is often sub-classified by specialists into “Traumatic” and “Atraumatic”, dependent on whether or not the instability started with a significant injury to the shoulder.

Traumatic instability

In this category of instability, the patient will usually give a history of a significant injury as a precipitating event. With this type of injury, there is usually structural damage. If the bones are significantly damaged, the abnormality may be detected on X-ray. However, the vast majority of people with a symptomatic traumatic dislocation will require a special type of MRI to delineate the damage. This is known as an MRI arthrogram (or ‘MRA’). In such an investigation, some dye is placed in the joint prior to the scan. The dye then leaks into any abnormally torn areas or clefts. One of the most import issues that such an MRA will detect is the presence of a tear in the labrum. This is known as a Bankart tear and will be present in the majority of of traumatic dislocations. Bankart lesions are the most common cause of recurrent instability.

Treatment of traumatic instability

This will be dependent on the demands of the patient. For example, an elite rugby player will almost certainly require surgery without delay as they will have at best about a 30% chance of getting through the rest of a playing season without a further dislocation. For other patient groups, particularly those who have a lower risk of re-dislocation, specialist physiotherapy may be recommended, at least as a first line of treatment.

Surgery

The two main types of operation are an arthroscopic (keyhole) Bankart repair or a Latarjet procedure.

The best type of operation will depend on a number of factors, but some general rules of thumb are:

Arthroscopic repairs are indicated for people with soft tissue damage i.e. a labral (Bankart tear) with either recurrent instability, or often after a single dislocation e.g. in younger people who engage in contact sports.

An arthroscopic Bankart repair involves refixing the torn labrum to the edge of the glenoid using small implants called anchors. The anchors are fixed into the bone of the glenoid and then the attached stitches are passed through the soft tissues. Tensioning the stitches then brings the soft tissues back to their correct attachment on the bone where they then heal.

Click for post-operative rehabilitation protocol

A Latarjet procedure is more often performed for people who have damaged the bone of the socket, particularly if they engage in contact sports. People who have undergone previous stabilisation surgery, but have dislocated again, may also be considered for this option.

Following either type of surgery, the arm will need to be rested in a sling for two to three weeks. Physiotherapy will commence early in this phase and continue until the patient returns to good function. In elite athletes, return to contact sports can be in as little as eight weeks. Average return to contact would be about three months.

Atraumatic instability

With this type of instability (which often affects both shoulders) there is usually no history of a significant injury as a precipitating event.

Causes of this type of instability may include problems with the muscle control around the shoulder (both under activity and over activity of different muscles can contribute); problems with excessive elasticity of the soft tissues can also contribute (eg patients who are “double jointed” or hyper lax).

Other issues with posture, shoulder blade control, and core stability can also be implicated.

Treatment of atraumatic instability

The mainstay of treatment for this type of problem is specialist physiotherapy. It is imperative that the physiotherapist has experience in dealing with these problems. In some cases, usually after a period of appropriate physiotherapy, surgery may be indicated if symptoms persist. This type of surgery is technically demanding to get right and to avoid causing further problems. Skilled post-operative physiotherapy is equally as important.

Nerve problems affecting the shoulder

There are a number of nerve (neurological) problems which result in pain and / or weakness around the shoulder. Some of these conditions are quite rare and often only diagnosed by a specialist. Problems in the shoulder can arise from issues with the nerves as they arise from the spinal cord within the neck, or anywhere along their course to where they end by supplying the muscles of the shoulder girdle

Cervical nerve root entrapment

The nerves which supply the shoulder and much of the upper limb arise from the spinal cord and pass out between the bones of the spine (the vertebrae) within the neck (known as the cervical part of the spine). The main nerve roots involved in shoulder pain are known as the C5 and C6 nerve roots, so named because they emerge from the spine in the region of the 5th and 6th Cervical vertebrae.

These nerve “roots” pass into a type of “junction box” called the brachial plexus, within the neck. The roots branch and join with branches of other nerve roots, then divide again to form the nerves of the upper limb.

The nerve roots involved can become irritated or compressed in the neck by various structures. If this happens, the brain actually perceives the pain as arising from the shoulder (which they supply) in addition to the neck itself, which is the actual site of the problem.

Symptoms

Shoulder pain arising from the neck has certain characteristics. There is usually an element of neck pain. The pain typically radiates into the shoulder / upper arm. There may be tingling or numbness particularly on the outer aspect of the upper arm and forearm and a degree of weakness, particularly affecting the deltoid and biceps muscles.

Diagnosis

Diagnosis is made from a combination of the patients' symptoms, the examination and often by the performance of an MRI scan of the cervical spine.

Treatment

Fortunately in the majority of instances, this type of pain can be treated without surgical intervention. Physiotherapy / manipulations, medications, nerve root blocks and traction have all been shown to be effective in alleviating symptoms

Occasionally surgery may be indicated. In all cases, surgery would be preceded by the performance of an MRI scan. The scan would help determine if surgery is likely to be of benefit. The operations for this condition are performed by Spinal Surgeons or Neurosurgeons.

Supra-scapular nerve entrapment / injury

The suprascapular nerve is important for shoulder function as it supplies two of the muscles of the rotator cuff. These (the supraspinatus and infraspinatus muscles) are invovled in moving the arm up and out from the side (known as abduction and external rotation). This is the position in which the arm is placed, for example, when reaching back for a seatbelt or serving at tennis. 

The supraspinatus nerve also carries about 70% of the pain sensations from the shoulder back to the brain where they are perceived. (See also supra-scapular nerve blocks)

The nerve can be injured either by traction (stretching) or compression. This can occur with trauma; this can be due to a single event such as a fracture or due to repetitive activity such as during some overhead sports. The nerve is at particular risk of compression at two sites on its course around the shoulder blade (known as the supra scapular notch and the spinoglenoid notch).

Traction on the nerve can also occur if the shoulder blade is forced downwards e.g. with the use of a heavy rucksack, or during weightlifting.

Symptoms 

This condition often results in pain around the shoulder. This can be felt in various sites, but is most commonly felt to radiate down the back of the shoulder. Patients may notice some weakness of the movements of abduction and external rotation. 

Diagnosis

The diagnosis is suspected when on examination there is weakness and wasting of the supraspinatus and infraspinatus muscles. The nerve suplies the supraspinatus muscle first and the infraspinatus second along its course. Therefore, if the issue occurs at the upper part of the nerve (at the supra scapular notch), both muscles will be affected. If the lower part of the nerve is affected (at the spinoglenoid notch), the supraspinatus is spared and only the infraspinatus muscle. is involved.

The diagnosis (and cause) is often confirmed using MRI and nerve studies (EMG). The scan may show the presence of a cyst as the cause of compression

Treatment

This depends on the cause of the problem. If there is no specific site of on-going compression on the nerve, non operative measures are considered. 

Physiotherapy will focus on muscle strengthening, scapular stabilisation and may involve activity modification. 

If there is a site of ongoing compression of the nerve, early surgical treatment is more likely to be recommended. This is on the basis that the muscle wasting caused by this condition is, to a degree, irreversible. Dependent on the site of the problem, this will involve either the release of the restrictive over-lying ligament of the supra scapular notch, or dealing with the cysts which are the commonest cause of the issue at the spinogglenoid notch. 

Post operative rehabilitation will be along similar lines to that of the non-operative regime described above. The affected athlete may also need an assessment of technique, to see whether technique modification may help prevent further problems.

Throracic Outlet Syndrome

Thoracic outlet syndrome (TOS) describes the symptoms that arise due to compression of some of the nerves (usually) and / or blood vessels (more rarely) as they leave the chest to enter  the upper arm. These structures leave the chest through the “Thoracic outlet”. They can become compressed against a rib, the collar bone or against abnormal fibrous bands or even between enlarged muscles. e.g. in weightlifters.  Sometimes the problem arises as the result of the presence of an extra rib (known as a “Cervical Rib”). Occupations and sports with a lot of overhead activity are also risk factors.

Symptoms 

The nervous structures are usually involved in the compression and this may result in numbness and tingling in the arm, sometimes with accompanying weakness. There is usually pain which may involve the shoulder, inner arm, neck or upper back. If the blood vessels are involved, the arm and hand may become intermittently discoloured. 

Diagnosis

A diagnosis is made by a combination of clinical examination tests and special investigations such as EMG studies (to assess the nerves) and blood flow studies (called Doppler ultrasound) to assess the blood vessels.

Treatment

In most cases TOS can be treated by non-surgical means. Physiotherapy is useful and may involve stretching, postural improvement and ‘nerve glides’

Very occasionally, surgery is indicated, particularly if the blood vessels are affected and if non-operative measures have failed. This involves exploration and release of the nerves at the site of compression.

Acute brachial neuritis

This condition, which has many other names (Parsonage-Turner Syndrome, neuralgic amyotrophy, brachial neuropathy etc), is an inflammation of one or more of the nerves arising from the brachial plexus. The brachial plexus is the confluence of nerves which arise from the cervical spine (in the neck) and go on to supply the shoulder girdle and arm. The cause is unknown, but it has been suggested that the onset of the condition may follow after having suffered from an infection, particularly viral.

Symtoms 

Typically, this condition is characterised by a relatively fast onset and severe pain affecting the shoulder and upper limb. This is followed by weakness and eventually wasting of many of the muscles of the shoulder and upper limb. However, these typical symptoms are by no means invariable. There are many cases described where there is minimal or no initial pain, followed by weakness. Conversely, there have been cases where there is marked pain at the onset but  with only minimal weakness and wasting subsequently. There are also many cases described where only one or two nerves and muscles are involved.

Diagnosis

The diagnosis is usually suspected from the symptoms and examination and can be confirmed with nerve conduction studies (EMG’s). Sometimes MRI scans will also be performed to rule out other causes of the associated symptoms.

Treatment

Parsonage-Turner syndrome is usually a self limiting condition, which means that it improves and resolves without any specific treatment. Recovery can take some time however and the symptoms can last for between a month or two and two years or more. It is unusual, but by no means unheard of, for the problem to recur. Treatment usually involves physical therapy to prevent stiffness and to also strengthen the weakened muscles.

Quadrilateral space syndrome

The quadrilateral (or quadrangular space) is a space bounded on three sides by muscles (teres major and minor and triceps) and one side by the upper arm bone (humerus) which is situated the back of the shoulder. The axillary nerve and an artery pass through the space. 

Quadrilateral space syndrome occurs when the nerve (and occasionally the artery) get compressed or damaged. This can occur over time, for example in overhead / throwing athletes such as swimmers or tennis players or more rarely after acute trauma e.g. with a shoulder dislocation. Sometimes the nerve can be compressed by a cyst.

Symptoms

Symptoms are often quite vague and as a result, this condition is often misdiagnosed. The pain is sometimes felt at the back of of the shoulder and sometimes in the deltoid region which is why this condition can be mis-diagnosed as an impingement problem. Sometimes there can be tingling in the deltoid region. Occasionally there will be weakness of the affected muscles. Symptoms are often worse when the arm is held at the upper/outermost part of the throwing action (at the end of the ‘cocking phase’)

Diagnosis

Diagnosis of this fairly unusual condition can be made form the history and examination and also with special tests.

On examination, there may be tenderness at the back of the shoulder at a point overlying the quadrilateral space and sometimes weakness (with the arm held abducted and externally rotated i.e. up and out)

MRI scans may show wasting in the muscles which the axillary nerve supplies i.e.the deltoid and teres minor. EMG (nerve tests) may show changes in the axillary nerve.

Treatment

Quadrilateral space syndrome can usually be treated by non-operative means. This may include provocative activity avoidance, and physiotherapy to focus on strengthening and posture.

Surgery is sometimes indicated if these measures fail to provide benefit. This involves making an incision at the back of the shoulder to explore the axillary nerve and release any areas of restriction along its course. If the problem is caused by a cyst arising from the shoulder joint, the cyst may be decompressed with a keyhole procedure.

Stingers / burners

Stingers (also known as burners) occur as a result of injury to some of the nerves which pass from the neck to the upper limb. These nerves form in the cervical spine (neck) and merge to form a type of “junction box” called the brachial plexus. The nerves then divide again to enter the upper limb. It is at the brachial plexus where a nerve injury most commonly occurs in a stinger type incident.

This type of injury commonly occurs in contact sports people when they injure the neck or shoulder. The injury can occur when the neck is forcibly flexed one side or to the other. This can cause traction or compression of the nerves in the brachial plexus. The other mechanism is a direct blow to the upper part of the shoulder as it merges with the base of the neck.

Symptoms

Stinger injuries result in numbness, tingling or burning feelings in the shoulder and arm on the involved side only. Sometimes weakness is also evident. These symptoms often only last for seconds or minutes but sometimes last for a number of days. 

Diagnosis

The diagnosis is usually clear form the history, but it is important to exclude more serious problems such as a fracture in the cervical spine.

Treatment

Avoidance of contact sports is essential until symptoms have fully resolved. Physiotherapy can be useful to help restore pain-free movement and flexibility to the neck and upper limb. The focus is then on improving strength and posture prior to return to sport specific exercises. These type of injuries not infrequently can recur and thus it is important for the rehabilitation team to focus on prevention as well as initial recovery.

In the rare instances when symptoms persist for longer than a couple of weeks, further investigations will be warranted. These may include an MRI scan of the neck and bracial plexus and EMG (nerve conduction) studies. The results of these tests will help guide further management.

Scapular problems

The scapula is the medical name for the shoulder blade. It is an integral part of the shoulder joint for a number of reasons: 

Firstly it is the outer part of the scapula which forms the socket (glenoid) of the shoulder joint. Secondly, many of the muscles involved in moving and stabilising the shoulder originate from the scapula. Thirdly, the scapula effectively forms the main attachment of the back of the shoulder girdle to the body via the "scapulo-thoracic articulation". This is not a true joint, but nonetheless, the muscle attachments here between the shoulder and the thorax are vital in the support of the upper limb and the control of the shoulder. 

Problems related to the scapula can include issues with posture; the rhythm of the movements; problems of attached muscle weakness; pain arising from the space between the scapula and the rib cage and problems with the rotator cuff.

Scapular winging

The shoulder blade (or scapula) is said to ‘wing’ when the shoulder blade lifts away from the chest wall and sticks out, particularly with movements of the shoulder.

There are a number of causes which can include weakness of the surrounding muscles (sometimes due to a problem with their nerve supply); lack of coordinated action of those muscles; or due to structural problems within the scapulo-thoracic articulation (where the shoulder blade and the chest wall meet).

Scapular winging may be present in children, but in these cases it is usually normal and often needs no further investigation particularly if there are no symptoms.

Two common patterns of scapular winging are so called ‘medial’ and ‘lateral winging’ which are due in each case to single muscle weakness as a result of issues with the nerve supply of the muscles

Medial winging

In this type, the upper inner corner of the scapula moves toward the spine (i.e. medially). This is due to weakness of the serratus anterior muscle resulting from a deficit in the supplying ‘long thoracic' nerve. The serratus anterior normally helps hold the scapula tightly against the chest wall. This type is often seen in the athletic population. Occasionally this may present as part of a more widespread nerve problem known as Parsonage -Turner syndrome

Lateral winging

In this rarer type, the upper inner corner of the scapula moves outwards away form the spine (i.e. laterally). This is due to a weakness of the trapezius muscle which is supplied by the ‘spinal accessory nerve’. This nerve is sometimes damaged in neck surgery.

Symptoms

The symptoms associated with scapular winging are variable and may depend on the cause.

At one end of the spectrum, the patient may not have perceived any problems at all, with the issue having been noticed by someone else, for example when the patient had their shirt off. At the other end of the spectrum, there may be significant pain, poor range and strength of shoulder movements and even problems with shoulder stability.

Diagnosis

This is usually suggested by the physical examination and the cause may be confirmed by the performance of nerve conduction studies

Treatment

Treatment depends, to a large degree, on the cause. In the majority of cases, physical therapy is recommended.

Rarely, surgery is indicated. This may involve nerve exploration, tendon transfers.etc. There is a rare type of progressive muscular dystrophy known as “Fascioscapulohumeral dystrophy” where many of the muscles supporting the scapula (and face) get steadily weaker. This is sometimes treated by fixing the scapula to the underlying rib cage ( a scapula-thoracic fusion) to improve movement and function of the upper limb.

Snapping scapula

This is a problem where patient suffers from a grinding, popping or clicking sensation arising from the under the shoulder blade with movements of the shoulder, particularly when shrugging and rolling the shoulders. This is due to some structural issue causing a ‘catching’ thus preventing the normal smooth gliding of the scapula over the chest wall.

Causes

These may include:

weakening and thinning of the muscles between the scapula (shoulder blade) and the chest wall;

inflammation of the bursae (the small sack-like structures found throughout the which are designed to stop muscles and tendons rubbing against adjacent structures) or of the muscles. This is often the cause in overhead athletes; 

bleeding into and scarring of the muscles or bursae;

or boney problems such as structural abnormalities of the undersurface of the scapula or outer surface of the ribs, or curvature of the spine. 

Symptoms

The patient with a snapping scapula will complain of the type of noises described above. This may be painless, but often is associated with aching and pain, most commonly felt  at the upper / inner corner of the shoulder blade i.e. near the base of the neck. Sometimes the pain can be quite disabling.

Diagnosis

This is usually fairly obvious from the described symptoms and physical examination. Investigations may be considered necessary and can include MRI, CT and dynamic ultrasound. These investigation aim to detect any ares 

Treatment

Treatment may include physical therapy to strengthen the muscles under and around the scapula and to improve any issues with posture and positioning of the scapula. Often, a sub-scapular (under the shoulder blade) steroid injection will be performed to reduce any suspected inflammation. On rare occasions, and almost always when the above treatments have been tried unsuccessfully, surgery will be performed. This is an arthroscopic procedure which is uncommonly performed and this treatment is only offered in limited circumstances 

Investigations and imaging

Investigations and imaging related to shoulder problems may be performed for a number of reasons. They may be used variously as a  diagnostic aid; to help plan treatment of some conditions; to help plan surgery; to monitor the progress of the healing process; or to guide the placement of injections.

X-ray images

X-rays are a part of the so called electromagnetic spectrum, as is visible light. The colours that we can see have different 'wavelengths' and X-rays have an even shorter 'wavelength' than any of the visible colours.

X-rays can pass through the tissues of the body much more easily than visible light. Just how easily they can pass through depends on the density of the tissue, so x-rays pass more easily through soft tissues such as muscle than the more dense bones.

 An x-ray image (or more correctly a radiograph) is taken by passing an X-ray beam through the relevant part of the body. A detector is placed on the other side of the body to detect the x-rays which pass through the tissues, producing an image. The X-rays pass through the soft tissues producing black areas on the image, but where there are dense bones, a white area is produced. Thus the position and shape of the bones can be 'seen' with the x-rays.

In the investigation of the shoulder, X-ray images are used to assess the bones in fractures; to asses any 'metalwork' which has been placed in the shoulder e.g. a shoulder replacement  and also to look for areas of abnormal dense calcium in the the tendons.

X-ray imaging results in exposure to a very low dose of radiation and thus should be used cautiously in pregnancy. There are no other major restrictions to its judicious use.

Ultrasound Scans (Sonograms)

These use high frequency (inaudible) sound waves to form images of parts of the inside of the body. The ultrasound waves reflect off different tissues in different ways and the reflected waves are used to build up a picture. The scans do not involve any radiation and there are no known risks associated.

Less dense tissues reflect fewer ultrasound waves than denser ones. The reflected waves are called ‘the echo’, just as we all describe the same phenomenon with audible sound waves. The differing echo produced by differing tissues allows a picture of those structures to be formed on the screen. 

Ultrasound is a realtime, dynamic type of imaging. This means that it is a bit more like a video than a photograph. Changes can be seen as they happen and the structure being scanned can be assessed as it moves. A good example of this is the use of the scans to look at the baby during pregnancy.

Ultrasound scans are pain-free and non-invasive. They are performed by the operator placing some gel on the skin overlying the part of the body to be scanned. By placing the probe on to the gel the underlying tissues at differing depths can be assessed.

There are many applications within medicine, but this type of scan is particularly useful for assessing the soft tissues of the body. The scan will also detect areas of inflammation. 

As regards to applications in the shoulder, ultrasound is commonly used to assess the tendons, particularly the rotator cuff and the biceps tendon. Ultrasound is sometimes used to guide, and ensure accurate placement of, injections. 

CT (Computerised Tomography) scans 

This is a special type of X-ray machine which takes multiple images of a part of the body which are then built up into a detailed and accurate picture of the area of interest. 

Unlike in a standard x-ray image, a CT scanner  sends beams of x-rays at multiple different angles through the body to produce information which the computer builds into images of 'slices' of the body. This type of 'slice' is known as a tomographic image. 

Modern scanners have software which even can reconstruct the scan information to produce 3D pictures.  CT scans have many uses in medicine, but around the shoulder are particularly used to assess the bones of the shoulder girdle, providing significantly more detail than standard X-rays. They are often used, for example to give detailed information about fractures around the shoulder and sometimes to assess the shoulder joint prior to shoulder replacement surgery.

As in x-ray imaging, undergoing CT scans involves exposure to some radiation, but at a higher level than during plain x-ray imaging. Consequently they are best avoided during pregnancy. For most patients, however, the levels of radiation involved are very safe.

MRI (Magnetic Resonance Imaging)

This is an advanced form of imaging which gives information on all the structures in the body, but (like ultrasound), is particularly useful in the assessment of the soft tissues.

The machine consists of a very powerful magnet which produces data which is analysed by the computer to produce incredibly detailed images.

The body has a high water content, which varies between different types of tissues. Water contains hydrogen ions(or protons)

In an MRI scanner, the strong magnetic field causes these protons to line up. Powerful radio waves are then passed through the tissues, and when these are turned off, the protons return to their resting state, releasing energy which is detected by the machine. Different tissues will release this energy in different ways, thus allowing the MRI to distinguish between the different types of tissue. 

Thus an extremely detailed picture is built up of the exact structure of the body part being scanned. The scans will even clearly show any areas of inflammation within the tissues.

When assessing shoulder problems, MRI scans have many uses and will demonstrate inflammation and damage in the majority of the structures.

Sometimes a special dye is placed into the shoulder joint (this is called an MRA or Magnetic Resonance Arthrogram) to further delineate certain areas of damage. MRA’s are used, for example, to assess the unstable shoulder by accurately demonstrating damage to the labrum (the lip of tissue surrounding the socket)

MRI scans are extremely safe and are not associated with any risks. However their is a very small theoretical risk of affecting the early development of the foetus. Thus they tend to be avoided in the early stages of pregnancy. After the first twelve weeks, however, there are no known issues or risks for the pregnant lady undergoing MRI scanning.

Nerve Conduction Studies (NCS) and Electromyography (EMG)

Every muscle in the body is supplied by a nerve. The (motor parts of) the nerve carry the electrical impulses from the brain and/or the spinal cord to control the contraction and therefore function of the muscle. The (sensory part of) the nerves also carry pain sensations from the muscle back to the brain where they are perceived. 

Problems with the nerves can therefore manifest as loss of function, weakness and wasting of the muscle concerned, as well as pain. A number of such conditions affecting muscles around the shoulder are discussed in the conditions section

Nerve conduction studies (NCS) are often used to investigate such problems. NCS are often performed with EMG (Electromyographic) studies which look more directly at muscle as well as nerve function. EMG and NCS are often collectively termed ‘Electrodiagnostic studies’ or ‘Neurophysiological studies’.

NCS 

NCS are performed by placing small electrodes various points along the course of the nerves. Small electric currents are then passed between the electrodes producing information which includes data about the electrical conduction of the sensory and motor parts of the nerve. 

EMG

EMG is performed by placing tiny needles into the muscles. This gives information about the nerves, but also about the electrical characteristics of the muscle itself.

Combining the information from these studies can help diagnose and differentiate a number of conditions which can affect nerve and muscle function.

Physical therapy

Physical therapy is a vital component in the treatment of the majority of shoulder problems, as a treatment in its own right or as part of the rehabilitation after different forms of treatment such as surgery.

For more information, please see individual conditions and the resources section where you can find protocols and links to selected physiotherapists, osteopaths and pilates experts

Inter-scalene nerve blocks

Interscalene blocks are used to provide pain relief (analgesia) during and after surgery to the shoulder or upper arm. This type of nerve block involves placing local anaesthetic around the nerves to the shoulder / arm as they pass between the “scalene” muscles at the base of the neck. 

Ultrasound is used for guidance for the safe and accurate placement of the anaesthetic. This results in prolonged pain relief after the surgery which can last for up to forty eight hours.

The procedure is both safe and effective and the anaesthetist will discuss the extremely rare possible complications with you prior to the operation. You will then have the opportunity to decide whether or not you wish to proceed with the nerve block. If you choose not to, the anaesthetist will prescribe a different form of pain relief.

Interscalene nerve blocks are used in two different ways in shoulder surgery:

Firstly, it can be used for postoperative pain relief (analgesia) alone. In this circumstance, the nerve block is administered by the anaesthetist immediately prior to the general anaesthetic.

Secondly, in some instances, it can be used instead of the general anaesthetic altogether. In these cases the nerve block is used as an anaesthetic during the operation and as  analgesia (or pain relief) after the operation as above. Again the nerve block is administered just before the operation begins. This is ideal for patients who wish to remain awake for their surgery, or for those who may have other medical conditions which mean that it is safer to avoid general anaesthetic if possible.

Supra-scapular nerve blocks

If a patient has an on-going problem with pain in the shoulder which has not responded to simple measures such as steroid injections and / or physiotherapy, a supra-scapular nerve block may be recommended.

This is a simple pain relieving measure which may give relief of symptoms for up to six months.

The supra-scapular nerve supplies the brain with pain signals from about three quarters of the shoulder, so by blocking the nerve, pain can be significantly reduced. This is a safe and simple procedure which is performed under local anaesthetic using an ultrasound machine and does not require a stay in hospital. The procedure is almost painless. Pain relief can last for anything from a few weeks to six months or more.

This may be a particularly good option if the patient wishes to avoid an operation in the treatment of their shoulder problem. There are however, some patients and conditions for whom this is not an appropriate treatment and this would only be offered as an option to those who are suitable.

Arthroscopic Surgery

Arthroscopic, or “key-hole”, surgery is a way of doing operations through very small incisions whilst  the surgeon views the operation on a large screen.

Many operations can be carried out using this type of surgery, but not all are possible and some procedures need to be done through “open” incisions e.g. Joint replacement surgeries.

Arthroscopy has been made possible through the development of fibre-optic technology; there is a light source that shines light via the arthroscope (joint telescope) which has a camera mounted on the back of it. The camera then transmits the image to the screen. Modern High Definition equipment provides extremely detailed and sharp images. Photographs and video can also be taken to record the procedure.

During the  procedure, fluid is pumped into the joint to inflate it to facilitate an improved view of the structures within that joint. When a procedure is being performed, various small cuts are needed – called “portals”. Specialised instruments can then be passed through the portals to perform various surgical procedures within the joint.

The number and position of these portals varies with the type of operation, but they usually heal with minimal scarring. Each of the “portals” is repaired with a single stitch which is removed at between eight and twelve days after the surgery.

During the procedure, the fluid often leaks out into the tissues causing some temporary swelling.This is perfectly normal and harmless and usually settles very quickly. In most cases early movements can begin as no muscles have been cut in order to perform the surgery (this is often not the case in “open” surgery whereby the healing of cut muscle determines when free movements can be.

This minimally invasive type of  surgery allows for less discomfort and a quicker recovery with less scarring.

Steroid injections

Corticosteroids, often known as steroids, are an anti-inflammatory medicine prescribed for a wide range of conditions.

Possible side effects

Steroids that are injected into  joints may cause some pain at the site of the injection. In other words your shoulder pain may actually get slightly worse for a day or two before it gets better. However, this “steroid flare up” should pass within a day or two. This happens in about 30% of cases. Other possible side effects can include infections, temporary blushing (redness) of the skin around the face, and thinning and lightening of the skin in the area where the injection is given. Steroid injections can also cause muscle or tendon weakness if given too often. Because of the risk of side effects, steroid injections are often only given at intervals of at least three weeks and a maximum of three injections into one area is usually recommended. There aren't usually any severe side effects if you take steroid injections.

Cautions and interactions

For most people, including pregnant or breastfeeding women, steroid injections are safe. Care should be taken if you are Diabetic as a steroid injection may cause a rise in blood sugar levels for a few days. This is usually not a problem but the patient needs to be aware of this effect as blood glucose levels may need to be monitored more closely.