GPs see a lot of shoulder pain and injuries. At the SMA March Medical Update, Dr Paul Jarman gave us an overview of common shoulder conditions and wowed us with the range of high-tech procedures available to treat them.
Rotator cuff and biceps tears
Rotator cuff tears are very, very common. There is sophisticated technology available to reattach the muscle to the bone if surgery is required. Biceps tears are less important as the biceps does not add stability, strength or proprioception feedback to the shoulder. There are options available for repairing biceps tears if they are causing problems though.
This can be a response to a minor injury and can settle without surgery, but can be very painful. Steroid injections are an option. It can become more painful when the calcium deposit is liquefying – consider attempting barbotage under ultrasound. Sometimes this does need surgical debridement.
Frozen shoulder causes insidious global pain, often from only a trivial injury. It leads to progressive restriction of motion. There often isn’t a lot to see on xray / ultrasound. There are 3 phases: inflammatory, stiffness and resolution, each lasting up to six months. Most will have other pathology, e.g. common with endocrine pathology. It is important to note that a rotator cuff tear alone will not make the shoulder stiff. Intra-articular steroid, not just subacromial, can be helpful for comfort but may not affect long term prognosis. Physiotherapy can be counterproductive sometimes. There is generally a limited role for surgery, apart from possible arthroscopic release in stiffness phase.
AC joint injuries
The AC joint is often injured by a fall onto the point of the shoulder, e.g. bikes / motorbikes / football. Sometimes patients report that they feel like their ‘arm is falling off my shoulder’. AC joint injuries are graded into types, where type 1-2 you do nothing, 4-6 = surgery, and 3 nobody really knows what to do with yet.
Dislocation or subluxation of the glenohumeral joint can be anterior or posterior, single or recurrent. Patients are now offered reconstruction after a single dislocation. They may even return to contact sport midseason if the injury was a subluxation. There are arthroscopic and open options. Revision surgery may be needed in some instances.
Reverse shoulder arthroplasty
This high-tech solution has been around since about 1988, where the shoulder joint is replaced but in reverse so that the ‘ball’ is on the scapula and the ‘socket’ is on the humerus. This operation can be flexible, adaptable, useful for pseudoparalysis (i.e. lost active but not passive range of movement), as well as for managing some fractures, revisions or arthritis.
Take home messages
- Advanced surgical techniques mean more options for patients.
- Consider referral if a large functional impairment, or not responding to conservative treatment.
- Some shoulder operations are time-sensitive, so if you are concerned or unsure then refer for opinion early. Especially if they are an athlete.