Shoulder Injuries

The shoulder is one of the most complex joints in the body, offering more range of movement than any other joint. If your shoulder is injured, day to day activities become very difficult; brushing your hair, dressing in the morning, hanging out the washing. The pain can be so debilitating that it prevents you playing sports, going fishing, getting groceries out of the trolley and sleeping. A shoulder injury can result from an accident or a pre-existing medical condition; these injuries can leave the shoulder severely weakened, in unbearable pain or completely incapacitated.

Mr Durrant is an expert in the field of shoulder injuries in both the diagnosis and treatment of the conditions and disorders that can affect the shoulder. He and his team implement the latest techniques in diagnosis, including careful physical examinations and high-field strength MRI scans, to help insure they make the correct diagnosis.

Surgery will not be necessary for all shoulder problems; Mr Durrant will assess the injury and may suggest rest and/or physical therapy. In the end, if shoulder surgery is required you can be assured of Mr Durrant’s experience and wealth of knowledge to ensure you have the best possible and least invasive treatment available.

The symptoms of an AC injury include:

• intense pain over the top of the shoulder
• swelling
• redness and bruising
• pain on movement of the shoulder

It is important to note that an AC injury does not have to involve any bones being broken. It is the joint, either the ligaments holding the joint in place, or the clavicle bone, that is separated or displaced.

AC joint injuries are graded in severity from I to VI. With a minor AC joint injury, some of the ligaments that stabilize the shoulder joint may be partially torn. In a severe AC joint injury the clavicle may have been pushed into the shoulder muscle and caused puncture or tearing of the muscle or the clavicle may be displaced down into the scapula. In severe AC joint injuries there will be a prominent visual bump over the top of the shoulder accompanied by intense pain.

Non Surgical

Treatment for an AC joint injury will initially involve rest and support of the shoulder joint, application of a cold compress, and often anti-inflammatory medication to reduce swelling and pain. For less severe injuries, grades I, II, this initial treatment as well as physical therapy is usually sufficient enough for the person to fully recover within four weeks to four months. For grade III injuries surgery may be required if recovery is too slow. Mr. Durrant may choose to see if the shoulder will recover with non-surgical treatment before operating on the injured shoulder. For more severe, grade IV, V, and VI, injuries surgery is almost always required.

Surgical

Surgical treatment of AC joint injuries aims to stabilize the clavicle into the correct position. Sometimes arthroscopic surgery is sufficient, where the end of the clavicle is removed or resected. In moderate injuries this procedure is sometimes enough to ease the pain and discomfort in the shoulder, and regain full mobility of the joint. However for more severe injuries, a combination of arthroscopic and open surgery is likely to be required.

Mr. Durrant uses a procedure to reconstruct the ligaments that secure the AC joint. A hamstring tendon or an artificial graft is used to reconstruct the ligaments as the damaged ligaments are usually not repairable. This then provides greater stability for the AC joint and aims to eliminate pain.

Your recovery from AC Joint surgery depends on the severity of the injury. Generally patients will experience a greater range of movement of the shoulder and less pain within about three weeks. The recovery process will continue for the next three months, where significant mobility and very little pain should be experience. Within the next six to nine months after surgery, the shoulder should fully recover, regaining its full strength.

Mr. Durrant has extensive experience in dealing with mild and severe AC joint injuries. He is very well versed with the advancements made in shoulder surgery over the past decade and performs much of his shoulder surgery via arthroscopic, or keyhole, surgical procedure. Arthroscopic surgery is a less invasive procedure which offers a faster recovery time and less visual scarring compared to traditional open surgery. Whether your AC joint injury is mild or severe, Mr. Durrant is able to correctly diagnose and provide effective treatment for your AC joint injury.

The shoulder joint requires smooth cartilage surfaces covering the ball and socket bones of the joint in order to function correctly. With osteoarthritis the cartilage becomes worn away, and the bones can begin to rub and grate against each other. This is caused by age and simple wear and tear on the joint. Osteoarthritis causes pain in the shoulder, often at the front of the shoulder, and this pain increases with movement. Joint stiffness, weakness, and reduced mobility are common symptoms of shoulder arthritis.

With disease related arthritis, such as rheumatoid arthritis, it is not the wearing away of the cartilage that causes the problem, but inflammation of the ligaments around the shoulder joint, and the fluid within the joint cavity that is the cause of the pain. In rheumatoid arthritis, the person’s immune system attacks healthy tissues of the body, most notably the soft tissue around the joints. Symptoms of rheumatoid arthritis include joint pain, swelling, redness around the joint area, and stiffness and loss of mobility. The joint pain is most notable in the morning upon waking, or after prolonged rest, and the pain is usually present for more than one hour. Unlike osteoarthritis, the pain in the joint is often eased with gentle use and exercise.

Post traumatic arthritis may occur within a joint that has been previously injured. This type of osteoarthritis is commonly seen in a person who has experienced a severe shoulder injury such as a dislocation, a rotator cuff injury, or an AC joint injury. Often the injured part of the joint can become uneven, enlarged, or slightly deformed. Although swelling reduces after an injury, sometimes this residual effect remains and over time causes disruption to the movement of the joint. Symptoms of post traumatic arthritis are the same as in osteoarthritis and include limited range of motion in the joint, pain, joint stiffness, and weakness.

Non Surgical

Medical treatment for arthritis of the shoulder involves the use of cold compresses to help ease pain and reduce swelling. Anti-inflammatory drugs are also commonly used to reduce swelling and ease pain. Physical therapy is also important as the joint needs to remain as mobile as is possible. Once a joint has lost mobility, it is very difficult to regain this movement. Gentle non-strenuous regular exercise is important for shoulder arthritis. If pain is severe then steroid injections into the joint may be necessary. However these injections are not considered the best course of treatment long term, as they only last up to a few months, and are only effective in reducing pain, not dealing with the cause of the pain. If joint deterioration is severe enough surgery may be required.

Surgical

Surgical treatment will usually involve arthroscopic removal of any loose cartilage or bone fragments that are causing irritation and pain in the joint. If the joint is severely damaged, then a joint replacement arthroplasty may be required. Shoulder replacements are not as common as other joint replacements such as knee and hip joints, and Mr. Durrant will only suggest a shoulder joint replacement if it is the only treatment option available. A shoulder joint replacement is where the damaged portion of the bone is removed and replaced with a metal, ceramic, or pyrocarbon joint. Through thorough physical examination, x-ray and MRI scanning, Mr. Durrant will be able to accurately diagnose arthritis of the shoulder, and suggest the most appropriate and effective course of treatment for you.

The symptoms of shoulder instability and dislocation include:

• pain in your shoulder
• a sensation that your shoulder feels ‘loose’
• an inability to move your arm
• numbness down the affected arm
• visual displacement of the joint

Often a ‘popping’ sensation is felt when you dislocate your shoulder. This can be very painful and will require medical attention.

Non Surgical

Immediate treatment for a dislocated shoulder includes moving and manipulating the joint back into place, and this should only be performed by an experienced medical doctor. Strong pain relief is often given as the pain experienced is usually very intense, anti-inflammatory drugs will help to reduce swelling and relieve pain. Sometimes the arm may benefit from support, by using a sling, and physical therapy in the weeks following a dislocation can help to strengthen the joint.

Surgical

Sometimes surgery may be required in the months following the dislocation in order to repair or remove any damaged tissue that is causing problems.

If a previous dislocation has caused shoulder instability, and regular physical therapy is not a suitable option, Mr. Durrant may recommend surgery in order to stabilise the joint. Mr. Durrant will perform a shoulder arthroscopy in order to repair and ‘tighten’ the ligaments along the front of the shoulder joint (this is the preferred method). A small thin camera is inserted into the shoulder joint along with narrow instruments, and the repair is performed all internally. In over 90% of cases this provides sufficient stability so the shoulder no longer dislocates.

For serious shoulder instability, an open surgical operation may be required for Mr Durrant to replace lost bone around the shoulder socket.

The symptoms of a labral or SLAP tear include:

• pain in the shoulder when lifting heavy objects
• placing the arm in certain positions
• reduction in movement
• a loss of strength in the shoulder
• a grating, locking, or catching sensation in the joint

People may also experience a dull aching pain in the shoulder, and have difficulty sleeping due to shoulder discomfort. Athletes will often describe a sensation of having a ‘dead arm’.

Type I SLAP lesions are common and often associated with the normal ageing process. Type II SLAP lesions involve a tearing and detachment of the long head of the biceps tendon. Type III SLAP lesions involves a “bucket handle” tear of the superior labrum without involvement of the biceps tendon. Type IV SLAP lesions involve both a tear of the labrum and detachment of the biceps tendon.

Treatment of labral and SLAP tears generally require surgery. The majority of people with labral tears will not regain full shoulder strength unless it is repaired surgically. Non-surgical treatment will simply involve physical therapy to try to strengthen the shoulder and maintain full range of motion, as well as anti-inflammatory drugs.

Most labral and SLAP repairs are carried out by arthroscopy. A small camera, as well as long narrow instruments, is inserted through small cuts into the shoulder. The small camera gives Mr. Durrant a clear view of the labral cartilage and the tear. The tear is repaired using sutures and it is then tied back into place using ‘anchors’ that are inserted into the bone.

The main symptoms of a rotator cuff injury include pain, usually experienced in the front of the shoulder during movement, and reduced range of motion of the shoulder joint, especially the lifting movement of the arm up to the front. These symptoms are caused by the inflamed muscles rubbing against the bony structure of the acromion.

With acute rotator cuff injuries the person may experience a tearing feeling in their shoulder which will cause intense pain down into the arm. With serious rotator cuff tears the arm may not be able to be lifted away from the body unassisted. The person may also be able to pin point the exact spot where the pain is most intense, usually indicating the location at which the tear has occurred.

Symptoms of chronic tears, which normally affect the tendons within the shoulder, include pain which increases at night, and a gradual increase in pain and weakness within the joint. The joint affected is often on the dominant side.

Non Surgical

Immediate treatment of a rotator cuff repair includes putting an ice pack on the shoulder and resting and supporting the arm with a sling. However care should be taken not to use the sling for any extended period as the shoulder may stiffen and cause further problems. Anti-inflammatory drugs will help with any swelling and pain experienced.

Medical treatment usually involves physical therapy in order to regain and maintain full range of motion and strength of the joint. A steroid injection may be required to ease the pain in order for full recovery to be made. The steroid injection will enable use and movement of the shoulder.

If the tear is severe or pain and stiffness is not easing within a few months of the injury, Mr Durrant may recommend surgery on the affected rotator cuff.

Surgical

Rotator cuff surgery is often required if the tear is complete. Often surgery is performed on patients with partial tears where pain and lack of full movement is still present after a few months of medical treatment. Surgery on patients who are under the age of 60 has been found to offer the best chances of recovery in high grade partial rotator cuff tears.

The aim of surgically repairing a rotator cuff tear injury involves reattaching the tendon to the humeral bone. Mr. Durrant will do this by inserting sutures that are attached to ‘anchors’. These anchors are inserted into the humeral bone and the suture is used to tie the tendon in place against the bone.

This surgery can be performed arthroscopically or open. Arthroscopic surgery involves a few small holes being made in the shoulder where a long thin fibre optic camera is inserted into the joint, along with some long small instruments.

Arthroscopic surgery has a number of advantages over open surgery. With arthroscopic surgery recovery time is shorter and pain, swelling, and bleeding is minimised.

With arthroscopic surgical repair of a chronic rotator cuff injury Mr Durrant is able to view the joint internally, and is better able to remove any damaged muscle tissue or bony prominences that may be causing problems.