Shoulder Anatomy:
The shoulder joint is a ball and socket joint. The “socket” is called the glenoid and the “ball” is called the humeral head, it is also surrounded by two layers of shoulder muscle. The first layer is the deltoid muscle¸ a large powerful muscle that is the “cape” around the shoulder joint.
Other bigger muscles at the back of the shoulder are the
trapezius and
latissimus muscles which help stabilise the shoulder blade (
scapula) in different arm positions. A deeper layer of rotator cuff muscles are attached to the scapula: there are four of these muscles that then go on to attach to the humeral head. The
rotator cuff tendon is a collective name for the four tendons that insert onto the humeral head. The four tendons are the
supraspinatus (on top)¸ the
subscapularis (in front), and the
infraspinatus with the
teres minor at the back of the humeral head. Together all these muscles help control the movement of the ball within the socket.
Above the supraspinatus tendon is the
subacromial space. This is a small area which contains a spongy piece of tissue called a bursa. The roof of the subacromial space is a bony prominence of the shoulder blade called the
acromion.
The
bursa can get inflamed and is called bursitis and so can the tendon and is called tendonitis.
The glenoid and humeral head are covered by healthy
cartilage which allows smooth movement in the shoulder. The shoulder joint is surrounded by a tough
capsule which holds it together, the capsule is also strengthened on the inside by ligaments which span from the socket to the ball¸ these are called the
glenohumeral ligaments. The socket is reinforced around its edge with a rim of firm cartilage called the
labrum, which can be pulled off when the shoulder dislocates.
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Shoulder Impingement Syndrome:
This is a common painful condition of the shoulder and affects people in their late thirties up to sixty years of age. Symptoms include pain and weakness when lifting your arm above shoulder height. Weakness can also be associated with an underlying rotator cuff tendon tear.
The pain can be severe enough to cause sleeplessness. It is caused by a prominence on the humeral head called the greater tuberosity rubbing on the undersurface of the acromion. This occurs when the shoulder movements are abnormal due to the rotator cuff muscles not working properly. The rotator cuff tendons insert onto the humeral head and control the movements of the head in the glenoid (socket). They may not function properly due to pain, tendon degeneration or tears and also an inflammation within the subacromial space. The space between the undersurface of the acromion and the rotator cuff is called the subacromial space.
Pain is also caused by abnormal acromion shapes. Some are pointed or hooked and dig into the tendon which can cause tears and make the impingement worse.
An injection of steroid and local anaesthetic into the subacromial space usually helps with the diagnosis and can control the pain in order to strengthen the rotator cuff muscles around your shoulder.
An injection is usually given after a rotator cuff tendon tear is ruled out using either an ultrasound or MRI of the shoulder. If the shoulder pain does not respond to this treatment then a “keyhole” or arthroscopic operation is performed to remove the hook of bone and at the same time any other causes of your pain or weakness can be addressed such as a repair of a tear in your rotator cuff tendon.
Rotator Cuff Tendinitis:
This type of shoulder pain arises when the rotator cuff tendon becomes inflamed within the subacromial space. The space is inflamed and causes pain when you move your arm forward or out to the side above shoulder height. It usually responds to simple measures of rest, ice compresses and physiotherapy. Your physician may prescribe pain-killer tablets known as NSAIDs (non-steroidal anti-inflammatory drugs) which are also helpful.
Rotator Cuff Tears:
The rotator cuff muscles provide coordinated movements of the shoulder joint because they insert on to your humeral head. The tendons can get torn due to degenerative changes associated with increasing age or a direct trauma to your shoulder. If the rotator cuff is damaged then you will notice weakness and pain in your shoulder and you may even have subacromial impingement as well.
Usually the diagnosis can be made following a surgeon´s examination of your shoulder and an ultrasound scan of your shoulder.
In some cases this condition could be treated with steroid injections into the shoulder joint followed by physiotherapy¸ especially for those patients who are not keen on surgical repair¸ or who are not fit for a surgical procedure. The majority of patients would benefit from a repair by arthroscopic surgery to try and prevent the tear from getting bigger or causing arthritis (rotator cuff arthropathy). Sometimes the tear is too big so the tendon can only be partially repaired arthroscopically or if this cannot be performed the tendon tear is trimmed back (debrided) so that it is less likely to cause pain. The operation is also combined with a subacromial decompression as well. Rotator cuff repair is a major undertaking and postoperative recovery period can take up to 3-6 months. The shoulder is rested in a sling for a period of 4-6 weeks but exercises are commenced straight away out of the sling. Return to full activity is usually at 3 months and contact sport can be up to 6 months.
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Calcific Tendinitis:
The symptoms are very similar to shoulder impingement syndrome. It is caused by flecks of calcium (chalk), forming within the rotator cuff tendon which causes inflammation and pain when moving the arm out to the side or in front up to shoulder height and beyond.
The cause is mainly as a result of the tendon cells turning into chalk and it can resolve on it´s own eventually. Usually the diagnosis is made on an X-ray. It can respond to a course of steroid injections into the subacromial space. If this is not helpful for your shoulder then an arthroscopic shoulder decompression is performed and the telescope is also used to identify the chalk deposits in your tendon so that they can be removed.
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Frozen Shoulder (Adhesive Capsulitis):
The shoulder can become painful and stiff due to inflammation of the capsule of the ball and socket joint. As a result of the inflammation the shoulder capsule contracts which will limit the range of shoulder motion. Pain is quite disabling, interfering with your sleep and the stiffness with your general activities of daily living.
It may be caused by diabetes but most of the time it has no known cause. It can result from a trivial injury to the shoulder. It has three stages: the “painful freezing” (inflammatory phase), the "stiff" phase and a "resolution" phase.
A steroid joint injection can improve pain, especially in the painful “freezing” stage and physiotherapy stretches help range of motion. However it has a self-limiting course of recovery and the “frozen” stage may take up to 3 years to resolve. Eventually the shoulder will stretch out during the “thawing” phase of the condition. Shoulder arthroscopic releases and a manipulation can allow a faster recovery with your frozen shoulder.
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Acromioclavicular Joint (ACJ) Disorders:
The ACJ lies on top of the shoulder and is the connection between the collar bone (clavicle) and the shoulder blade (scapula) at a bony prominence called the acromion.
(i) Arthritis
Arthritis of this joint can cause pain in extreme positions above shoulder height and especially when placing your arm across your body. The joint can also be painful when directly pressed and when trying to sleep on the affected side. It can be aggravated when trying to lift heavy objects in your hand. A steroid injection into the joint may alleviate the pain but if this doesn´t work then the joint can be excised using arthroscopic techniques.
(ii)Meniscal Injury
In 60% of people there is a small cartilage called a meniscus lying within the acrimioclavicular joint. In some patients a fall or a sporting injury to the shoulder can tear/damage the cartilage leading to pain and discomfort with shoulder movements. This can be treated with a steroidal injection and in cases where this fails it can be excised along with the ACJ arthroscopically to help with pain relief and return to your activities/sport within 6 weeks.
(iii) Dislocation
There are a range of dislocation injuries affecting the ACJ that may occur following a fall on to your shoulder. A simple sprain to the ligaments of the joint are usually treated with rest, ice compression and painkillers with a graded re-entry to your activites. The rest of the injuries are graded according to the severity of the ligament damage. The end of the clavicle may be seen to protrude upwards and is very painful. Milder forms of this injury can be managed with a sling and physiotherapy but in active individuals and sportsmen it may be best to repair the injury. Severe forms of the injury or those which have been neglected and are still painful usually require surgical reconstruction.
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Osteoarthritis/Rheumatoid Arthritis:
Patients with painful stiff shoulder movements may have an underlying arthritis from either of these conditions. The pain is due to destructive changes of the articular surface which coats the ball and socket joint. As a result of the underlying destruction the normal shape of the joint alters and leads to reduced and painful movements of the shoulder joint.
Although the condition affects people above the age of 60 years it can occur in younger patients who may have had a previous fracture of their shoulder joint or had lots of shoulder dislocations. If a rotator cuff tear is large enough it can later cause arthritis and we call this condition rotator cuff arthropathy .
Pain can be controlled with regular painkillers and physiotherapy exercises but if these treatment strategies fail then a joint replacement can be considered. There are a range of different types of joint replacements available to accommodate your underlying shoulder condition. If the arthritis is minor then just the surface of the humeral head can be replaced and is called a surface replacement.
If your arthritis is quite extensive then both the ball and socket may need replacing which is called a total shoulder replacement. If the damage involves a large rotator cuff tear as well, then a different type of replacement will be needed to improve your function. This type of prosthesis “reverses” things around so that the socket is made into a ball and your ball then becomes a socket. This is called a “reverse total shoulder replacement”.
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Shoulder Dislocation/Instability:
There are different types of shoulder instability / dislocation affecting different patients and age groups.
There are two main groups of patients:
(i) Traumatic Shoulder Dislocation:
This is a common condition and frequently affects the younger individuals of 15-40 years of age. In most cases the ball comes out through the front of the socket and in a small percentage of patients it will go out through the back. It is a common sporting injury particularly in people who play contact sports but it can occur if you fall either on an outstretched hand or directly on your shoulder, or from any major accidents.
If the shoulder dislocates it will have to be put back in at your local hospital, usually in the A&E Department but may require you to be put to sleep (general anaesthetic). The shoulder may be prone to dislocating again and the younger you are the greater the chances of it doing so. The shoulder may not come out again but leave you with the sensation that it wants to and this is called a subluxation. This can leave you with pain and insecurity with your shoulder movements that will affect your daily activities and sport. In these situations you may have pulled off the rim of cartilage around your glenoid (socket) or even part of the bony socket which holds the humeral head (ball) in place.
This is called a Bankart Lesion which in certain shoulder positions (abduction and external rotation) allows the humeral head to slip out of the glenoid. When the shoulder dislocates a bony depression fracture can occur on the humeral head (called a Hill-Sachs lesion). This can also play a part in future shoulder dislocations/instability if this defect is large enough.
The treatment of your first episode of traumatic shoulder dislocation consists of reduction under sedation or general anaesthetic followed by a special external rotation brace. It has been shown to be helpful in the “first time” dislocators but not if your shoulder has had multiple dislocation events.
(External Rotation Brace)
The pulled off labrum can be reattached by arthroscopic bankart repair techniques and full contact sport can be achieved up to 3 months later. Sometimes the injury is not repairable by arthroscopic methods especially if there is bone missing from the socket and/or the humeral head and this is reconstructed by open surgical techniques.
(ii) Atraumatic Instability:
If you have ligaments that are lax and have been able to bend your joints beyond normal limits then you may be prone to this type of shoulder complaint. You may suffer with a condition called multidirectional instability which can cause instability in more than one direction. It also affects people who have repetitive sporting movements such as tennis, swimming, basket ball and throwing etc. These repetitive movements may lead to stretching out or micro-tears of the shoulder ligaments and capsule. A traumatic dislocation can still occur as a consequence of a fall but the main symptoms are of instability and pain with above shoulder or head height activities.
Most patients respond well to dedicated physiotherapy and shoulder training, however if this does not improve with a prolonged rehabilitation program, arthroscopic surgery may be considered. Surgical techniques may include tightening the capsule (capsular plication or capsular shift).
In some patients the shoulder muscles may not be contracting properly or may be more active than the others, creating an imbalance of the shoulder.This can create symptoms of shoulder instability, this is called “shoulder muscle patterning” and can be quite a subtle finding during your examination. Your shoulder would not benefit from shoulder surgery and usually needs an appropriate course of specialist shoulder physiotherapy rehabilitation.
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Shoulder Arthroscopy- Patient Information:
Shoulder arthroscopy has developed over the last two decades and now can be used to treat a wide range of shoulder conditions. The advantages of this technique over the more traditional surgical exposures/techniques are:.
- A better cosmetic appearance.
- Faster rehabillitation.
- Quicker return to work.
- Ability in the diagnosis of shoulder pain due to a more direct visualisation.
- You can go home later on the same day as your operation (daycase).
- Reduced post-operative pain and stiffness.
The surgery involves using small “puncture” incisions of the skin around your shoulder joint to allow the telescopic camera and instruments to perform the different procedures. Salt water fluid is then pumped into the shoulder joint to allow the various operations to be performed. The shoulder joint is first assessed to check the cartilage, tendons, and ligaments of the shoulder.
Any damaged tissues are repaired using additional small incisions to insert other instruments.
This may involve the repair of torn ligaments and cartilage to stop a shoulder from dislocating. The camera is also then placed into the space above the rotator cuff tendons (the subacromial space) and a decompression is performed if you have symptoms of impingement and if necessary a rotator cuff tear repair is also performed. Other types of arthroscopic surgery can be used to release contracted tissue such as in frozen shoulders or excise diseased painful arthritic acromioclavicular joints.
You may wake up from the surgery with a swollen shoulder, but the fluid is slowly absorbed and the swelling decreases over the next few hours following your surgery. Your anaesthetist will have administered a special anaesthetic block for your shoulder to reduce your pain following the surgery (scalene block anaesthesia). You will be guided as to your post operative rehabilitation by your physiotherapist according to the operation performed. The smaller “puncture” (portal) incisions are not always closed with sutures but larger incisions are closed with internal dissolvable sutures. Dressings are usually light and are kept on for a couple of days and should be kept clean and dry. Often some surgical fluid drainage occurs from the wounds during the first day.
You will then be seen for consultation following the surgery to discuss the further rehabilitation, check the wounds and show you any pictures taken during your procedure.
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Elbow Anatomy:
The end of your arm bone (humerus) and the tops of your two forearm bones (radius and ulna) meet together to make the elbow joint. The elbow joint is a “hinge joint”. The main job of the elbow is to position your hand to perform the activities of every day living. A capsule surrounds the elbow joint and is reinforced by strong ligaments which span across the elbow joint. If these ligaments become stretched or torn you may experience a painful and unstable elbow joint.
The small spongy elbow pad which we lean on is called a bursa and if it becomes inflamed it is called an olecranon bursitis as it lies over the bony prominence at the back of your elbow (olecranon process).
The smooth covering cartilage that covers the elbow joint surfaces can become damaged in rheumatoid/osteoarthritis/ arthritis which can cause pain and stiffness. Small chips of cartilage or bone may break off from these surfaces and create painful loose bodies within your elbow joint. These loose bodies can cause painful catching/locking of your elbow.
There is a nerve that lies close to the elbow joint which you may be able to feel on the inner aspect of your elbow. This is called the ulna nerve and it feels uncomfortable if you accidentally hit it against an object. It is held in position next to the inner aspect of the elbow within a structure called the cubital tunnel. Occasionally this tunnel is too tight and may cause pins & needles in your fingers and may require releasing from it´s tunnel.
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Tennis Elbow (Lateral Epicondylitis):
Cause of pain is over the outside (lateral) aspect of your elbow and is made worse by repetitive stress on the extension muscles of the lower arm. It is one of the commonest causes of elbow pain and it is not only tennis players who get it.
The pain can radiate down the forearm and into the hand and the pain can be felt over the bony part of the lateral epicondyle which sits on the outer side of your elbow. Gripping objects and extending your wrist and fingers can be very painful. It is thought to be due to damage or degeneration of a tendon called the ECRB (extensor carpi radialis brevis).
Treatment with NSAIDs (non steroidal anti-inflammatory) tablets, physiotherapy and a course of steroid injections remains the mainstay of treatment. Most elbows improve within 8-12 months. Surgical release of the extensor origin at the elbow with particular attention to that of ECRB is used when conservative measures fail.
Golfers Elbow (Medial Epicondylitis):
Although golfers elbow is not as common as tennis elbow it can cause a lot of discomfort especially when flexing and pronating your forearm (a movement which involves turning your hand palm down). It can also be associated with problems of your ulna nerve, which may be compressed at the inner side (medial) of your elbow.
Treatment is the same as for tennis elbow with an open surgical excision of the damaged tissue for pain that does not settle within 6 to 12 months. Your ulna nerve may also need to be released from the cubital tunnel if it is contributing to your pain. Occasionally the nerve may flip out of its position in which case it will need to be moved into a better position to stop it from causing pain. This is called a transposition.
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Osteoarthritis/Rheumatoid Arthritis:
Usually arises on its own or if you have damaged the elbow in the past (fractures or dislocations). Osteoarthritis may also occur if you have rheumatoid arthritis, loose bodies in the joint or even gout. The typical symptoms are those of pain, stiffness, and reduced movement in the elbow with swelling.
X-rays show the degree of joint damage and loose bodies. Treatment starts with NSAIDS (Non-steroidal anti-inflammatory) tablets, physiotherapy and cortisone joint injections.
The ulna nerve may be irritated by abnormal bone (osteophytes) and may require a release and transposition. Initial surgery for arthritic elbows may involve the surgical removal of bony spurs and any loose bodies. An OK (Outerbridge-Kashiwagi) procedure involves making a hole within the back of your humerus (olecranon fossa) to remove loose bodies from the front of the elbow. An elbow joint replacement is considered for patients with more severe pain and joint disease.
Rheumatoid Arthritis
Can cause significant joint destruction and pain. This can lead to a reduced movement of your elbow that will restrict your function and activities. Even simple tasks such as feeding, washing your hair and dressing will be affected. It is caused by an inflammatory destruction of the joint surfaces, ligaments and bone which can lead to profound weakness and deformity. X-rays help identify the extent of the disease and plan your treatment.
Synovectomy (removal of the diseased painful lining of your joint) may be considered if all conservative measures have failed. This may be combined with a radial head excision (the top part of your forearm bone in your elbow).
However due to modern tablets and medication, these procedures are not so common any more. In quite severe rheumatoid disease and those with osteoarthritis a total elbow replacement may be considered.
Loose Bodies
Inside the elbow joint can cause recurrent episodes of elbow locking, pain and swelling. There are many causes of them but the majority arise from underlying arthritis or traumatic injuries of your joint surfaces. Less common causes include osteochondritis dissecans and synovial chondromatosis.
X-rays and CT scans are helpful to identify them and if troublesome they can be removed by arthroscopic / “keyhole” surgery . If the condition is more extensive this can be done through an open incision where a hole is burred through the back of the elbow which is called an OK (OuterBridge-Kashiwagi procedure).
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Ulna Nerve Condition:
Subluxing/Dislocating Ulna Nerve:
If the ulna nerve flips out of it´s groove when you bend your elbow it can cause pain. This is called neuritis and can give you shooting pain or pins and needles down the inner aspect of your forearm and into your little and ring fingers. This problem can occur on its own or if you have damaged the elbow in the past as a result of a fracture or dislocation.
It is painful over the ulna nerve as it passes behind the inner aspect of your elbow (medial condyle) and can be felt to dislocate when bending the elbow. In longstanding cases there can be loss of power and sensation in the hand.
If your elbow is painful enough to need surgery then the ulna nerve is decompressed and moved in to a better position (transposition). The nerve can either be placed into a tunnel fashioned under the skin (subcutaneous) or beneath your elbow muscles (submuscular).
Ulna Nerve Compression:
The ulna nerve can become compressed by a number of tough tissue strands as it passes above, through and below the elbow joint. Other underlying conditions may give rise to nerve compression such as joint swelling in rheumatoid disease, arthritic bony spurs or if the nerve is stretched due to deformed elbows.
You may complain of pins and needles in the little and ring fingers and a weakness in your hand. Electrical studies (nerve conduction and EMG) on your elbow and wrist can confirm the diagnosis. As the symptoms can be worse at night from sleeping in awkward positions a night splint may help.
If your elbow is painful enough to need surgery then the ulna nerve is decompressed and moved in to a better position (transposition). The nerve can either be placed into a tunnel fashioned under the skin (subcutaneous) or beneath your elbow muscles (submuscular).
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Triceps/Biceps Pain:
Biceps Ruptures:
Can occur by forceful movement on your bent elbow. The biceps is the strong muscle at the front of your upper arm which attaches the shoulder to the elbow through tendons. The elbow end of the tendon may already be weak and degenerate before it ruptures. It may occur by lifting heavy objects at work, in the gym or playing sports such as rugby.
You may notice a sudden painful swelling and bruising around your elbow and a change in the appearance of the biceps in the arm as it curls up the arm. As the pain subsides your movement may return after a few days. If it is left untreated you may experience a cramp-like pain and notice weakness when turning the forearm to a palm-up position against resistance (for example when using screwdrivers). Typically patients get fatigue and pain in the elbow with a repetitive use of the arm.
Most people want a near normal use of their arm and the best results are achieved with early repair within 2-3 weeks of the injury. After this time you may need a reconstruction using your own tendons (hamstring : a tendon around your knee) or artificial ligaments.
Occasionally tears are incomplete and do not need surgery. Ultrasound and MRI scans can assist in your diagnosis. Surgery is not indicated for longstanding tears or if you have low demands upon the use of your arm.
Snapping Triceps:
In certain activities which involve lifting heavy weight, a painful snapping sensation is felt over the inner aspect of your elbow (medial epicondyle). This is due to a big muscle (medial head of triceps) which can cause the irritation as it rubs over the medial epicondyle. Occasionally it can also irritate your ulna nerve or compress it. Treatment is a reduction in activity, a steroid injection and resistant forms can be treated by surgical decompression and transferring the tendon of the triceps onto the olecranon bone further away from the affected area.
Triceps Tendonitis:
This is caused by bad habits with sportsmen who lift heavy weights or gymnasts over extending their elbows. The condition can also occur with olecranon impingement. Rest, ice compression therapy and correct physiotherapy with the use of biceps strengthening may make your elbow better.
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Pain In The Back Of The Elbow:
Olecranon Bursitis (Student Elbow):
Lying beneath the skin over the point of your elbow (olecranon) is a soft spongy bursa. This can become inflamed by leaning on the elbows too much or even infected from minor skin punctures. Gout or rheumatoid arthritis can also cause it. The skin of the elbow becomes stretched and swollen and it may discharge some pus. Your elbow movements may reduce due to the soft tissue swelling. Usually it will settle with rest, anti-inflammatory tablets like ibuprofen and antibiotics if it becomes infected. Occasionally an enlarged infected bursa may need to be surgically excised.
Olecranon Impingement:
This type of pain is caused by repetitive forcible extension of your elbow in sporting activities which involve throwing. It can also occur in heavy manual work as well. Tenderness is felt at the back of the elbow in a small depression of bone called the olecranon fossa and at the tip of the elbow. The pain is made worse when the elbow is pushed into full extension. There may be small loose bodies present within the back of the elbow joint as well.
A steroid injection in to the area can help but surgical removal (decompression) of any loose bodies and bony spurs can be performed by “keyhole” or arthroscopic surgery. If the condition is more extensive this can be done through an open surgical incision where a hole is burred through the back of the elbow which is called an OuterBridge-Kashiwagi (or OK) procedure.
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Elbow Dislocations/Instability:
Elbow Instability
The elbow is a stable joint with strong ligaments on each side which provide support. Together the ligaments and the bony structures of the elbow joint resist any strong forces that could cause a dislocation during sporting and everyday activities.
Elbow injuries such as dislocations, fracture-dislocations and ligament tears/sprains can give rise to instabilities and arthritis. Elbow instability can give rise to painful clicks or locking of the elbow especially when extending your elbow. Some injuries are very subtle such as Postero-lateral Instability and may need to be diagnosed by examining your elbow whilst under a general anaesthetic.
X-rays are helpful and an MRI may also demonstrate damage to the joint surfaces. The majority of all these injuries are managed with physiotherapy; however persistent instability resistant to intensive rehabilitation will require surgical reconstruction.
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Elbow Arthroscopy-Patient Information:
The majority of modern day elbow surgery is performed through open incisions. Due to recent advances in “keyhole” surgery there is a greater range of procedures that can be performed for various elbow conditions. The elbow arthroscopy is technically harder as it has important nerves crossing it.
Accurate positioning for the keyholes is therefore required to prevent damage to them and this is a recognized complication. The elbow can swell up and can also compress the nerves which may lead to a temporary weakness of the hand or wrist.
Painful loose bodies can be removed, stiff elbows can be released and painful arthritic spurs can be excised. “Keyhole” tennis elbow surgery can also be performed. The joint surfaces can be evaluated for damage and any elbow instabilities can be evaluated using keyhole techniques.
The advantages of elbow arthroscopy are:
- A better cosmetic appearance
- Faster rehabilitation
- Quicker return to work
- Ability in the diagnosis of elbow pain due to direct visualisation of internal structures.
- It can be performed as a same day (day case) procedure
- Reduced post-operative pain and stiffness
Physical Therapy:
Is a program of guided exercise that helps you regain movement and strength in your shoulder or elbow. There are a number of different exercises to be performed either before any surgery is planned and after surgery. We will provide you with an appropriate program of exercises to complement your surgery and these commence straight after your operation.
These exercises are supervised by your physiotherapist as an outpatient but the majority of your rehabilitation is performed by you at home. It may involve additional exercises from the ones described below and your physiotherapist will show you how to perform them. You will also be guided as to how many to do and how many times a day.
Below are descriptions of common exercises you will use following your surgery.
The Pendulum:
Is the commonest exercise after the arthroscopic procedure. It is done by leaning forward, dangling the arm in front of yourself and slowly swinging your arm in small circles. This helps prevent you stiffening up and improve movement.
Isometric Exercises:
Are exercises in which the muscles are tightened without actually moving the joint. Depending on the procedure, these may be prescribed in the first week or two after the arthroscopic surgery.
Stretching Exercises:
As the name suggests this will involve you positioning your arm in different positions either standing, sitting or lying down to help regain range of motion. You may be given advice of using simple pulleys to help you do these exercises.
Passive Range Of Motion Exercises:
Are performed by another person (your physiotherapist) who helps move your shoulder, usually the physical therapist. As you become confident you may use your good arm to assist the side you were operated on. The idea of this is to continue movement of your joint and resting any structures that were repaired and usually start without stressing any of the repaired tissues. Depending on the procedure, these exercises may be started within a few weeks after the arthroscopic surgery.
Active And Resistance Exercises:
Are performed by moving your arm against resistance and start at 4 to 6 weeks with rubber tubes (Therabands) and eventually to light weights.
Rehabilitation is the most important part of any surgical treatment. Chances of a successful outcome are not just dependant on the surgery performed, but your active participation in your exercise program.
Xrays:
Are routine pictures taken to identify bone damage to your shoulder/elbow joint .They can be very informative especially when dealing with broken bones, diagnosing arthritic conditions and for surgical planning.
Ultrasound Scan:
Is performed either by your surgeon or a radiologist. It is a little similar to those done on pregnant women to check the baby growth. Jelly is applied onto the shoulder and a probe is used to look at the deeper shoulder structures to help in the diagnosis of your shoulder complaint. An injection can also be placed into various parts of your shoulder with the help of ultrasound. It is a quick and easy test and is not harmful to the body.
MRI (Magnetic Resonance Imaging) Scan:
Is requested if further information is needed to diagnose your complaint or to measure the extent of damage to ligaments, tendons and cartilage. It is a little more extensive than an ultrasound scan as you have to lie within a tunnel quite still whilst the machine takes detailed pictures of your shoulder/elbow joint. A lot of information can be gathered from these types of imaging and occasionally the radiologist may inject some dye into the joint to help highlight injuries.
CT (Computer Tomograms) Scan:
Requires you to lie in a “polo-mint” shaped machine to take accurate bone pictures of your arm. It is useful for identifying pieces of bone which either may be fractured, missing or loose within a joint, which are not easily seen on a normal x-ray. Occasionally the radiologist may inject dye into the shoulder to help identify subtle injuries of your shoulder. It may also help with the diagnosis of your elbow complaint.
Electromyography (EMG) and Nerve Conduction Studies (NCS):
These are examinations of your nerves and muscles performed by another hospital specialist called a neurophysiologist. Speeds at which nerves carry messages are measured by placing electrodes on your skin and giving an electrical stimulus to a nerve. Muscle tests are done by inserting a single use electrode needle into a muscle and measuring its electrical activity on a monitor and a loud speaker so the specialist can see and hear the activity. Together with your clinical examination these tests help determine the type and severity of your problem and therefore the treatment of your condition.
