Medical and Surgical Management

Surgical Management

Shoulder ArthroscopyShoulder-pain_Patient-and-doctor

Shoulder arthroscopy is a type of surgery to examine or repair the tissues inside or around the shoulder joint. The procedure uses a small camera, called an arthroscope which is inserted through a small incision. If the doctor is going to repair the joint, small surgical instruments are also used.

Shoulder arthroscopy may be recommended if a patient has a painful condition that does not respond to nonsurgical treatment. Nonsurgical treatment includes rest, physical
therapy, and medications or injections that can reduce inflammation. Shoulder arthroscopy may relieve painful symptoms of many problems that damage the rotator cuff tendons, labrum, articular cartilage, and other soft tissues surrounding the joint.

Common arthroscopic procedures include:
•Rotator cuff repair
•Bone spur removal
•Removal or repair of the labrum
•Repair of ligaments
•Removal of inflamed tissue or loose cartilage
•Repair for recurrent shoulder dislocation

Subacromial Decompression (Acromioplasty)

Subacromial decompression aims to increase the size of the subacromial area and reduce the pressure on the rotator cuff muscles. It involves cutting the ligament and shaving away the bone spur on the acromion bone. This reduces the impingement on the rotator cuff tendons, thus allowing the muscles to heal.

Subacromial decompression can usually be done arthroscopically as an outpatient procedure. 83% to 94% of patients who undergo the procedure experience good to
excellent pain relief, and 75% are able to return to sports. The recovery time ranges from 3 to 4 months (Cosdi 2007).

A Cochrane review concluded that there is silver level evidence that there are no significant differences in outcome between open or arthroscopic subacromial decompression and active non-operative treatment for impingement (Coghlan et al 2009). In addition Shi and Edwards (2012) investigated the role of acromioplasty in the management of rotator cuff problems and found that current evidence does not support the routine use of acromioplasty in the treatment of rotator cuff disease.

Subacromial Bursectomy

Subacromial bursectomy is removal of the subacromial bursa sac (a small, fluid-filled sac that acts as a cushion at a pressure point in the body – often near joints where tendons or muscles cross either bone or other muscles). The subacromial bursa is innervated by sensory nerves and is proposed to be a source of pain in shoulder patients.

Rotator Cuff Repair

Rotator cuff repair is a type of surgery to repair a torn tendon in the shoulder. The procedure can be done with a large/”open”incision or with shoulder arthroscopy, which uses small button-hole sized incisions. The three techniques most commonly used for rotator cuff repair include traditional open repair, arthroscopic repair, and mini-open repair.

Open Repair

A traditional open surgical incision (several centimeters long) is often required if the tear is large or complex. The surgeon makes the incision over the shoulder and detaches the shoulder muscle (deltoid) to better see and gain access to the torn tendon. During an open repair, the surgeon typically removes bone spurs from the underside of the acromion (this procedure is called an acromioplasty). An open repair may be a good option if the tear is large or complex or if additional reconstruction, such as a tendon transfer, is indicated.

All-Arthroscopic Repair

All-Arthroscopic repair is the least invasive method of rotator cuff repair. This is due to the use of an arthroscope, which requires only very small incisions in the shoulder region. This procedure is usually conducted on an out-patient basis.

Mini-Open Repair

The mini-open repair uses newer technology and instruments to perform a repair through a small incision, which is usually 3 to 5 cm long. This technique uses arthroscopy to assess and treat damage to other structures within the joint. Bone spurs, for example, are often removed arthroscopically and thus avoids the need to detach the deltoid muscle. Once the arthroscopic portion of the procedure is completed, the surgeon repairs the rotator cuff through the mini-open incision. During the tendon repair, the surgeon views the shoulder structures directly, rather than through the video monitor.

It should be noted that a Cochrane review (Coghlan et al 2009) concluded that surgery is not superior to exercise management for rotator cuff disorders.

Arthroscopic Capsular Release

Patients with adhesive capsulitis that does not respond to a minimum of 12 months of physical therapy are potential candidates for manipulation under anaesthesia and capsular release. Results depend on the cause of the adhesive capsulitis. Idiopathic frozen shoulder responds better to surgical management than do posttraumatic and postsurgical frozen shoulders (Cosdi 2007).

Shoulder Instability

Surgical procedures for multi-directional instability are considered for patients who have persistent symptoms of the shoulder instability despite lengthy non-surgical treatments. Most often, the surgery involves tightening the ligaments that surround the shoulder. This may be performed arthroscopically or through standard surgical incisions. Surgery for shoulder instability may include is a form of a capsular shift or capsular plication, which are both procedures that tighten the shoulder capsule. In addition, some surgeons will perform a rotator interval closure, a procedure that closes the gap between two of the rotator cuff muscles.

Medical Management

Therapeutic Injection Therapy

Outlined below are the common injection therapies for people with shoulder pain. It is important to clarify this with your patient or their medical practitioner.

Image Guided Injection

Traditionally, injection for the treatment of shoulder pain has been performed guided by anatomical landmarks alone. With the advent of readily available imaging tools such Shoulder injectionas ultrasound, image-guided injections have increasingly become accepted into routine care (Cosdi 2007).

A recent Cochrane review reported that

“Based upon five trials, our review was unable to establish any advantage in terms of pain, function, shoulder range of motion or safety, of ultrasound-guided glucocorticoid injection for shoulder disorders over either landmark-guided or intramuscular injection. The lack of any added benefit of ultrasound guided injection into the subacromial bursa of the shoulder over intramuscular glucocorticoid injection administered into the upper gluteal region in the buttock suggests that the benefits of glucocorticoid may arise independent of accuracy of needle placement. Therefore, although ultrasound guidance may improve the accuracy of injection to the putative site of pathology in the shoulder, it is not clear that this improves its efficacy to justify the significant added cost.” (Bloom et al 2012)

However the findings of the Cochrane review conflict with a review by Soh 2011 who concluded that patients who underwent image-guided (ultrasound) injections had statistically significantly greater improvement in shoulder pain and function at six weeks compared with those who received blind (landmark-guided) injections although did note that the results should be interpreted cautiously in view of the limited number of studies and small sample sizes (Soh 2011).

Corticosteroids

Many treatments, including corticosteroid injections in and around the shoulder, are advocated to be of benefit for shoulder pain. Corticosteroid injections are a commonly used modality to treat shoulder pain irrespective of underlying aetiology.

Corticosteroid may be injected into the glenohumeral joint via an anterior or posterior approach, into the subacromial space (subacromical injection), tendon sheaths of specific tendons, or locally into trigger or tender points. These are usually performed by the clinician who uses anatomical landmarks to guide blinded placement of the needle. Apart from placement of the injection into various anatomical sites, other variations in the use of steroid injections include single or multiple injections over time; injection of different sites at one time; use of different corticosteroid preparations, different volumes and types of local anaesthetic; and different total volumes of injection.

According to a Cochrane Review (Buchbinder et al 2009) “there is little evidence to either support or refute the efficacy of steroid injections for shoulder pain.” The authors attributed their conclusion to the limitations of the studies included in the review and highlighted small sample sizes, variable methodological quality and heterogeneity in terms of population studied, injection modality employed and choice of comparator results in little overall evidence to guide treatment among these limitations. This review also concluded that there is evidence to support the use of subacromial corticosteroid injection for rotator cuff disease although its effect may be small and not well-maintained, and it may be no better than NSAID. Finally the review suggested that intraarticular steroid injection may be beneficial in the short-term for adhesive capsulitis but again the effect may be small and not well maintained.

Injection Sites

1. Subacromial Injection

Injection into the subacromial/subdeltoid bursal space can be utilised for rotator cuff impingement syndrome, calcific tendinitis, subacromial/subdeltoid bursitis and adhesive capsulitis. A lateral approach generally is used. Because they are injected locally, intraarticular steroids avoid most of the systemic effects of oral steroids, including muscle weakness, skin thinning resulting in easy bruising, peptic ulceration, and aggravation of diabetes (Lavelle et al 2007).

2. Intra-articular Injections (GHJ and AC joints)

GHJ Intra-articular Injection
Injection directly into the glenohumeral joint space can be used for acute and chronic capsulitis (i.e. frozen shoulder), glenohumeral arthritis and synovitis (e.g. rheumatoid arthritis).

AC Joint Intra-articular Injection
Injection is directly into the AC joint space, which can be palpated about 1 cm medial to the top of the acromion and can be approached for injection from above and from a slight anterior position.

3. Biceps Injection

The goal of this injection is to enter the tendon sheath of the biceps tendon and/or the bicipital groove around the tendon without injecting into the tendon itself. The tendon is identified in the bicipital groove of the humerus. A needle is inserted into the skin over the point of maximal tenderness and directed into the groove at an angle with the needle tip nearly parallel to the groove. Increased resistance to flow of the injection should suggest an intra-tendinous location and direct the caregiver to withdraw the needle tip slightly.

Hydrodilatation/Hydrodistension

A fine needle is inserted into the shoulder using ultrasound guidance control to ensure that it goes directly into the joint. A small amount of contrast medium, long-acting local anaesthetic and steroid are injected into the joint. Sterile saline is then injected to distend the joint capsule and break down adhesions. This may result in a transient feeling of tightness, increased pressure or heaviness in the shoulder or down the arm.

Medications

Oral Steroids for Adhesive Capsulitis

Oral steroids were first used in the 1950’s; anecdotal evidence suggests expedited recovery and reduced need for manipulation under anaesthesia with oral steroid use, while more recent evidence regarding efficacy is equivocal.

However, as there is good evidence that oral steroids such as prednisolone and prednisone dramatically reduce the symptoms of inflammatory joint disease such as rheumatoid arthritis (Gotzsche 1998), and that oral steroids may also be effective for short-term pain relief in adhesive capsulitis, particularly early in the course of the disease.

The Cochrane review by Buchbinder et al (2006) reported that there is Silver level evidence based upon three small randomised controlled trials that a short course of oral steroids for adhesive capsulitis may be of significant short-term benefit when compared to placebo or no treatment but the effect is not maintained at six weeks. There is a lack of reliable evidence to support or refute the efficacy of oral steroids compared to other treatments (specifically, intra-articular corticosteroid injection alone or in combination with manipulation under anaesthesia). While the adverse effects of steroid therapy in the trials in the review were minor and short-lived, the potential risks of long-term oral steroid use are well described, and include high cholesterol and hypertension, as well as detrimental effects on bone quality.