Is your shoulder bothering you? Pain or some other ailment may be caused by many different reasons. For example, it can be trauma-based or result from strain. I am specialised in shoulder surgery, and my aim is to give you solutions to your problems. When you’re having shoulder problems, you can trust the know-how of the shoulder surgeon.
The shoulder joint is surrounded by a rotator cuff made up of four tendons. With this, we can raise and rotate the arm in different directions. Rotator cuff injuries most often come about when falling onto an extended limb, when the arm is wrenched hard and sometimes through extreme exertion.
Through falling or wrenching, the shoulder becomes painful, and in the initial stage the pain may cause restricted movement. The pain often radiates to the top part of the arm and raising the arm sideways does not work because of the pain. Cold compresses, rest and anti-inflammatory drugs are home treatments in the initial stage. The pain and inflammatory reaction after a sprain injury usually subside within two weeks, but if the shoulder pain is prolonged, you should see an orthopaedist for an assessment. At the surgery, the shoulder is examined through numerous tests and it is decided whether an X-ray or MRI scan is needed as a further examination.
A complete tear of the rotator cuff that has resulted from an accident is treated, as a rule, through surgery on those of working age. With extensive tears, the arm is left restricted in terms of movement as well as strengthless, and a three-week monitoring period can be considered the limit: if the limb does not independently rise above the level of the shoulder within this period, it should be examined. If left untreated, permanent atrophy and disability develops in the musculature of the shoulder. The torn edge of the tendon is left in the constricted intermediate space of the shoulder to chafe and snag against the acromion. The line of treatment for partial tears of the tendon is affected by many operational and structural factors. The situation may often just be monitored while the paths of motion are worked on through physiotherapeutic means. These days, surgical treatment of shoulder tendon damage is almost always done arthroscopically through 5 mm-sized holes. The procedure requires a great deal of experience and an experienced surgeon to achieve a good end result. In conjunction with the corrective work on tendons, the lower part of the acromion can be polished down at the same time, thus making room for the pathway of the tendon. Stitches do not have to be removed because the small arthroscopy holes can be closed with dissolvable stitches.
Although the tendon repair itself is done quickly, time should be set aside for rehabilitation. The upper limb is generally kept in a sling for a total of six weeks. During this period, the tendon reattaches to its original position with the help of scarring. Physiotherapy begins four weeks after surgery, and at that time there is also a check-up visit at the operating doctor’s surgery. The sling can be taken off when going for a shower and a few times a day to be able to stretch the elbow joint. However, all encumbering motions must still be avoided. When six weeks from the operation are up, the sling can be put away and independent (so-called active) motion exercises of the shoulder can be begun step by step under the guidance of the physiotherapist. Rehabilitation from corrective tendon surgery often takes a total of 6-12 months. The period of work incapacity depends largely on the profession and on which arm the injury is concentrated. Some return to office work with a sling two weeks after surgery, but those doing heavy physical work only return around three months after surgery.
Dislocation of the shoulder joint happens most commonly when falling on an outstretched upper limb. The shape of the shoulder changes visibly as the head of the humerus drops forwards and downwards. The nerve structures that are nearby may be stretched through the injury, and for that reason the shoulder joint should be put back into place quickly. Dislocation of the shoulder joint causes different kinds of injuries in different age groups. With young people, the cartilage ring bordering the joint cavity often becomes detached and this may lead to looseness of the joint and repeated dislocations. Without surgery, the risk of new dislocations is about 70% in the case of young people who actively practise sports. Often fractures on the edge of the joint cavity and cartilage damage are also found. In such cases the line of treatment is solved on a case-by-case basis, deciding between surgery and rehabilitation.
Immediate treatment is to set the shoulder back in place by hanging or manipulating it. X-ray imaging is often necessary to exclude the possibility of fractures. After this, the upper limb is kept in a sling against the body for 1-2 weeks. At about three weeks, motion exercises can be begun but external rotation should still be avoided for six weeks so that the damaged joint capsule can recover undisturbed. At the check-up visit around week 6, the paths of motion and possible looseness can be tested. MRI scanning is irreplaceable in indicating structural damage. If the shoulder joint is left loose and symptomatic, arthroscopic surgery comes into consideration, in which the detached cartilage ring is fixed in place with suture anchors.
To ensure attachment, the upper limb is kept in a sling for three weeks. After this, physiotherapeutic rehabilitation to restore the range of motions begins. Stitches do not have to be removed because the small arthroscopy incisions can be closed with dissolvable stitches. There is a check-up visit at the surgery four weeks after the operation. The period of sick leave depends largely on the profession and on how much inconvenience the sling causes. It is possible to return to office work three weeks after surgery. In total, rehabilitation from this operation takes about three months, after which the patient can return to sports pursuits step by step. In terms of older patients, dislocation almost always leads to tearing of the rotator cuff, which is often left unnoticed in the initial stage. For that reason, a monitoring visit to the surgery is necessary to ensure rehabilitation and, if needed, to plan follow-up examinations.
Injuries to the head of the clavicle typically result from falling on one’s side with the elbow stretched out. The injury is common in ice hockey in side tackles, in combat sports and, for example, when falling while cycling. A symptom of mild-degree injuries is that the joint capsule is swollen and sore in movement from a week to two weeks. The pain in these injuries is localised on top of the shoulder where this joint is. If the energy of the injury is great, the head of the clavicle may rise completely out of the joint, in which case the ligaments that support the joint also tear. In these so-called fourth-degree tears, the head of the clavicle becomes free to move backwards and forwards as well in connection with the movements of the arm, often causing significant pain symptoms.
With mild-degree injuries, a sling will be used during the period of pain, as well as cold compresses and anti-inflammatory drugs. The AC joint is particularly encumbered in bench-pressing, when lifting heavy weights from the floor and in reaching exercises that stretch across the body, such as the movements done with a diagonal pulley. These should be avoided, depending on the degree of the injury, for one to four weeks. In the case of fourth-degree injuries, operative treatment becomes necessary. With new injuries, the head of the clavicle is fixed in place in arthroscopic surgery, and a sling is worn for four weeks to ensure the attachment. In delayed situations, the torn ligaments are replaced with a tendon transplant in conjunction with the operation. Rehabilitation for sport takes, depending on the sport in question, about four months.
The biceps muscle is firmly attached to the coracoid in the top part of the upper arm. The other so-called long tendon of the biceps goes around the front of the shoulder in a narrow bony groove, attaching to the top edge of the elbow cavity. In its bottom part, the biceps muscle is attached to the radius in the top part of the forearm.
Symptoms relating to the long tendon of the biceps are particularly common with people who do throwing sports as well as swimmers. The tendon chafes in its bony groove through repeated movements and may become inflamed. Symptoms include pains that are localised to the front part of the shoulder. Lifting motions done from the front with an extended upper limb are painful. The biceps tendon is often also tender when pressed in the top part of the upper arm in its bony groove. Treatment naturally includes calming down the inflamed and irritated tendon with rest and a course of anti-inflammatory drugs. Cold compresses a few times a day in the shoulder area alleviate the pain. In the case of a prolonged inflammation, cortisone injections are also used to calm down the inflammation.
Biceps tendon ailments, such as ruptures or fraying, can also manifest themselves as different kinds of shoulder pain states. A rupture usually doesn’t need surgical treatment, only time. Fraying, on the other hand, may require treatment: either cutting or reattachment. An expert orthopaedist can advise you on the right option.
In association with a wrenching injury of the shoulder or a fall, the structures that keep the biceps tendon in its bony groove may be damaged. Through this, the tendon tries to slip out of the groove when turning the upper limb in an external rotation. Symptoms are pain or a clear intermittent popping sound in the front part of the shoulder, particularly in association with external rotations of the upper arm. The syndrome also often includes tearing of the subscapularis tendon. Tennis serves and throwing become impossible because of the pain. Treatment in the initial stage is alleviating the inflammatory reaction and pain after the injury, and restoring paths of motion through physiotherapeutic methods. After this it is assessed whether detrimental symptoms will remain. In surgical treatment of a tendon that is trying to move out of position, the tendon can be reattached to the top part of the upper arm. If the tendon is in a bad condition due to fraying, it can simply be cut. Together with the cutting, the shape of the biceps changes a little, but the action does not cause functional detriment as such – the biceps muscle is still firmly attached to the coracoid. In the case of young, active people, the primary aim is to reattach the tendon.
The long tendon of the top part of the biceps is, while moving in its bony groove, subject to chafing, inflammation and the degeneration of the tendon. Through this, the tendon often gets weaker, frays and splits lengthways over time. A rupture of the tendon in conjunction with an exertion is very common with elderly people. Due to the rupture, the shape of the biceps turns into a so-called Popeye muscle. The pain stage normally lasts for a few weeks, after which the shoulder usually recovers to normal in stages and no functional detriment remains. Motions that encumber the biceps should be avoided for about a month so that no annoying muscle cramp presents itself. A tear in the upper part of the biceps tendon is hardly ever treated through surgery. The lower part of the biceps detaching from the radius typically happens when carrying a heavy burden with an outstretched limb. The most common situations are, for example, tears that occur through a slight stumble when carrying a washing machine in a staircase. The pain is localised in the area of the crook of the elbow, and the biceps muscle rises. These tendon detachments of the bottom part of the biceps are fixed through surgery. Personally, I have used so-called double attachment in these operations, which makes moving the upper limb possible right after the operation and returning to work unencumbered is possible as early as one week after the operation. Actual muscle exercises for the biceps should only be begun three months after the operation. If operated on using the older techniques, the arm is kept in a sling for four weeks, on account of which recovery is considerably slower.
Fractures of the upper part of the arm result from falling. The pain is usually so intense that it drives patients to scans and treatment in good time. Bruising often appears on the skin and moving the arm is not possible because of the pain.
The line of treatment is defined on the basis of X-ray imaging. Fractures that are in a good position are taken care of with a sling for about three weeks, after which guided motion exercises are begun in physiotherapy. Restoration of the range of motions takes many months and, as a result of the fracture, even permanent restrictedness of movement may remain in the case of extreme motions. The tendons attached to the edge of the head of the humerus may also detach a piece of bone when falling. In these cases, the tendon may pull the piece of bone with it into the intermediate cavity of the shoulder, causing a mechanical obstacle to movements. An ordinary X-ray is a sufficient examination. A fracture of the tendon attachment area always requires surgical treatment. Fractures of the joint cavity usually arise in conjunction with dislocation of the shoulder and the line of treatment is decided on the basis of the size and displacement of the fracture piece. Some fractures that require surgery can be done through an arthroscopic technique.
Clavicle fractures happen when falling on one’s side with the shoulder first. Bruising appears in the area of the fracture and the pain drives the person to the doctor. The line of treatment is decided on the basis of X-ray imaging. Clavicle fractures usually ossify well, which has led to their often being treated without surgery, with a sling for four weeks. If the fracture is permitted to ossify in the wrong position, the result is a permanent bone ridge under the skin which often causes problems e.g. when carrying a rucksack, with the shoulder strap rubbing against the skin. Through early surgical treatment, these problems can be avoided by setting the ends of the bone in their natural position.
Problems with your shoulder? Get in touch and book an appointment with shoulder surgeon Ilkka Moilanen, who operates in Espoo and Helsinki!