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CALCIFIC TENDONITIS

What is calcific tendonitis?

Calcific tendonitis usually presents with sudden onset of severe pain without preceding trauma, although it can also present in different ways depending on the stage of the disease process, size and location of the calcific deposit. It generally presents with features of subacromial impingement due to the clacification and the space occupying deposit within the tendon. It persists as dull aching pain with episodes of acute pain due to chemical inflammation from leakage of the calcium crystals into the subacromial bursa. Presentation can be sometimes confused with frozen shoulder due to pain inhibition of movements.

How is it diagnosed?

Usually the diagnosis is straightforward on X rays (pic 1). Occasionally ultrasound scan (pic 2) may be helpful if the size of the deposit is too small to be seen on X-rays. MRI is rarely needed. There are signs of impingement on clinical examination and cuff strength may appear less due to pain inhibition.

What are the predisposing factors?

The condition is not fully understood and as such there are no known risk factors. It is more common in middle aged women (30-50 years).

Will it resolve itself?

It varies; the body might absorb the calcium but it may take years to happen if the deposit is consolidated.

What are the treatment options?

Initially this can be treated with Painkillers and anti-inflammatory medications. Physiotherapy can be useful to keep your shoulder strong and flexible but may be difficult in acute phase due to pain inhibition

Cortisone steroid injections are useful to reduce inflammation and control the pain, but effect is variable and usually temporary. The deposit can also be broken under ultrasound guidance and the calcium can be sucked out into a syringe. It has variable success rate and some patients will continue to experience pain due to residual calcium crystals in the bursa that generate inflammation.

Surgery is required if the pain is not controlled with conservative means. The aim is to reduce the bulk of calcium deposit to prevent subacromial impingement and pressure effect of the deposit itself (pic 3). It is performed through keyhole (arthroscopy) and can be done as a day case (link to video).

The recovery is as per ASD procedure (see separate link – to the physio protocol page for subacromial decompression). For more information, please visit my website www.drsarda.in

If you are suffering from this condition, please contact —– to arrange an appointment.

FROZEN SHOULDER

This is perhaps the most common diagnosis when a patient presents with shoulder pain. However, painful shoulder with limited movements is not always a true frozen shoulder. Frozen shoulder means that the movements are physically restricted, usually due to mechanical causes.

The pathology can be primary (idiopathic) or secondary. By far the commonest secondary pathology is diabetes, trauma or arthritis. Other relatively rare causes may include thyroid or parathyroid disorders, Parkinsonism, and cardiac conditions. Pain can also arise from a variety of other causes like tendon tear, bursitis, impingement or muscle incoordination that can cause restricted movements due to pain inhibition, which frequently gets misdiagnosed as frozen shoulder.

Historically, three stages of adhesive capsulitis have been defined, although in reality, these are not distinct and overlap significantly:

  • Freezing (painful) stage – This is the acute inflammatory phase that is usually extremely painful, and the symptoms in this stage that can last between 3-9 months. (pic)
  • Frozen (stiff) stage – This is when the acute pain settles down, but patients are left with varying degree of stiffness. There are two distinct subtypes: one with a ‘hard’ end point when there is no further gain beyond the end point, or with a ‘soft’ end point, wherein the tissues appear slightly more pliable allowing some more passive movements beyond the active range. The frozen stage can last 12 – 18 months in total.
  • Thawing (resolution/ return of mobility) stage – This is when tissues begin to loosen up, and movements begin to improve towards normal. Most patients however are left with slight deficit towards the end range, but this does not hamper any activities of daily living. The stage can last another 12-18 months.

EXAMINATION:

Overall, the natural cycle of frozen shoulder can last 2-4 years, there is considerable variation in individual presentation, and examination is important to establish the diagnosis.

INVESTIGATIONS:

It is a clinical diagnosis, but other investigations may be used to aid the diagnosis. Plain X-ray should be obtained to rule out arthritis, and sometimes MRI scan may be necessary to rule out cuff tear or an occult fracture.

TREATMENT:

  • Physiotherapy: Most patients benefit from physiotherapy input in the frozen or resolution stage.
  • Hydrodistension: It is an outpatient procedure done under local anaesthesia with a success rate of about 50% in suitable patients.
  • Arthroscopic release: Done as a day case surgery, it involves releasing the thickened and tight capsule to restore the joint mobility. This is followed by early aggressive physiotherapy. The red inflamed tissue seen in the picture below is typical of adhesive capsulitis.

The second picture below shows release of the capsule whilst taking care to preserve the important structures like tendons, and cartilage.

The operation is done as a day case under regional block with or without GA. The shoulder can be intensely painful after releasing the tough capsule, and the block is very useful for the first 24-48 hours when the pain can be at its worst. It is a fairly common procedure with good outcomes. Success rates vary between 80-95%.

Here is a short video of the arthroscopic procedure. Please contact using the details on this website if you need a consultation.

IMPINGEMENT SYNDROME

What is Impingement syndrome?

Put simply, it is the irritation of rotator cuff tendon under the acromion (a bony roof that covers the tendon).

There are a variety of causes ranging from abnormal shape of the acromion (curved or hooked) to dysfunction of the rotator cuff tendon that can lead to imbalance of the shoulder girdle and functional impingement as the cuff can no longer effectively compress the ball of the joint during overhead movements. This leads to dynamic impingement of the tendon. Sometime repetitive overuse as in athletes involved in throwing sports (javelin, fast bowling etc).

What are the symptoms?

  • Dull, sometimes nonspecific aching pain around shoulder
  • Worse pain during overhead movements
  • Difficulty in lying on the affected side, sleep may be disturbed.

How is it diagnosed?

It progresses slowly and usually without specific history of trauma. Diagnosis is confirmed by clinical examination using special tests. It is not uncommon to have an associated rotator cuff tear or other pathology like arthritis of the acromioclavicular joint (the ‘point’ of shoulder). An X ray and MRI or ultrasound scan aids the diagnosis.

Will it resolve itself?

Depending on the cause, like a rotator cuff strain, it can resolve with rest, NSAIDs and physiotherapy. However if there are structural problems like a curved acromion or calcified ligament, the condition may become chronic and surgery may be necessary.

What are the treatment options?

  • Initially this can be treated with Painkillers and anti-inflammatory medications. Physiotherapy can be useful to keep your shoulder strong and flexible but may be difficult in acute phase due to pain inhibition.
  • Steroid injections are useful to reduce inflammation and control the pain, but effect is variable and usually temporary. It also works as a diagnostic aid when the diagnosis is in doubt. I usually do not do more than one injection as it can predispose the rotator cuff to rupture.
  • If there is documented inflammation or partial tear of the rotator cuff tendon, PRP injection has more than 50% success rate.
  • When conservative treatment has failed, surgery is necessary and gives predictable results. This involves removing the inflamed bursa (bursectomy) and shaving any spurs (acromioplasty).

It is performed through keyhole (arthroscopy) and can be done as a day case (link to video).

What is the recovery after surgery?

  • Pain management:
    The shoulder will be sore and you will be discharged home with painkillers. Ice packs may also help reduce pain. Wrap frozen peas or crushed ice in a damp, cold cloth and place on the shoulder for up to 15 minutes. Please ensure you have covered the dressing / wound with some cling film before applying the ice pack to avoid getting the wound wet.
  • Wound management:
    This is a keyhole operation usually done through two or three 5mm puncture wounds. There will be no stitches only small sticking plaster strips over the wounds. These should be kept dry until healed. This usually takes 7 – 10 days.
  • SLING:
    Unless otherwise advised, this is for comfort only and should be discarded as soon as possible (usually within the first 2 to 4 days). Some people find it helpful to continue to wear the sling at night for a little longer if the shoulder feels tender. You are allowed full range of movements as your pain will allow.

If you think you may be suffering from this condition, please contact Dr Sarda to arrange an appointment.

Mode of Injury

ROTATOR CUFF TEAR

The rotator cuff is a group of muscles closely wrapped around the shoulder. They work to keep the ball centred in the socket when we move our shoulder. The muscles can be torn through general wear and tear or after an accident/ fall. If one or more muscles are torn, the movement of the shoulder is no longer smoothly controlled. As a result the shoulder may become weak and painful.

Mode of Injury

Mostly this is a result of chronic wear and tear or overuse. Sometimes this can happen after a heavy fall or injury directly to the shoulder. It is quite common in the elderly population and does not always need repair. The decision for surgery is based on clinical findings. If you suffer from persistent pain and weakness, you need to have it repaired.

Investigations

Being a tendon, the rotator cuff cannot be seen on standard X rays which is normal most of the times. The tear can be diagnosed on clinical examination and confirmed by MRI scan or Ultrasound scan.

Treatment

A full thickness tear in young or middle-aged patients should be repaired to prevent future problems. In older age group decision is taken on individual basis depending on clinical examination and other factors.

What is the procedure and what does it involve?

The operation is usually done by keyhole surgery (Arthroscopy).

Most people are given a General Anaesthetic (you will be asleep). Some people will also have an Interscalene nerve block which will numb the arm and may last for 12-24 hours. This is to help with pain relief following your surgery.

A few 5mm puncture wounds are made around the shoulder to allow entry of the surgical instruments, one of which is a camera. The aim of the surgery is to repair the torn tendon. During the operation further damage may be identified within the shoulder that needs addressing. As the strength of the repair and the size of the tear can vary between patients, recovery period will also vary accordingly.

What are the potential benefits of the procedure?

  • To improve your pain.
  • To improve your shoulder movement and the function of your arm.

What are the risks of the procedure?

All operations involve an element of risks that include infection, stiffness, bleeding or nerve injury. However these complications comprise less than 10% taken together. In large tears or poor tissue quality, there is a re tear rate of upto 20%

Frequently asked questions

Will it be painful?

Although the operation is to relieve pain, it may be several weeks before you feel the benefit. You may have a nerve block- Interscalene Block (ISB), which will numb the arm and may last for 12-24 hours. This is to help with pain relief following your surgery.

This will mean you will wake up with a numb arm. This will wear off after 12-24 hours.
Following the operation, it is important that you take your pain medication regularly to keep the pain under control. This will help you to be able to do the exercises that the physiotherapist will provide you. You will be discharged from the ward with medication appropriate to your needs. You will be given one week’s supply. If you need further medication please book an appointment with your GP

The amount of pain you experience will vary from patient to patient, therefore take the amount of pain relief you need. This can be discussed with your GP if needed.

Do I need to wear a sling?

You will need to wear a sling for up to 4 weeks initially post-surgery. This is to protect the repair that you have had done in the initial phase of healing. It is also for your comfort. The sling needs to be worn all of the time, except for washing, dressing and doing your physiotherapy exercise.

Sleeping- Keep your sling on when you are sleeping until you are advised to remove it. For the first few weeks- you may find it more comfortable to sleep on your back initially, with a pillow under your operated arm for support. This will support your arm so that it doesn’t fall backwards. You may also find it more comfortable to sleep in a semi-sitting position. Your Physiotherapist will discuss this with you.

When can I go home from hospital?

The majority of patients go home on the same day.

When can I return to work?

You can return to sedentary jobs after 2 weeks as you feel able. For more manual jobs you should wait until after 12 weeks following your surgery, this should be guided by your Consultant.

Do I need to do exercises?

Yes, you will be given exercises and should be supervised by a Physiotherapist. The aim of these is to stop your shoulder stiffening up.

Here is a video of the procedure – please contact using the details on this website to book a consultation if you think you may have a cuff tear.

SHOULDER DISLOCATION

Frequently asked questions

The shoulder joint is a ball and socket joint. It is designed to give a large range of movement to allow you to move your arm and hand. It has a large ball (head of humerus) and a smaller, shallow socket (glenoid). The advantage of this design is that a very large range of movement at the shoulder is possible, the disadvantage however is that the shoulder can become unstable.

Shoulder stability is controlled by various structures. The most important ones are:

  • Ligaments; which hold the bones together
  • A rim of cartilage; called the Labrum which deepens the socket and gives stability.
  • Muscles; which keep the shoulder blade and joint in the correct position when moving or using the arm.

What is Shoulder Dislocation

When the ball comes out of the socket, it is called shoulder dislocation. Comme causes are

  • Injury: It is commonest cause of dislocation, most frequently encountered in young adults. Following a traumatic injury to the shoulder, the ball may come completely out of the socket and dislocate at the front of the shoulder.
  • Neurological disorders: Like Epilepsy, or even electric shock may result in a dislocation, more commonly at the back.
  • Systemic Laxity: A small group of patients have more elasticity in their tissues, making the shoulder and other joints unstable even without injury.

As a result of dislocation, the structures in the shoulder are often damaged. This may lead to recurrent symptoms of instability, particularly when the arm is lifted upwards and outwards. If your symptoms have not improved with Physiotherapy, lifestyle and hobby modification- you will benefit from surgery

What is the procedure and what does it involve?

The operation is usually done via a key hole (arthroscopy). You will have a General Anaesthetic, i.e. you will be asleep. The aim of the operation is to tighten and /or repair any structural problems in the shoulder. You can usually go home either on the same day or the next day.

Do I need to wear a sling?

You will need to wear a sling for up to 4 weeks. This is to protect the surgery during the early phases of healing and to make your arm more comfortable. Keep your sling on when you are sleeping until you are advised to remove it.

When can I participate in my leisure activities?

Your ability to start these will be dependent on the range of movement and strength that you have in your shoulder following the operation. As a general rule, the following timelines apply:

Cycling – 4 to 6 weeks.

Swimming – 12 weeks.

Light sports/racquet sports using non-operated arm – 10 weeks.

Racquet sports using operated arm – 16 weeks.

Contact or collision sports which includes horse riding, football, martial arts, rugby, racquet sports and rock climbing – 6 months. Discuss with the Consultant.