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The shoulder consists of a ball-and-socket joint formed by the spherical upper end of the arm bone called the humerus and a socket called glenoid. The shoulder is a very flexible joint, hence although it has some stability due to muscles and ligament, it has a wider range of mobility. The structures of the shoulder include:

Cartilage-The joint is lined by a smooth layer called the cartilage which enables pain-free and frictionless gliding movement. Loss of cartilage layer is called arthritis, which is the end result of many diseases of the shoulder joint.

Acromioclavicular joint-There is one more joint called the acromioclavicular joint. This lies above the actual shoulder joint between the clavicle(collar bone)and the acromion bone. This joint can get dislocated (acromioclavicular joint dislocation) or can get arthritis in weight lifters etc..

Synovium-The shoulder joint is surrounded by the synovial layer of tissue which produces the synovial fluid for lubrication. This tissue can get inflamed in conditions like periarthritis and rheumatoid arthritis. Capsule-This layer around the synovium,called the capsule onto which many ligaments and muscles attach to. This capsule can get inflamed in periarthritis and then get contracted and shrunken called as Frozen Shoulder (adhesive capsulitis) leading to severe restriction of movements.

Glenoid labrum- the labrum is a fibrocartilage ring like structure around the glenoid bone which is responsible for stabilising the shoulder joint. A tear of the front portion of the labrum called as Bankart’s tear is responsible for recurrent dislocation of the shoulder joint. A tear of the upper end of the labrum is called SLAP tear.

Ligaments-There are many rope like structures called the gleno-humeral ligaments attached to the bone and the capsule. These ligaments are the primary stabilisers and prevent dislocation of the shoulder joint. It is common for the ligament and capsule in front to get torn and never heal (Bankarts lesion) leading to Recurrent Dilsocation of the shoulder joint.

Rotator cuff muscles-Around the joint space are muscles – the most important being the Rotator Cuff muscles. These muscles include the supraspinatous, the infraspinatous, the teres minor and the subscapularis muscles. These muscles can get torn with trauma and age and this common condition is called as Rotator Cuff Tear.

Biceps tendon- a part of the biceps muscle starts from inside the joint from the top of the glenoid bone. This biceps can get inflamed (bicipital tenosynovitis) or can get torn (partial/complete tear of the biceps muscle)

Bursa-There are two filmy sac-like structures called bursae permit smooth gliding between bone, muscle, and tendon. They cushion and protect the rotator cuff from the bony arch of the acromion.

Shoulder Pain Treatment in Coimbatore
Shoulder Pain Treatment in Coimbatore
READ ABOUT ARTHROSCOPY BEFORE PROCEEDING FURTHER What shoulder conditions/problems can be tackled by arthroscopy?- Most of the shoulder disorders can be operated by shoulder arthroscopy

   Rotator cuff tears
   Recurrent dislocation of shoulder
   Sub acromial impingement
   SLAP tear
   Acromioclavicular arthritis
   Calcific tendinitis shoulder
   Frozen shoulder
   Synovitis shoulder (Rheumatoid/Tuberculosis)
   Septic arthritis shoulder

Shoulder Pain Treatment in Coimbatore

ROTATOR CUFF TEAR

The rotator cuff are a group of 4 muscles responsible for different shoulder movements. They include the supraspinatous, the infraspinatous, teres minor and subscapularis. These muscles can get torn due to trivial fall to sports injury or Road Traffic Accidents leading to severe pain, reduced movements and weakness.

Spontaneous tear of the cuff is possible in the elderly due to thinning and fatty infiltration of the muscles. However a trivial trauma including lifting weights may predispose in such individuals. In the young and middle age individuals, there is a significant history of fall/contact sports/accident causing tear.

Pain at overhead abduction, pain at range of shoulder movements, pain at rest, weakness of the arm, crackling sensation of the shoulder at certain positions are some symptoms of rotator cuff tear.

Based on the amount of muscle fibres which are torn, Rotator cuff tears can be partial/complete tears.

Not always. Your doctor will advice an MRI scan after clinical examination to assess the quality of the muscle and also check the percentage of fibres which are torn. Usually conservative treatment can be tried if less than 50% fibres are torn.

Surgical reattachment of the completely torn rotator cuff muscles is performed by open/mini-open/arthroscopic repair

Mini-open cuff repair is now performed instead of open repair. A 4-7 cm skin incision is made over the top of the shoulder to expose the rotator cuff muscle and repair it. Although it is technically easy for the surgeon, it is more morbid than arthroscopy because the incision is large, blood loss is present, other muscles need to be split resulting in temporary weakness sometimes, pain is more than in arthroscopy and needs pain killers, hospital stay is longer.

Just like in knee arthroscopy, small skin portals are made to visualise the joint. The cuff muscles are found retracted usually and brought back to its native attachment on the humeral head called the footprint and is repaired with devices called suture-anchors. These suture anchors are small bioabsorbable/metallic screws with threads attached to it. The screw enters the bone and the threads purchase the torn cuff and then pull toward the footprint.

Age alone is not the criterion. The physiological status, the nature of work, the mechanism of tear (trauma/spontaneous) and the quality of cuff tissue are different criteria to consider

The purpose of a successful rotator cuff repair is torestore the range of movement and strength of the shoulder joint.

The purpose of a successful rotator cuff repair is torestore the range of movement and strength of the shoulder joint.

Although it is not possible immediately after surgery, it is possible once the repaired rotator cuff reattaches well to the bone and when strengthening exercises have been performed for some time atleast.

Adequate strengthening exercises and guided physiotherapy protocols avoids recurrent tears of the rotator cuff. But if the tissue quality is poor due to age and long standing cuff tear, then the chances of retear are high

The role of a physiotherapist is to concur regularly with the operating orthopaedic surgeon and train and help the patient achieve normalcy of activities. Their role is vital after surgery.

RECURRENT DISLOCATION OF SHOULDER

This is a condition where the ball of the shoulder joint called head of humerus slips out of the socket called glenoid. This needs to be put back in position.

All joints are surrounded by soft tissue structures called capsule-ligament complexes. Due to fall/road traffic accident/sports injuries, the ligament/glenoid labrum in front of the shoulder tears and gives way for the head of humerus to come out of position and lie outside the joint. This is a very painful condition.

It is imperative to consult your nearest orthopaedician immediately to reduce the shoulder joint back to normal. This is usually done under sedation/anaesthesia in a painless and comfortable manner for the patient. If the shoulder is reduced back in position very crudely and forcibly by amateurs/quacks, the ligament may tear more in the process (or) the socket bone called glenoid may fracture.

In this condition, the shoulder dislocates repeatedly. The frequency of dislocation increases over time. Also, with every dislocation which occurs, the next dislocation happens even with trivial activities like combing the hair, yawning in the morning, stretching hands after a journey etc..

Unhealed ligament in the front of shoulder called BANKART’S TEAR may allow recurrent dislocation to occur. Also, with continuous dislocations, the margin of the glenoid bone erodes leading to decreased width of the socket, allowing further repeated dislocations.

The ligament (BANKART’s TEAR) can be repaired by open/arthroscopy surgeries to avoid future dislocations. The torn labrum is reattached back to the glenoid bone using special devices called suture anchors. The overstretched capsule ligaments are tightened. Occasionally the glenoid rim has undergone so much attrition, that the bone stock is so reduced needing bony buildup by Laterjet operation.

There is a bone called coracoid process nearby which is cut along with its muscle attachments and reattached to the front of the glenoid safely. This increases the bone width and avoids future dislocations.

Recurrent dislocation is common in the young age mainly. Age by itself is not a criteria. The presence of recurrent dislocation is the criteria.

The fact that your shoulder dislocated a second time indicates poor healing of the ligament. Hence surgery is a must.

To understand the benefits of arthroscopy, see this link…………………..

Yes after a suitable interval of 6-12 weeks of exercises.

Yes, but usually after 3 months of surgery. The same applies to contact sports too

Adequate strengthening exercises and guided physiotherapy protocols avoids recurrent episodes in the future.

The role of a physiotherapist is to concur regularly with the operating orthopaedic surgeon and train and help the patient achieve normalcy of activities. Their role is vital after surgery.

SUBACROMIAL IMPINGEMENT/ IMPINGEMENT SYNDROME

This is also called swimmer’s shoulder or tennis shoulder.

In this condition there is impingement of the rotator cuff tendons on the undersurface of the acromion bone causing pain, weakness and difficulty in raising arm overhead. This is due to the activities persay or be associated with a bent-type acromion bone called curved/hooked acromion. If it continues, the Rotator cuff muscles get torn finally.

This happens in certain positions of the shoulder as in swimming, sports with overhead activities like tennis/shuttle/badminton etc.. this is more possible in the presence of a predisposing hooked type of acromion bone which narrows the space for the muscles to freely glide about.

Patients complaint of pain with activities, pain in provoking position (called impingement position), pain at rest, weakness of the arm and difficulty in overhead abduction movement.

The first line of treatment includes Rest, arm sling (if needed), Ice application/contrast bath and avoiding sports. The second line of treatment includes one to three episodes of cocktail injection of Intraarticular steroid injections admixed with a long- and short-acting local anaesthetic. Surgery is the last line of management.

Injections are the bridging treatment between conservative and surgical management. The purpose is to reduce inflammation and provide pain relief.

Open/arthroscopic subacromial decompression is performed to lavage the joint, excise the subacromial bursa and also flatten the undersurface of the acromion and remove the bony spur causing impingement. If cuff tears are identified, they are repaired concomitantly.

SLAP TEAR

SLAP stand for Superior Labrum Anterior Posterior, that is tear of the labrum from the upper end of the glenoid bone. The biceps muscle of the arm starts as a cord like structure from this location inside the shoulder joint. It then traverses the shoulder joint and exits at the bicipital groove.

Overhead and contact sports are common causes of SLAP tear. Fall on outstretched arm, repetitive overhead activities and lifting heavy objects are causes.

The patient’s history is of foremost importance. The presence of pain at certain activities is classical. Your doctor may perform some manouvers to confirm the diagnosis and to identify concomitant findings. The O’Briens test is a manoeuvre performed with the shoulder forward and inward with the fingers pointing downward. Pain on active resistance in this position is diagnostic of SLAP tear.

If conservative treatment fails, patients need arthroscopic debridement or repair of the SLAP tear with suture anchors.

CALCIFIC TENDINITIS SHOULDER

Calcific tendinitis shoulder is a an acutely painful shoulder condition where there is calcium deposition in the shoulder rotator cuff muscles. This is usually seen on xrays.

There is a predisposing tear/damage/degeneration in the rotator cuff muscles which predisposes to dystrophic calcification (calcium deposit in dead tissue). This calcium can get released on and off into the joint predisposing to inflammation.

Rest, Ice and anti-inflammatory medications are the first line of treatment.

Intraarticular shoulder injections can be given for pain relief. But it is better to do Ultrasound/Image Intensifier guided needling/trephination of the calcium deposit and thereby breaking it into fragments.

If these measures do not work, mini open/arthroscopy techniques can be performed to let the calcium out.

FROZEN SHOULDER

As the name suggests, the shoulder is practically frozen with almost no movements. The patient has varying degree of pain and there is almost no movement at all.

Frozen shoulder is the end stage complication of many predisposing diseases like earlier inflammation (periarthritis), rotator cuff tear, long standing immobilisation after fractures esp by quacks.

Anti-inflammatory medications, aggressive physiotherapy and mobilisation exercises is the main line of treatment. But recovery is not usually complete with this technique.

Intraarticular steroid injections may give pain relief and the patient may then cooperate for physiotherapy after that.

The shoulder can be manipulated when the patient is under anaesthesia and movements can be restored to some extent. Another suitable alternative is Arthroscopic Adhesiolysis- here the tight adhesions between various muscles and ligaments can be released by arthroscopy so that movements can be restored.