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Patient Guide to Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years.

Your risk of developing frozen shoulder increases if you’re recovering from a medical condition or procedure that affects the mobility of your arm — such as a stroke or a mastectomy.

Treatment for frozen shoulder involves stretching exercises and, sometimes, the injection of corticosteroids and numbing medications into the joint capsule. In a small percentage of cases, surgery may be needed to loosen the joint capsule so that it can move more freely.

SYMPTOMS OF FROZEN SHOULDER

Frozen shoulder typically develops slowly, and in three stages. Each of these stages can last a number of months.

  • Painful stage. During this stage, pain occurs with any movement of your shoulder, and your shoulder’s range of motion starts to become limited.
  • Frozen stage. Pain may begin to diminish during this stage. However, your shoulder becomes stiffer, and your range of motion decreases notably.
  • Thawing stage. During the thawing stage, the range of motion in your shoulder begins to improve.

For some people, the pain worsens at night, sometimes disrupting normal sleep patterns.

CAUSES OF FROZEN SHOULDER

The bones, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, restricting its movement.

Doctors aren’t sure why this happens to some people and not to others, although it’s more likely to occur in people who have recently experienced prolonged immobilization of their shoulder, such as after surgery or an arm fracture.

RISK FACTORS OF FROZEN SHOULDER

Although the exact cause is unknown, certain factors may increase your risk of developing frozen shoulder.

Age and sex
People 40 and older are more likely to experience frozen shoulder. Most of the people who develop the condition are women.

Immobility or reduced mobility
People who have experienced prolonged immobility or reduced mobility of their shoulder are at higher risk of developing frozen shoulder. Immobility may be the result of many factors, including:

  • Rotator cuff injury
  • Broken arm
  • Stroke
  • Recovery from surgery

Systemic diseases
People who have certain medical problems appear to be predisposed to develop frozen shoulder. Examples include:

  • Diabetes
  • Overactive thyroid (hyperthyroidism)
  • Underactive thyroid (hypothyroidism)
  • Cardiovascular disease
  • Tuberculosis
  • Parkinson’s disease

TESTS AND DIAGNOSIS:

During the physical exam, your doctor may ask you to perform certain actions, to check for pain and evaluate your range of motion. These may include:

  • Hands up. Raise both your hands straight up in the air, like a football referee calling a touchdown.
  • Opposite shoulder. Reach across your chest to touch your opposite shoulder.
  • Back scratch. Starting with the back of your hand against the small of your back, reach upward to touch your opposite shoulder blade.

Your doctor may also ask you to relax your muscles while he or she moves your arm for you. This test can help distinguish between frozen shoulder and a rotator cuff injury.

Frozen shoulder can usually be diagnosed from signs and symptoms alone. But your doctor may suggest imaging tests — such as X-rays or an MRI — to rule out other structural problems.

TREATMENTS AND DRUGS:

Most frozen shoulder treatment involves controlling shoulder pain and preserving as much range of motion in the shoulder as possible.

Medications
Over-the-counter pain relievers, such as aspirin and ibuprofen (Advil, Motrin, others), can help reduce pain and inflammation associated with frozen shoulder. In some cases, your doctor may prescribe stronger pain-relieving and anti-inflammatory drugs.

Therapy
A physical therapist can teach you stretching exercises to help maintain as much mobility in your shoulder as possible.

Surgical and other procedures
Most frozen shoulders get better on their own within 12 to 18 months. For persistent symptoms, your doctor may suggest:

  • Steroid injections. Injecting corticosteroids into your shoulder joint may help decrease pain and improve shoulder mobility.
  • Joint distension. Injecting sterile water into the joint capsule can help stretch the tissue and make it easier to move the joint.
  • Shoulder manipulation. In this procedure, you receive a general anesthetic so you’ll be unconscious and feel no pain. Then the doctor moves your shoulder joint in different directions, to help loosen the tightened tissue. Depending on the amount of force used, this procedure can cause bone fractures.
  • Surgery. If nothing else has helped, you may be a candidate for surgery to remove scar tissue and adhesions from inside your shoulder joint. Doctors usually perform this surgery arthroscopically, with lighted, tubular instruments inserted through small incisions around your joint.

PREVENTION OF FROZEN SHOULDER:

One of the most common causes of frozen shoulder is the immobility that may result during recovery from a shoulder injury, broken arm or a stroke. If you’ve had an injury that makes it difficult to move your shoulder, talk to your doctor about what exercises would be best to maintain the range of motion in your shoulder joint.

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Patient Guide to Shoulder Pain

Shoulder pain should not be ignored. Early treatment can prevent further injury and chronic shoulder problems. Pain in the shoulder may also be referred from other areas of the body, e.g. disc problems the neck.

The Shoulder Joint

The structure of the shoulder joint allows more range of motion than any other joint in the body.

The shoulder actually has several joints that work together to allow a wide range of motion. Most injuries occur at the “main” shoulder joint, where the head of the upper arm meets the shoulder blade; the term “shoulder joint” refers to this joint. The other smaller shoulder joints are referred to by their specific names.

The head of the upper arm bone sits on a very small and shallow socket in the shoulder blade. This allows for the shoulder’s wide range of motion but makes it susceptible to injury. Because there is little bony stability, the shoulder relies greatly on connective tissue (e.g. ligaments, tendons, muscles) to hold the bones of the joint together and to stabilize the joint.

Causes of Shoulder Pain

The Most Common Cause of shoulder joint pain is rotator cuff tendonitis – injury and inflammation of the tendons (rotator cuff tendons) that envelope the shoulder joint. The most common cause of rotator cuff tendonitis is overuse of the shoulder, though the rotator cuff tendons may be injured suddenly as a result of a fall or accident.

Muscle strain is common in the muscles that run over the shoulders to the neck . It is often the result of holding the shoulders in a raised position for long periods of time. The muscles between the shoulder blades are often strained from slouching from long periods of time. Muscle strain varies in severity.

Other painful shoulder conditions, such as frozen shoulder, may occur for no apparent reason. (The risk of frozen shoulder increases when the shoulder is not used enough after a painful injury). The cause of calcium deposits in the shoulder, which may trigger episodes of acute inflammation of the tendons, is also unclear. Arthritis sometimes occurs in a previously injured shoulder joint.

Slap Lesion

Slap Lesion

Risk Factors

WEAK ROTATOR CUFF MUSCLES

Weak or fatigued rotator cuff muscles can lead to soft tissue injury. If the muscles that stabilize the shoulder joint (mainly the rotator cuff muscles) are weak or fatigued, the muscles fail to fully stabilize the joint. If the head of the upper arm bone is not kept in place in its socket, abnormal force is placed upon tissue surrounding the shoulder joint and can lead to injury. Shoulder tendonitis and bursitis are common.

OVERUSE

Shoulder pain is frequently caused by chronic overuse of the shoulder. The shoulder may become injured suddenly from a blow or fall, but gradual injury from chronic overuse of the shoulder is more common. Repetitive lifting, pushing, pulling, throwing, and especially overhead activities may lead to injury. Pain may be mild and intermittent in the beginning and worsen over time. Combining repetitive overhead activities with force increases the risk of injury further (e.g. stacking heavy objects on a high shelf).

Repetitive overhead activities can be particularly damaging. When the arm is raised overhead, the head of the upper arm bone migrates upward on the shoulder socket somewhat and rotator cuff tendons come into contact with the roof of the shoulder blade. Repeated contact and friction of the rotator cuff tendons often leads to irritation and inflammation of the tendons (tendonitis).

A strong rotator cuff helps keep the head of the upper arm bone from riding up excessively but some contact between the rotator cuff and bones in the joint still occurs with overhead activity. The bursa that lies under the roof of the shoulder blade may also be affected and become inflamed (bursitis). Shoulder bursitis often occurs along with shoulder tendonitis.

AGING

Aging is a major factor in rotator cuff injuries Tendons lose elasticity with aging and they become more susceptible to injury. Muscle mass also decreases with age. Both the rotator cuff muscles and tendons can be strengthened with resistance exercises.

Prevention of Shoulder Pain

Overuse shoulder injuries often can be prevented.

Weak rotator cuff muscles may be unable to adequately stabilize the shoulder joint. Rotator Cuff Exercises can help. Building up strength of the rotator cuff through exercise helps to stabilize the shoulder joint to prevent abnormal pressure on the soft tissues surrounding the joint. The muscles that control the shoulder blade also play a role in stabilizing the shoulder joint.

Avoid repetitive overhead activities. If you are involved in activities that involve repetitive overhead movements, take frequent breaks. Fatigued rotator cuff muscles lose the ability to keep the shoulder stabilized.

Avoid doing too much too soon. If you are going to engage in any overhead activity you haven’t done for a long time, such as getting back into playing tennis, endurance must be built up slowly. Exercises to strengthen the muscles you will be using in an activity reduce the chance of injury.

Warm up before engaging in sports such as swimming, tennis or throwing sports that require overhead movement.

Proper form for your sport should be learned and practiced to prevent injury.

Maintain proper posture. Muscles over the shoulders become strained from holding the shoulders in a raised position for long periods of time. Muscles in the upper back, between the shoulder blades, become strained as a result of slouching.

Treatment of Shoulder Pain

Prevent major problems by treating minor problems early. If a minor injury is not given a chance to heal before it is subjected to the same activity, pain and inflammation may become chronic.

Treatment of shoulder pain depends on the cause – seek a proper diagnosis from a qualified physician. Most shoulder injuries heal with conservative treatment. Healing takes time. The time it takes to recover depends upon several factors, e.g. the severity of injury, the type of injury, how quickly one heals, how early one begins treatment.

Typical treatment of shoulder pain (for most conditions) involves a combination of rest (not complete rest), exercise, anti-inflammatory medication, applying cold or heat to the shoulder joint and, in some cases, an injection of steroids into the shoulder joint.

Doing activities that aggravate shoulder pain often cause further damage, delay healing, and may lead to long-term problems. However, not using the shoulder at all weakens the shoulder and leaves it more vulnerable to injury. Immobilizing the shoulder may also lead to frozen shoulder. Stretching exercises help prevent this condition.

Strengthening exercises for the muscles that support the shoulder, particularly the rotator cuff (the muscles and tendons that dynamically stabilize the main shoulder joint) are a major part of treatment for most shoulder injuries, but strength training before adequate healing has taken place may cause further pain and injury. A physician or physical therapist can determine when the shoulder is ready for strengthening exercises. Shoulder Exercises can prevent injury from recurring.

Massage therapy is also used to treat many soft tissue injuries. From muscle strain to tendonitis to frozen shoulder, massage therapy increases circulation, speeds healing, improves range of motion and relieves pain.

Most shoulder pain improves with conservative treatment; however, surgery may occasionally be required (depending upon the type of and severity of the injury). Surgery may be performed to tighten loose ligaments, repair a torn tendon, remove a calcium deposit, trim a damaged tendon, etc. when conservative treatment doesn’t adequately resolve symptoms.

Diagnosis of Shoulder Pain

Many shoulder conditions have similar symptoms and it may be difficult to diagnose the problem from symptoms alone. A physician, often an orthopedist, diagnoses the cause of shoulder pain by taking into consideration the patient’s symptoms and medical history, findings of a physical examination and sometimes diagnostic testing, such as x-rays, a CT scan, or an MRI.


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Shoulder Bankart Repair Surgery

What is a Bankart Repair?

The aim of a Bankart repair operation is to restore stability to the shoulder. The operation is suitable for people who have detached the labrum and ligaments at the front of the shoulder as a result of an original violent dislocation. Usually the shoulder has remained unstable and may have dislocated on a number of further occasions.

After the operation you should not suffer further dislocations and have much reduced pain.

bankart_repair1

What does Bankart Repair involve?

Bankart Repair surgery is performed under general anaesthetic and takes around an hour and a half.  Usually the nerves to the whole arm are also numbed with local anaesthetic which lasts for sixteen to twenty-four hours. This technique is called a regional block and is similar to the idea of an epidural anaesthetic frequently used in childbirth. This regional block not only means that a lighter general anaesthetic is required, reducing postoperative sickness and nausea, but also provides excellent pain relief afterwards.

The operation is carried out as a conventional open operation through an incision at the front of the shoulder, or telescopically through a number of small incisions around the shoulder.  The aim is to restore the labrum and ligaments to their original position on the edge of the socket and encouraged to heal there. The first step in the operation is to mobilise and re-position the labrum and ligaments and to create an environment in which healing can occur. Little harpoons or anchors are then inserted into the bone on the edge of the socket, which gain a good grip. Stitches on these anchors are then used to suture the labrum and ligaments back into place. The anchors and sutures then hold everything in the right place while natural healing occurs.

The incisions are closed with stitches and waterproof dressings are applied.

When will I recover?

The operation requires a one night stay in hospital and your stitches will come out at one to two weeks after the surgery. Your arm is placed into a special shoulder-immobilising sling and exercises and physiotherapy start on the day of surgery.  Your physiotherapist will teach you all you need to know for the first couple of weeks before your discharge from hospital.

As a general guideline your sling will be retained for a period of four weeks during which time you will be quite one-handed. At four weeks the sling generally goes and increased exercises and movement are encouraged. Most people can return to driving a car at around six weeks and will have regained good ordinary use of the shoulder by eight to ten weeks.

Physiotherapy and exercises continue for four to six months and sports that do not impose too much stress on the shoulder, such as running, can start again at around eight to ten weeks. Activities such as golf and swimming can be resumed at around three months. Contact sports, such rugby and football and other high demand sports such as surfing and climbing can be reintroduced at six months.

In addition to regular treatment with the physiotherapist, follow up is required with your surgeon. This is to monitor and guide progress and to look out for complications which are fortunately all rare.

What risks should I know about?

Bankart Repair is a very successful operation but there are some potential complications you should be aware of even though they are uncommon.

  • Infection can occur although it is rare and infection rates are at 1%.
  • Shoulder dislocation can occur although this risk is minimised by having the operation done very carefully and adhering to the physiotherapy regime.

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Shoulder AC Joint Injury

What is the Acromioclavicular Joint?

The AC joint is short for the acromioclavicular joint. Separation of the two bones forming this joint is caused by damage to the ligaments connecting them. It is sometimes also referred to as a shoulder separation injury.

The acromioclavicular joint is formed by the outer end of the clavicle (collar bone) and the acromion process of the scapular (shoulder blade). The acromion is a bony process which protrudes forwards from the upper part of the scapular. This joint forms the highest part of the shoulder.

The two bones are attached by the acromioclavicular (AC) ligament. There are several other ligaments which can be of importance in AC joint injuries, including the coracoclavicular (CC) ligament (divided into conoid and trapezoid sections) which joins the clavicle to the coracoid process, another forward protruding part of the scapula, slightly below and to the inside of the acromion.

A third ligament is the coracoacromial ligament which attaches the acromion process to the coracoid process, although it is rarely involved in this type of injury.The most common way of injuring the AC joint is by landing on the shoulder, elbow, or onto an outstretched hand.

Symptoms include:

  • Pain at the end of the collar bone
  • Pain may feel widespread throughout the shoulder until the initial pain resolves, following this it is more likely to be a very specific site of pain over the joint itself
  • Swelling often occurs
  • Depending on the extent of the injury a step-deformity may be visible. This is an obvious lump where the joint has been disrupted and is visible on more severe injuries
  • Pain on moving the shoulder, especially when trying to raise the arms above shoulder height

AC joint injuries are graded from 1-6 using the Rockwood scale which classifies injuries in relation to the extent of ligament damage and the space between the acromion and clavicle, as shown in the pictures opposite.

Grade 1 is a simple sprain to the AC joint, grade 2 involves rupture of the AC ligament and grade 3 rupture of both AC and CC ligaments which often results in a superior displacement. From this point onwards the scale and grade of injury depends on the degree of displacement of the clavicle.

Grade 4 involves posterior displacement and grade 5 superior displacement, to a greater degree than grade 3, with an increase in coracoclavicular space by 3-5 times the norm. A step deformity may be apparent with grade 3, 4 & 5 injuries. Grade 6 (not shown) involves full rupture of both AC and CC ligaments with the clavicle being displaced inferiorly.

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