Shoulder Pain Management

Arthroscopy

Dislocation and Separation

If patients experience multiple dislocations, arthroscopic surgery or traditional open surgery can correct the problem.

If the ligaments are too severely torn to keep the clavicle in place, arthroscopy may be the best option for repair.

Fractures

If shoulder function is not restored after realignment or if an X-ray reveals that realignment is not possible without surgery, patients may benefit from either arthroscopy or open surgery depending on the severity of the fracture.

Figure 1: An X-ray showing a shoulder fracture.

Synovitis

Arthroscopy may be necessary to remove the inflamed synovium if discomfort persists.

Tendonitis, Bursitis and Impingement Syndrome

If symptoms are not well controlled with rest, medication or injections, then surgery to remove the inflamed bursa and bone spurs may be necessary.

Shoulder Instability

Surgical referral is recommended when conservative treatment fails and activities remain problematic for the patient. Age, degree of restriction, occupation, right- or left-handedness and patient expectation may predict whether the outcome of surgery will be successful.

For multidirectional instability, the surgical options are arthroscopic or open capsular shift. For unidirectional anterior instability, anterior inferior glenohumeral ligament repair (Bankart repair) is the preferred surgical option.

Two mnemonics list the characteristics of each type of instability: AMBRI (Atramatic Multidirectional Bilateral Rehabilitation Inferior shift) and TUBS (Traumatic Unidirectional Bankart Surgery).¹

After surgery, refer the patient for physical therapy.

Acromioclavicular Joint Arthritis

When 6 months of conservative treatment of acromioclavicular joint arthritis does not provide pain relief, or when the condition is impeding daily activity, your patient’s orthopaedic shoulder specialist may recommend surgical intervention.² Open or arthroscopic distal clavicle resection are the surgical options for acromioclavicular joint arthritis. After surgery, the patient will be referred for physical therapy.

Figure 2: Preoperative (A) and postoperative (B) radiographs of a successful arthroscopic distal clavicle resection.³

Glenohumeral Arthritis

Surgical treatment should be considered for patients who do not benefit from conservative treatment.

Young patients (<35-40 years) with early arthritis may have short-term pain relief and increased range of motion after arthroscopic shoulder debridement and capsular release. However, outcomes for arthroscopy are best in patients with loose bodies or interposed soft tissue.

For patients with rheumatoid or inflammatory arthritis with severe synovitis but minimal articular degeneration, arthroscopic or open synovectomy may be the preferred surgical option.

Figure 3: View of the shoulder showing glenohumeral arthritis.

Rotator Cuff Tears

The most common surgical procedures for rotator cuff repair include open, mini-open and arthroscopic repair.

Open repair has the advantage of easy visualization of the rotator cuff tendons. However, the disadvantages include a long incision of 6cm to 10 cm, possible deltoid injury and a painful recovery.

Mini-open repair can be done with a shorter incision of 3cm to 4 cm to allow use of an arthroscope for tendon repair and removal of damaged tissue or bone spurs. Typically, recovery from mini-open repair is less painful and shorter than in open repair.

Arthroscopic repair is the least invasive method of repair and is associated with less post-surgery pain and less muscle injury than open methods. Arthroscopic repair requires extensive surgeon training and may be less successful than open methods.

Figure 4: View of the shoulder showing a rotator cuff tear.

References