Dr Sachin Tapasvi: Ouch, my shoulder hurts…

Shoulder pain is a common presenting complaint in all age groups. It is very disabling as it decreases the mobility and hampers the function which is why it’s important to go somewhere like Kirk E. Hilborn, D.C. Sterling Heights Chiropractic for help with the pain. In severe cases, daily activities such as bathing, dressing and even eating and writing get compromised. Previously, all shoulder pain was thought to be and treated as “frozen shoulder” – certainly a dustbin diagnosis, a dumping ground for shoulder pain. I remember my days of orthopaedic training when all the treatment that we ever wrote for patients with shoulder pain was nothing more than painkillers, shortwave diathermy and shoulder wheel exercises. The treatment and management of shoulder problems has undergone a paradigm shift with better imaging, better diagnosis, and improved treatment methods such as specialised physiotherapy programmes, arthroscopy or key hole surgery and replacement prosthesis. The options available should be discussed with you in great detail when you visit your shoulder surgeon.

Shoulder problems are very age-specific. In the teens and early thirties, problems of instability are more common. In the late thirties to the fifties, issues with tears of the rotator cuff tendons of the shoulder dominate; whereas, the later decades are dominated by problems of arthritis. Needless to say, this is just a rough guide and either of these problems may occur at any age group. This week, I will focus on the teen and early age issues of instability of the shoulder.

“Shane Warne dislocates his shoulder during the One Day game against England game” – not an uncommon statement to come across. Why does a shoulder dislocate more often then any other joint in our body? The secret lies in the particular nature of the shoulder of the joint to move through a far greater arc than any other joint. As well all are aware – ‘range of movement is at the expense of stability’. The shoulder is a ball and socket joint and to allow for this increased motion, nature has made the ball of the shoulder large and round; and the socket small and shallow. Thus the analogy is that of a golf ball being balanced on a golf tee. The body offers increased stability to this inherently weak mechanism by adding a thick layer of cartilage all around the border of the socket – referred to as ‘labrum’ in medical terminology. During a shoulder dislocation episode, the ball is forced out of the socket, usually in a forward direction. This is referred to as an anterior dislocation, in which the humeral head (ball of the shoulder) lies anterior (in front) to the glenoid (socket of the shoulder). During the occurrence of such a forceful dislocation the labrum, ligaments and capsule that lie in front of the shoulder joint are torn. The muscles that are in front of the shoulder may also get traumatised. There is severe pain and deformation with an inability to move the arm in the acute scenario. It is of utmost importance to shift the patient to an appropriate medical centre wherein the shoulder has to be relocated under full sedation or general anaesthesia. A check x-ray is made to confirm the reduction and then the shoulder is immobilised in a sling for at least three weeks. Ice packs or cryotherapy is used after reduction to decrease the pain and reduce the inflammation. You can access cryotherapy in jacksonville fl, or in many other locations. Once the shoulder starts settling in, gentle range of motion exercises are started, that are later progressed to resistance and coordinated exercises.

Shoulder dislocation is cursed by the complication of ‘recurrence’. If the age of the patient is less than 20 years at the time of the first dislocation, the risk of re-dislocation is almost about 95%. For this very reason, a lot of medical centres will promote surgery after the very first dislocation in patients less than 20-25 years of age. I prefer to wait till they have a second episode since you cannot predict if the patient will be in the 05% or the 95% patient group. This risk of re-dislocation drops to about 40% if the age of the patient during the first dislocation is between 20-40 years; and to about 15% risk of the age of the patient at the time of the first dislocation is more than 40 years.

With every subsequent dislocation two things occur – the bone on the front of the glenoid socket starts getting worn out and the labral cartilage gets tattered. The treatment for recurrent dislocation is surgery. Surgery is done via arthroscopic techniques wherein three or more puncture holes are made around the shoulder and the torn labral cartilage is repaired back to the glenoid socket. The success rate of this procedure is as high as 96%. In patients with several episodes of dislocation the bone loss is quite significant. These patients need to be treated with bone grafting of the glenoid socket.

I think the message to take back is that dislocations can be very effectively treated. A high degree of awareness is necessary for appropriate diagnosis and effective outcomes.

Dr_Sachin_Tapasvi2Dr Sachin Tapasvi is one of India’s leading joint replacement surgeons. He practises in Pune and has been awarded several fellowships with experience garnered internationally as well as in India.

Dr Sachin Tapasvi