Shoulder Arthroscopy

Introduction

The shoulder can perform movements in more directions and to greater extents than any other joint in our body. But because it can perform so many movements, the shoulder is vulnerable to stress and injury. Shoulder injuries are very common, especially among people who play sports that require overhead arm motions.

Strong tissues hold the shoulder bones together. The tissues are more likely than the bones to be affected by stress, injury, and “wear and tear.” They may stretch or rupture, causing the shoulder to become weak, unstable, or dislocate. Some shoulder conditions require surgery. Arthroscopy allows surgeons to see, diagnose, and treat problems inside the shoulder joint.

Before arthroscopic surgery existed, surgeons made large incisions that affected the surrounding joint structures and tissues. They had to open the shoulder joint to see it and perform surgery. An arthroscopy requires small incisions and is guided by a small viewing instrument. Arthroscopy is less invasive than traditional surgical methods. It has a decreased risk of infection and a shorter recovery period.

Anatomy

Our shoulder is composed of three bones. The Humerus is our upper arm bone. The Clavicle is what we call our collarbone. The Scapula is the shoulder blade that moves on our back. An edge of the scapula, called the acromion, forms the top of the shoulder. There are a total of four joints in our shoulder complex. The humerus and the scapula form the main shoulder joint, called the Glenohumeral Joint.

Several ligaments connect our shoulder bones together. The ligaments are strong tissues that provide stability. The glenohumeral joint is not a true ball-in-socket joint like the hip. The top of the humerus is round like a ball. It rotates in a shallow fossa (cavity), called the glenoid, on the scapula. A group of ligaments, which form the joint capsule, hold the ball of the humerus in position. In other words, the joint capsule is responsible for holding our arm in place on our body.

Tendons attach our muscles to our bones. Our muscles move our bones by pulling on our tendons. They move our arms to position our hands for a variety of functions. The Biceps tendon attaches at the front of the shoulder. The Biceps works with other muscles to bend or flex our elbow. The shoulder provides stability when our elbow flexes and as we lift objects.

The Rotator Cuff tendons connect strong muscles to the humerus bone. These muscles allow the arm to rotate and move upward to the front, back, and side. A structure called the Subacromial Bursa lubricates the rotator cuff tendons allowing us to perform smooth and painless motions.

We use the rotator cuff muscles to perform overhead motions, such as lifting up our arms to put on a shirt, comb our hair, or reach for an item on a top grocery shelf. These motions are used repeatedly during sports, such as pitching in baseball, serving in tennis, and passing in football.

Causes

Shoulder problems are very common. Shoulder conditions occur more frequently in the muscles, ligaments, and tendons than in the bones. However, bone degeneration can occur from arthritis. Shoulder problems can occur from injury, “wear and tear,” disease, or aging. Arthroscopic surgery is used to treat shoulder instability, dislocation, impingement syndrome, rotator cuff tears, and some fractures.

Shoulder instability can occur when the muscles, ligaments, or tendons are over stretched or become weak. In some cases, one of the shoulder joints may move or be forced out of its position causing the shoulder to dislocate.

The glenohumeral joint is vulnerable to dislocation because it is not a true ball-in-socket joint. In severe cases, the muscle may even detach from the bone. The Biceps muscle, in particular, is prone to pulling away from the Glenoid bone under sharp force, such as from extreme weight lifting.

The rotator cuff is a common source of shoulder pain. The risk of rotator cuff damage increases with age. The aging process can cause the tendons and muscles to degenerate and weaken. This can also result from sudden shoulder movements or overuse, such as pitching in baseball.
Sometimes the aging process can cause bone spurs to grow on the scapula, particularly in the acromion area.

Shoulder impingement syndrome occurs when bone spurs or bursa inflammation narrows the space that is available for the rotator cuff tendons. The tendons can tear as they rub across the bone spur, particularly when the arm is elevated. Irritated tendons may develop tendonitis, a painful condition. Often the pain comes from tendon degeneration, similar to the process in tennis elbow. Shoulder impingement syndrome may even cause the tendons to detach from the top of the humerus.

Symptoms

A shoulder condition can cause your shoulder to feel painful, stiff, and weak. The pain may be bothersome at night and disrupt your sleep. If your shoulder is unstable, it may feel like it pops out of place when you move it. You may have difficulty elevating your arm or performing shoulder movements. You may experience pain and weakness if one of your rotator cuff tendons is torn. However, not all tears are painful.

Diagnosis

A doctor can evaluate your shoulder by performing a physical examination and viewing medical images. Your doctor will ask you about your symptoms and medical history. You will be asked to perform simple movements to help your doctor assess your muscle strength, joint motion, and stability.

Your physician will order X-rays to see the condition of the bones in your shoulder and to identify arthritis or bone spurs. Sometimes a soft tissue injury does not show up on an X-ray. In this case, your doctor may order a Magnetic Resonance Imaging (MRI) scan. A MRI scan will provide a very detailed view of your shoulder structure. Like the X-ray, the MRI does not hurt and you need to remain very still while the images are taken.

Treatment

Most shoulder conditions can be treated with non-surgical methods. Treatments may include physical or occupational therapy and anti-inflammatory medication to reduce pain and swelling. Cortisone injections may sometimes be helpful. Arthroscopy is recommended when such treatments have provided minimal or no improvement of your symptoms. Arthroscopic surgery is commonly used to reconstruct ligaments or remove damaged tissue and bone spurs. In some cases, both arthroscopic and open surgery techniques are used. Your doctor will discuss your examination results and help you decide on your course of treatment.

Surgery

Almost all of arthroscopic shoulder surgeries are performed as outpatient procedures. You will require anesthesia for the surgery.

Your surgeon will make several small incisions, about ¼” to ½” in length, near your joint. Your surgeon will fill the joint space with a sterile saline (salt-water) solution. Expansion of the space allows your surgeon to have a better view of your joint structures. Your surgeon will insert the arthroscope and may reposition it to see your joint from different angles.

During the surgical treatment, your doctor may make additional small incisions and use other slender surgical instruments. In some cases, a procedure called Thermal Capsulorrhaphy is used to treat tendons and ligaments with heat. Because the surgical incisions are so small, they will require just a stitch or Steri-Strips and will then be covered with a bandage.

Recovery

Your shoulder will need several weeks to heal from the surgery. Your surgeon will restrict your arm movements for a short period of time following your procedure. You will most likely wear an arm sling. The length of time necessary depends on the procedure performed. An occupational or physical therapist will gently help you move your arm at first, and then you will progress to strengthening exercises.

Generally, most individuals regain functional movement and strength by four to six months after surgery. Your recovery time will depend on the extent of your condition and the amount of surgery that you had. Your surgeon will let you know what to expect.

Overall, arthroscopic shoulder surgery requires a shorter length of time for recovery than open joint surgery. It also has a reduced risk of infection and causes less pain and stiffness because only small incisions are used and less surrounding tissue is affected or exposed. Most individuals achieve good results.

Prevention

It is helpful to exercise to maintain a strong, stable, and flexible shoulder. Avoiding repetitive overhead movements may help to prevent certain conditions from worsening. Further, it is important to follow your doctor’s instructions for any weight lifting or motion restrictions