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The Shoulder Joint, Rotator Cuff Syndrome, Impingement Syndrome

The shoulder joint is a complex joint with movement in three directions Flexion/Extension, Abduction/Adduction, Horizontal Flexion/Extension. The ball of the head of the humerus articulates with the concave surface of the end of the scapula. This joint is called the Gleno-humeral joint (G-H J). The joint is held together by ligaments surrounding the joint. The joint is a synovial joint with articular cartilage lining both sides of the joint. Dislocations of the GHJ can cause tears in the ligaments or the lining of the joint called the Labrum.

A common tear is the Superior Labrum Anterior to Posterior (SLAP) tear. Osteoarthritis can develop in the joint from a trauma. Rheumatoid Arthritis can also develop in this joint. The 7 major muscles that cover the joint are (from outside to inside) Deltoid, Triceps, Biceps Supraspinatus (SSP), Infraspinatus (ISP), Subscapularis and Teres Minor. The Deltoid, Triceps and Biceps muscles are the power lifters of the shoulder, doing the strong contractions to lift weights to shoulder height or above, in front, back or out to the side of the body. The last four muscles make up the Rotator Cuff (RC). The RC are responsible for rotating the arm in all positions in front of the body, out to the side and above the head.

Tears in the RC can result from age, overuse or a trauma eg dislocation or too much force applied to the tendon eg digging, tennis serve, rugby tackle. If the tears are significant then the humeral head can migrate excessively which will cause instability and may lead to arthritis later in life.

RC Surgery can involve suturing the tear, removing any frayed tendon and fluid that may be preventing the tendon from healing or screwing the torn tendon back on to the bone.

The Acromio Clavicular (AC) Joint lies between the acromion process of the scapula and the clavicle (collar bone) . Beneath the acromion is the Sub Acromial Space and through this area passes the SSP tendon. Arthritis, Sub-Acromial Spurs (growths from underneath the acromion process) and Supraspinatus tendon swelling can develop with time and normal use. The space is narrowed and limits the ability of the tendon to move within the space thus causing Impingement. Impingement is usually demonstrated when it is painful to lift the arm up to eye level, with the thumb pointed down.

Treatment of shoulder pain requires an accurate diagnosis that may require a combination of investigations. Normal X-Ray, Ultrasound of tendons, CT or MRI scanning, with or without injecting the joint with a radiolucent dye (to show up tears in the labrum). Physiotherapy with specific exercises and medication is the first line of treatment unless there is gross trauma to the joint/ligaments/tendons that require surgical intervention. Post surgery, physiotherapy is important to help repair the joint and restore muscle function and strength.

 
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