Although not as common as severe arthritis of the hip, knee, or shoulder, rheumatoid arthritis of the elbow is among the most prevalent causes of severe pain and loss of function of the elbow. Individuals with rheumatoid arthritis involving one joint are likely to have involvement of other joints as well.
Elbow joint replacements are highly technical procedures which can relieve pain and help restore function. These procedures are performed less often than knee and hip replacements, thus it may be necessary to search for surgeon who has considerable experience with them.
Mechanical Problems of the Shoulder
Mechanical problems of the shoulder are common. They are often revealed by the answers to some simple questions:
- Is the shoulder stiff? Can the arm be put in all normal positions?
- Is the shoulder unstable? Does it feel like it is going to pop out or slide out of the socket?
- Is the shoulder weak? Does it have the strength to carry out desired activities?
- Is the shoulder rough? Does it catch and grind with use?
Non-Mechanical Problems of the Shoulder
There is another group of shoulder problems which is not related to shoulder mechanics. These include conditions such as arthritis of the neck, nerve irritation, bone infection, bone tumors, and various pain syndromes. These conditions typically produce pain whether or not the shoulder is being used. Persistent non-mechanical problems of the shoulder require a thorough evaluation which is not covered here.
Quick guide to the evaluation and management of shoulder problems
Unless there has been a major traumatic injury or evidence of infection, there is time for the ‘basic approach’ listed below.
Date and circumstances of onset
Factors that aggravate
The two key xrays to take are the AP in the plane of the scapula and the axillary lateral. These will show arthritis or may suggest instability. See the image:
IV. Initial management of shoulder problems that are not fractures or infections includes non-narcotic analgesics and gentle exercises that the patient can perform themselves.
Scapula and the Axillary Lateral
(click to enlarge)
When we speak of an unstable shoulder we usually are referring to the joint between the head of the humerus and the glenoid (theball and socket of the shoulder, respectively). Thus, we should more properly speak of glenohumeral instability (It is also possible to have instability at the other joints of the shoulder as well, such as the acromioclavicular, sternoclavicular, and scapulothoraic joints).
Glenohumeral instability is defined as the inability to maintain the humeral head centered in the glenoid. This condition has been recognized for many years as is revealed by a brief history.
Glenohumeral instability may arise from an injury to the bone, rotator cuff, labrum, capsule, and/or the ligaments which normally prevent excessive rotation. This we call traumatic instability. The most commonly torn ligaments run across the lower front part of the joint and prevent excessive rotation when the arm is held out to the side and rotated backward (as in a baseball throw). It takes a major force to tear these ligaments, such as a high energy fall with a landing on the arm (as in skiing). Recurrent traumatic instability typically produces symptoms when the arm is placed in positions near that of the original injury. If the ligaments do not heal after the first injury (which is often a complete dislocation), the arm continues to be unstable when it is held out to the side and rotated backward. In these circumstances, a surgical repair of these ligaments is usually successful in restoring stability to the shoulder. The post operative exercises are essential to optimizing the result of surgery.
A shoulder can become unstable without a major injury if it loses the ability to balance the muscle forces around it. The joint starts to slip when the arm is used out in front or down at the side. We call this atraumatic instability. Once the balance is lost, dedication to a regular muscle balancing exercise program is required to get it back. If the stabilizing mechanisms become severely decompensated, surgery to tighten the tissues around the joint can be of temporary benefit; but, it the final analysis, muscle balance must be restored through exercises if stability is to be regained. The postoperative rehabilitation after this surgery is particularly important.
There are a few instances where shoulder instability cannot be classified into one of these two groups. In these uncommon situations, we speak of Intermediate types of recurrent instability.
- Anterior glenoid reconstruction for unstable dislocating shoulders. Surgery to restore lost anterior glenoid bone and deep the socket with a bone graft can restore shoulder anatomy and lessen pain and improve function
- Bankart repair for unstable dislocating shoulders: Surgery to anatomically and securely repair the torn anterior glenoid labrum and capsule without arthroscopy can lessen pain and improve function for active individuals
- Home Exercises for the Unstable Shoulder
- Posterior glenoid osteoplasty for unstable dislocating shoulders. Surgery to build up the back of the glenoid socket using an osteotomy and graft can restore shoulder anatomy and lessen pain and improve function
- Surgery for Atraumatic Instability of the Shoulder
Shoulder arthritis is a condition in which the cartilage that normally provides a smooth covering over the ball and socket is lost. This cartilage loss can result from degeneration, wear and tear, inflammatory disease (i.e. rheumatoid arthritis), injury or prior surgery
Most of the common causes of shoulder stiffness are related to problems between the humerus and scapula. The normally supple capsule around the joint can become stiff--a condition known as frozen shoulder. Frozen shoulders can come on after a period of disuse of the arm. A frozen shoulder can also come on for no apparent reason at all. Frozen shoulders can be particularly severe in individuals with diabetes.
Shoulder stiffness can also result when the normal gliding surfaces of the shoulder become scarred after injury or surgery--a condition known as post-traumatic stiff shoulder.
The shoulder can become stiff because the joint surfaces have lost their normal smoothness--as in arthritis.
Finally, shoulder motion can be restricted by limited scapulothoracic motion (motion between the shoulder blade and the chest wall). Scapulothoracic range of motion can be limited by such factors as sternoclavicular arthritis, acromioclavicular arthritis, contracture, rib or scapular fracture, post-traumatic scarring, tumor, dislocation, or other factors disrupting the scapulothoracic motion interface.
Shoulder stiffness tends to be a chronic condition. Because of the condition's long course, the patient needs to play a major role in its treatment. We have designed a set of simple home shoulder exercises that have proven effective in improving the function of many stiff shoulders. These frequent, gentle exercises are performed at least three times a day, in a manner similar to what an athlete would use to develop more flexibility. Forceful stretching is avoided because of the risk of creating injuries to the capsule, which could then go on to heal with scar tissue.
When major functional limitations persist after six months of a first-rate effort at the home exercise program, a more aggressive approach is considered. If the persistent stiffness is due to a classical frozen shoulder, we consider an examination under anesthesia with gentle manipulation (unless the bone appears soft on X-ray).
Manipulation is not used in post-traumatic or post-surgical stiff shoulders because the scar tissue which may be stronger than the rotator cuff or bone. If examination under anesthesia is not successful, open surgical release can be considered. If the X-rays reveal a damaged joint surface, management of the glenohumeral roughness may deserve consideration.
- Diagnosis of the Post-traumatic Stiff Shoulder.
- Evaluation of the Stiff Shoulder.
- Examination Under Anesthesia.
- Home Exercises for the Stiff Shoulder.
- Surgical release for stiff frozen shoulders: Surgery to remove scar tissue and release contractures can lessen pain and improve function for stiff shoulders that have not responded to rehabilitation or physical therapy.
- Humeroscapular Positions and Motion.
- Humerothoracic Positions and Motion.
- Scapulothoracic Positions and Motion.
Rotator Cuff Tears
Strength is essential to carry out the functions of the shoulder. Many different muscles are required to power the shoulder because of the need to control both humeroscapular and scapulothoracic positions and to allow the vast range of motions of these articulations. For normal function, each muscle must be healthy, conditioned, securely attached, and coordinated.
Weakness of the shoulder can come from deficits in coordination, nerve, muscle or tendon. Often, weak shoulders will respond to a gradually progressive strengthening program. If shoulder weakness does not respond to these exercises, it may be due to a rotator cuff problem, or a nerve injury. In this section we focus our attention on the most common mechanical cause of shoulder weakness, rotator cuff failure.
- Rotator Cuff Failure
- Diagnosis of Rotator Cuff Tears
- Evaluation of the Weak Shoulder
- Home Exercises for the Weak Shoulder
- More Information on Rotator Cuff Surgery
- Repair of Rotator Cuff Tears: Surgery for shoulders with torn rotator cuff tendons can lessen shoulder pain and improve function without acromioplasty
- Subacromial Smoothing
- Mechanics of Shoulder Strength
- Rotator Cuff Clinical Presentation
- Rotator Cuff Differential Diagnosis
- Rotator Cuff Historical Review
- Rotator Cuff Imaging Techniques
- Rotator Cuff Relevant Anatomy and Mechanics
- Rotator Cuff Treatment