The Unstable Shoulder
Chronic Pain After Ankle Sprain
Recent Advances in Arthroscopic Surgery
Impingement Syndrome and Rotator Cuff Tears
 The Unstable Shoulder
by Peter Campbell
Shoulder instability is a common clinical problem, especially in the young sporting population. Instability may manifest as frank traumatic dislocations or more subtle "subluxation" with a feeling of impending dislocation and/or pain in the shoulder.
If one looks at the dry bone of the humeral head and bony glenoid it is a wonder that this joint is ever stable. A large circular head articulates with a small flat glenoid. The vital structure which provides stability to this construct is the fibrous labrum which encircles the glenoid and the various ligaments (gleno-humeral ligaments) which attach to it. Lesions of the labrum and attached ligaments result in instability.
All medicos would have at least a distant recollection of terms such as "Putti-Platt", "Bristow" or "Magnusson-Stack". These are operations to achieve shoulder stability by "extra-articular" means - that is moving muscles around the front of the shoulder to "tighten it up". These procedures often result in a reduction in external rotation which has been implicated in subsequent development of early osteoarthritis in the shoulder.
I perform arthroscopic stabilisation. This technique allows direct repair of the labrum and also ligamentous and capsular plication. There is less scarring and post-operative morbidity. External rotation is not reduced in the long term. With the technique I employ success rates are equal to open procedures.
After a shoulder dislocation prolonged physiotherapy and exercises will not return stability. The problem is labro-capsular - not muscular. I would offer stabilisation to anyone 25 or younger after their first dislocation and to anyone who has had two or more episodes.
A final note of caution is to suspect rotator cuff rupture in individuals 35 years or older who have a traumatic dislocation. The older the patient the greater the incidence. Acute traumatic tears require surgical repair.
 Chronic Pain After Ankle Sprain
by Gerard Hardisty
Lateral ankle sprains are the most common sports injury. It has been estimated that worldwide one in 10,000 people a day suffer this injury. Some athletes don't seek treatment and many who proceed through a functional rehabilitation program achieve a good result, usually returning to their sport within six weeks. However, the incidence of chronic symptoms after treatment of acute lateral ankle injuries is 10 -30 percent.
Causes
- Ligament Instability
- Chronic synovitis
- Missed fractures
- Talar dome
- Anterior process calcaneus
- Lateral process talus
- Peroneal tendon dysfunction
- Subluxation/dislocation
- Tears
- Tarsal coalition
- Impingement syndromes
- Anterior
- Posterior
- Other less common causes
Diagnosis
Most patients have a history of significant inversion sprain. Often the injury was treated inadequately. Rest Ice Compression and Elevation (RICE) is mandatory in the first 48 hours. Most patients with an uncomplicated sprain will be back on their feet, minimally symptomatic, within two weeks. Symptoms are usually pain, swelling and a feeling of the ankle giving way. Recurrent ankle sprains warrant physiotherapy. Symptoms for longer than three months constitute chronic ankle pain. Thorough examination and appropriate investigations will usually isolate the problem.
Investigation
A repeat radiograph should be considered for any persisting and disabling symptoms. Certainly if symptoms persist longer than three months it is mandatory. A usual investigative pathway is:
1. Plain films
2. Bone scan
3. CT scan
4. MRI (in selected cases)
Bone and CT scanning will provide most answers. MRI is not normally necessary but gives excellent visualisation of the soft tissues, particularly tendons. It can be useful in the protracted case without well -localised symptoms. Nucleotide (bone) scanning is an extremely useful technique in localising bone (and soft tissue) pathology to direct the CT scan. It can also be used to assess the significance of abnormalities seen on the plain films. Ultrasound is very operator -dependent but has its uses in diagnosing tendon disorders and fluid collections.
Treatment
Treatment depends on the cause. Briefly, instability often requires stabilisation. Chronic synovitis and anterior impingement often respond to steroid injection but sometimes require arthroscopic resection. Posterior impingement, tarsal coalition and peroneal tendon dysfunction usually require an open procedure.
 Recent Advances in Arthroscopic Surgery
by David Colvin
The term "minimally invasive surgery" is a buzzword in medicine at present. Many common procedures are now being performed using new techniques that allow smaller incisions, less tissue dissection and lower morbidity. This allows a shorter hospital stay, quicker recovery and a more cosmetic result.
One way to achieve this in orthopaedic surgery is to do "arthroscopically assisted" open surgery. Cruciate ligament reconstruction is a good example. The graft (hamstring tendons or patella tendon) can be harvested by open surgery using small transverse incisions, then the reconstruction itself is performed arthroscopically. Similarly, rotator cuff repair can be done with a "mini deltoid split" when combined with arthroscopic acromioplasty. An open acromioplasty requires detachment of part of the deltoid. Preserving the deltoid attachments improves rehabilitation and recovery.
Endoscopic carpal tunnel decompression is another example of arthroscopic surgical techniques resulting in improved recovery times. Not all patients are suitable for this procedure. Arthroscopic assistance in reduction of intra-articular fractures can improve the quality of reduction, and may permit percutaneous fixation rather than open surgery.
All new techniques require careful evaluation. Only when they allow us to perform the same operation with lower morbidity and fewer complications should they be adopted. The benefit to the patient is then a shorter hospital stay and quicker rehabilitation.
 Impingement Syndrome and Rotator Cuff Tears
by Hari Goonatillake
The rotator cuff is formed by the tendons infraspinatus, supraspinatus and subscapularis muscles. The supraspinatus tendon passes below the coracoacromial arch consisting of the coracoid process, the coracoacromial ligament and acromial process. Abnormal contact between the coracoacromial arch and the rotator cuff can lead to shoulder pain and impingement syndrome.
Intrinsic factors such as muscle weakness, tendinitis or tendon degeneration lead to a muscle imbalance and proximal migration of the humeral head leading to impingement.
Extrinsic factors such as acromial shape or morphology, subacromial spurs and AC join osteophytes can lead to encroachment of the subacromial space and impingement.
Rotator cuff tears occur as a result of tendon degeneration, impingement or trauma. A traumatic event can be repetitive or a single event such as a fall. In particular glenohumeral joint dislocation in a person over 40 years of age can lead to a rotator cuff tear.
Three clinical stages have been described by Neer.(1)
Stage One occurs in individuals less than 25 years old with reversible changes of oedema and haemorrhage affecting the rotator cuff. These patients usually respond to conservative treatment.
Stage Two involves fibrosis and tendinitis of the rotator cuff with patients presenting with recurrent pain after activity.
Stage Three occurs in patients over 40 years of age with bony spurts and rotator cuff tears, which lead to progressive disability.
Patients present with pain, particularly with overhead activities as well as pain at night. There may be associated weakness especially with rotator cuff tears. Examination may reveal supraspinatus and infraspinatus wasting, a painful arc in the mid range of shoulder elevation with impingement tests being positive. Investigations should include X-rays and an ultrasound or MRI scanning.
Non-operative treatment consists of rotator cuff strengthening exercises to address the muscle imbalance and anti-inflammatory agents. A subacromial injection of a corticosteroid with local anaesthetic may be required to help with this stage of treatment.
Failure to respond to conservative treatment is an indication for surgery, which consists of subacromial decompression and rotator cuff repair if a tear is present. Symptomatic rotator cuff tears should be repaired as these do not heal with conservative treatment and usually remain symptomatic. They may also enlarge with time. A small percentage may progress to rotator cuff arthropathy. Age is not a contraindication to surgery.
A recent prospective study concluded that "surgery for chronic rotator cuff disease reliably and significantly improves general health status".(2)
References
1. Neer, C.S. Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder.
J. Bone and Joint Surg.
54-A: 41-50, Jan., 1972.
2. McKee, M.D., Yoo, D.J. The Effect of Surgery for Rotator Cuff Disease on General Health Status. Results of a Prospective Trial.
J. Bone and Joint Surg.
82-A(7):970-978, 2000.
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