The rotator cuff is a group of tendons and muscles in the shoulder, connecting the upper arm (humerus) to the shoulder blade (scapula).

These tendons provide stability to the shoulder and the muscles allow the shoulder to rotate.

Rotator cuff surgery is a procedure performed on torn tendons and symptoms of rotator cuff pain typically include:

• Pain and swelling in the front of the shoulder and side of the arm
• Pain triggered by raising or lowering the arm
• A clicking sound when raising the arm
• Stiffness
• Pain that causes you to wake from sleep
• Pain when reaching behind the back

When is surgery appropriate?

As a first course of action, anti-inflammatory medication, steroid injections, and physical therapy may all help to treat symptoms of a rotator cuff tear.

Even though most tears cannot heal on their own, good function can often be achieved without surgery.

If, however, you are active and use your arm for overhead work or sports, then surgery is most often recommended because many tears will not heal without surgery.

Surgery is generally recommended if you have persistent pain or weakness in your shoulder that does not improve after several months of non-surgical treatments.

Surgery is also generally recommended when the tear is large (more than 3cm) and often recommended when the tear is caused by a recent, acute injury.

What happens during surgery?

During a rotator cuff repair, the tendon is reattached to the tuberosity bone of the humerus from which it has been torn.

This is done using suture anchors in minimally invasive, arthroscopic fashion.

Bone spurs can also be removed in a similar fashion to prevent further tendon injury.

Being a completely arthroscopic surgery, rotator cuff repair surgery is now a more minor procedure than it used to be and is often done as a day surgical procedure.

The recovery however, still often requires a sling for 6 weeks to protect the repair until it heals.

The unstable shoulder is one that recurrently dislocates due to torn or stretched ligaments.

In doing so, it may cause permanent damage to the delicate cartilage surfaces that line the shoulder joint. Symptoms of unstable shoulder include:

• Pain caused by shoulder injury
• Repeated shoulder dislocations
• Repeated instances of the shoulder giving out
• A persistent sensation of the shoulder feeling loose, slipping in and out of the joint

What happens during surgery?

Surgical stabilisation involves repairing the torn ligaments in an arthroscopic (minimally invasive) way.

As it is now a completely arthroscopic procedure, today it is considered significantly more minor procedure than it used to be and can often be done as a day surgical procedure.

The recovery however still often requires a sling for 6 weeks to protect the repair until it heals.

Frozen shoulder (adhesive capsulitis) is a painful stiffness of the shoulder that often occurs between the ages of 40 and 60 and is more common in women.

Either shoulder can be affected, in many cases the non-dominant shoulder (eg the right shoulder in a left-handed person).

In about 20 per cent of cases the condition also develops in the other shoulder.

People with diabetes and thyroid conditions are thought more likely to develop frozen shoulder.

Symptoms of frozen shoulder include:

• Pain and stiffness that makes it difficult to carry out a full range of normal shoulder movements such as bathing, dressing, driving and sleeping comfortably.
• Symptoms vary from mild to severe where it may not be possible to move the shoulder at all.
• It may be a self-limiting condition often resolving or “thawing” out, over a 2 year period.

When is surgery appropriate?

Once a diagnosis has been made, (and if the pain is severe and prolonged), your surgeon may recommend an arthroscopic capsular release to speed up recovery.

During this procedure the scarred capsule is divided or released to allow full shoulder movement.

Although this is a day surgical procedure there is usually a 6-12 week period of physiotherapy required afterwards to ensure it does not refreeze.

Advanced arthritis of the shoulder can be treated with a shoulder replacement (arthroplasty).

In this procedure, the damaged parts of the shoulder joint are removed and replaced with artificial components called prosthesis.

Symptoms of shoulder arthritis commonly include:

• Pain - which is aggravated by activity and progressively worsens
• A deep, aching pain in the joint
• Soreness to touch the joint
• Difficulty lifting arms to comb hair or reach to a shelf.
• Click and grinding sounds may also be noticeable as you move your shoulder
• Difficulty sleeping due to shoulder pain
• If the glenohumeral shoulder joint is affected, the pain is centered in the back of the shoulder and may intensify with changes in the weather.
• Arthritis relating to the acromioclavicular (AC) joint is focused on the top of the shoulder and this pain can sometimes travel to the side of the neck.
• Someone with rheumatoid arthritis may have pain throughout the shoulder if both the glenohumeral and AC joints are affected.

When is surgery appropriate?

• Before any decision is made regarding the type of surgery, non-surgical approaches, medications and physical therapy are tried first.
• If the pain is still not significantly reduced, total shoulder replacement surgery is considered.

Shoulder replacement options include:

• Hemiarthoplasty where just the head of the humerus (the long bone in the arm) is replaced not the socket
• Total shoulder arthroplasty where the head of the humerus is replaced with a metal ball and gleaned with a plastic socket
• Reverse total shoulder replacement - where the location of the new ball and socket are on the opposite or “reverse” sides of a normal shoulder. A new metal hemisphere is used to replace the socket of the shoulder blade and a metal and high-strength plastic socket is used to replace the head of the humerus.

The primary goal of these approaches is to relieve pain; while secondary goals are to improve motion, strength and function.

The degree of damage to the rotator cuff is one of the key factors in deciding which type of total shoulder replacement surgery is the better option.

Although standard shoulder replacement surgery reduces or eliminates pain and improves function, success depends on the condition of the rotator cuff.

The more intact the rotator cuff, the better the outcome.

Reverse total shoulder replacement is usually the best option for patients with severe arthritis and who have a large rotator cuff tear.

Shoulder injuries commonly occur as an overuse problem during throwing sports such as baseball and swimming or as a direct impact injury during a fall in collision sports such as rugby.

During these matches acute first aid treatment is usually performed by onsite physiotherapists or by a nearby hospital emergency department or a GP.

Injuries are usually splinted using a sling and it is important to reduce swelling with ice and elevation where possible.

Once imaging has been performed definitive treatment can be decided on the sooner the better.

Following surgery or injury of the shoulder compression and ice (cryotherapy) can be an effective way of reducing swelling and helping blood to clot allowing a quicker recovery and less pain.

Some commercial devices such as a Game Ready may be provided to you by your surgeon or physiotherapist.

It is important to follow the instructions carefully as ice left in contact with the skin too long can cause thermal burns. The technology was initially invented by NASA and has been used widely and safely.

Fractures of the shoulder are common injuries.

They can occur as a result of a high energy injury in strong bone or a low energy injury in weak bone.

Initial first aid treatment includes pain relief and a sling to rest the shoulder.

Ice and compression should be used to reduce the swelling and imaging performed to decide on treatment.

Most injuries can be treated conservatively with a sling and some physiotherapy usually for around 2 months.

Sometimes, due to deformity or poor healing, surgery is needed to reduce the fractured bone fragments and secure them to allow early movement.

It is important that early movement occurs after surgery or injury as otherwise the development of a frozen shoulder can occur.