Arthroscopic Treatment of Shoulder Pain

By: Mark J. Hanson MD, McLean County Orthopedics, Bloomington IL

The shoulder is the most mobile joint in the body and is a common source of pain. Problems involving the shoulder can affect all age groups. Arthroscopic treatment of these problems can provide a quicker recovery and less pain than traditional open methods. Surgeons use a fiber-optic camera, called an arthroscope, to see and repair problems within the joint. This is performed through tiny stab incisions in the skin, minimizing tissue trauma. Arthroscopy can be used to treat many different types of shoulder problems:

Rotator Cuff Disorders

The rotator cuff is made up of a group of tendons that cover the shoulder joint. It helps elevate and rotate the shoulder. Pain caused by rotator cuff pathology is the most common cause of shoulder pain in people over 40. It can disrupt daily function and even sleep. Rotator cuff pain starts with impingement of the cuff by the bony roof of the shoulder, called the acromion. If untreated, it can develop into a partial rotator cuff tear, or eventually a complete tear. It usually presents without an injury and is typically worse with overhead use or lifting. Diagnosis can be made through physical examination and magnetic resonance imaging (MRI).
Non-operative treatment includes activity modification, anti-inflammatory medicine (ibuprofen, naproxen), physical therapy, and steroid injections. If these fail, operative treatment may be necessary. Operative treatment consists of removing part of the acromion to relieve the pressure on the cuff, then reattaching the rotator cuff to the bone. In the past, this required a wide open approach where the deltoid muscle was detached from the bone. This open approach does not allow for visualization of the labrum, resulting in many untreated labral tears and continued pain. Modern minimally invasive options include an arthroscopic repair, or a mini-open repair assisted by arthroroscopy. Advantages of these techniques include preservation of the deltoid attachement, and the ability to inspect the labrum and repair it if necessary.

Labral Tears and Biceps Tendon Dysfunction

The labrum is a cartilage rim that surrounds the socket of the shoulder. The biceps tendon attaches to the labrum. Tearing or inflammation of these structures can result in significant pain. Tears can occur in anyone, ranging from young adults to the elderly. In young people, tears are usually caused by an injury. In older adults, they are often associated with rotator cuff disease. This pain is typically located in teh front of the shoulder and can be associated with catching and popping. Labral tears are usually undetectable by MRI, unless dye is placed in the joint.
Non-operative treatment consists of activity modification, anti-inflammatory medicine, physical therapy, and steroid injections. Arthroscopic treatment involves reattaching the labrum to the socket or removing the biceps from the labrum and anchoring it to the bone outside the joint.

Instability

The shoulder is a very shallow "ball and socket" joint, much like a golf ball on a golf tee. A shoulder can become too loose, resulting in the ball sliding out of the socket. This instability may be caused by an injury (dislocation) or can occur without an injury. Dislocations can take place in any age group. Instability that is present without an injury (atraumatic) usually affects people under the age of 30. Atraumatic instability is the most common cause of shoulder pain in young people. Dislocations can result in damage to the internal structures of the shoulder. Typically, young people tear their labrum, while older people tear their rotator cuff. These injuries usually need to be repaired with an operation.
In addition to repairing the rotator cuff or labrum, a capsulorrhaphy will often need to be performed. This is a tightening of the shoulder joint. A traditional open capsulorrhaphy is done through an incision in the front of the shoulder. This approach requires detachment of one of the rotator cuff tendons. The procedure can be done arthroscopically, preserving the rotator cuff attachment. Atraumatic instability can almost always be treated non-operatively. When this fails, these are also treated with a capsulorrhaphy.

Frozen Shoulder

A frozen shoulder, or adhesive capsulitis, is a decrease in motion of the shoulder associated with pain. It can occur spontaneously or after surgery. People with diabetes are at the highest risk. Most cases can be successfully treated with aggressive physical therapy and anti-inflammatory medicine. If this is unsuccessful, a manipulation under anesthesia may be necessary. This involves the surgeon stretching the shoulder while the patient is asleep, tearing the scar tissue that is restricting motion. If this fails, an arthroscopic capsulotomy (cutting the joint capsule) can be performed.

Arthritis

Arthritis occurs less frequently in the shoulder than in the knee or hip. It is much less common than rotator cuff problems. Arthritis presents as constant pain and a decrease in motion. The only true cure for arthritis is a shoulder replacement, but pain can be alleviated with anti-inflammatory medicine, glucosamine / chondroitin, physical therapy, and steroid injections. Arthroscopic debridement (clean out) can be used to relieve pain, especially if labral or biceps pathology are present.

In conclusion, most shoulder conditions that were previously treated with open surgeries can now be treated successfully with arthroscopy. In comparison to traditional methods, arthroscopic techniques are less invasive, resulting in decreased pain and recovery time.