The shoulder joint is the most flexible joint in the body. It is the principal operator joint of the hand allowing the hand to be placed in space to interact with the world around us. The flexibility, however, makes the shoulder susceptible to instability and injury. The shoulder joint can be the cause of significant pain and disruption to daily life.

Over the last years, there has been significant improvement in surgical operations including keyhole surgery and joint replacement with excellent long-term results. Shoulder surgery is a safe and effective way of improving pain and function and several studies show that this improvement is maintained even after 15 years of follow-up.

A large number of patients with shoulder pain seen at St Thomas hospital have found the long-term use of pain killers and physiotherapy as well as steroid injections into the joint as being less effective over time.

Furthermore, delaying the surgical repair of the shoulder joint can increase the likelihood that the problem will be more difficult to treat later. Studies have shown that early and correct diagnosis together with treatment of shoulder conditions can make a significant difference in the long run.

The most common causes of shoulder pain in the young generation mostly relate to injury or repetitive strain.  In the middle-aged and elderly population, wear and tear or arthritis of the shoulder joint is usually the cause.

The shoulder joint is a simple ball and socket joint surrounded by four muscles forming a sock round the head called the ‘rotator cuff’. The head is kept in the socket by a number of ligaments and a cartilage lip called the labrum.

In the younger generation, injury to the shoulder can cause a partial or full dislocation of the shoulder and cause damage and tears to the rotator cuff or labrum. In other cases, acute inflammation of the muscles can occur.

In all these cases the patient may complain of pain, clicking, weakness and loss of function of the shoulder joint.

Studies have shown that early and correct diagnosis together with treatment of shoulder conditions can make a significant difference in the long run

Arthritis or degeneration of the shoulder joint is a common condition where the joint lining erodes away causing the bone ends of the joint to rub against each other. Although genetics plays an important contributing role with patients reporting the existence of a family history of the condition, environmental causes and repetitive manual work are thought to contribute to the onset of symptoms.

This can be a source of debilitating pain and, although most commonly seen in the elderly population, it is more commonly being seen in the middle-aged population, particularly manual workers. It manifests itself in a condition called impingement or bursitis where the arthritis pinches the muscles and tendons around the shoulder, causing pain on lifting or rotating the arm or sleeping on it.

Although replacements of the knee and hip joints have been carried out for several decades, the story with shoulder joint replacements is relatively quite a recent one.  The significant health benefits of shoulder replacement are repeatedly borne out in several scientific studies with a tremendous improvement in function and quality of life due to improved levels of pain and mobility.

In a study on the quality of life improvement after shoulder replacement published in 2018, joint-specific and disease-specific quality-of-life scores all had statistically significant improvement.

There are broadly two types of shoulder replacements. The so-called anatomical replacement relies on the function of the muscles or rotator cuff to move the new implant. This may not always be the case, particularly in elderly patients where the rotator cuff or muscles around the shoulder are torn or not functional.

In these cases, a different type of replacement ‒ called a reverse shoulder replacement ‒ is indicated. It is so termed as the cup and ball part of the new replacement joint are reversed in position in the shoulder. This is thought to affect the mechanics of the shoulder and make use of other still intact muscles functioning around the new implant. 

Although both procedures are major, the outcomes are excellent with patients reaching near full function and pain relief about eight weeks following the procedure.

Keyhole or arthroscopic surgery of the shoulder joint, like other less invasive operative techniques, involves the use of very small surgical incisions and a camera placed in the joint to allow the surgeon to carry out the operation.  The benefits of keyhole surgery are tremendous. It allows unparalleled visualisation of the joint unachievable by open methods. It causes less injury to the tissues around the joint, hence decreasing the pain levels after the operation, allowing a quicker recovery time and earlier return to work and play.  In fact, most keyhole surgery operations can be carried out as a day case.

A variety of conditions may be treated this way, including cleaning and washing out of the shoulder joint when it is arthritic, repairing a torn tendon using special rivets, excising excess bone using a high-speed burr in the condition of ‘impingement’ where the wear and tear in the shoulder pinches the shoulder tendons.

Keyhole surgery of the shoulder joint is also useful in releasing the tight structures and tissues in the painful and stiff condition of frozen shoulder or repairing the avulsed cartilage lip or labrum in cases of recurrent dislocating shoulders.

If you recognise any of these symptoms and would like to discuss further treatment, one may contact the shoulder surgeons at St Thomas Hospital.

Alistair Pace is a consultant orthopaedic, trauma and upper limb surgeon and a senior lecturer at the University of York and Hull.