Shoulder Conditions

Shoulder Impingement

This is a painful disorder whereby pain and weakness occur  in the mid arc of elevation which comes about either due to repetitive injuries or occasionally following one single injury. Broadly speaking the older the patient is the more likely this will occur.   The likelihood of an associated rotator cuff tear occurring is also proportionate to the age of the patient.  The older the patient is then less and less force is required to produce more and more symptoms. Patients complain of pain and discomfort when reaching for a seat belt, hanging clothes, turning onto the affected side at night time, reaching for an object behind them, putting hands in the back pocket, putting hands on the steering wheel, changing gearstick, moving suddenly, lifting something from a shelf at the mid height.  The vast majority of impingement syndromes are self-limiting and never make it either to general practice or to see a shoulder specialist.  A small proportion of such presentations do go on to require a referral to general practice and subsequently on to a shoulder specialist.

Features on the History

There is pain in the mid arc of elevation made worse on resisted activity with relative relief on passive elevation.  Movements which involve internal and external rotation in elevation are painful and we went through some of his daily activities, which were quite typical.  The symptoms are also problematic nocturnally and certain fine and powered activities have been significantly affected.

Nuggets of Wisdom

CO-EXISTENT NECK AND SHOULDER PROBLEMS:

Shoulder and neck problems often co-exist, which is not surprising given their close anatomical proximity. It is important to decide through the history and physical examination, which of the two is the most dominant contributor to the sum total of the symptoms.  A careful clinical examination of the cervical spine and the shoulder very often resolves this.  Imaging may not achieve this, thus further highlighting the crucial role of a thorough clinical examination.

“Great surgeon. I felt well informed at all stages. Great outcome from my surgery, absolutely delighted. He was highly recommended to me by 4 friends who had experienced his top rate surgical skills and they didnt’ lie! A lovely man too and first class bedside manner.”

Features on Examination

The signs on examination consist of typical tenderness and crepitus over the greater tuberosity; positive thumbs up and positive thumbs down and positive cross adduction impingement test. These tests are designed to stress  the rotator cuff in varying degrees of internal/external rotation whilst the shoulder is in the mid-arc of elevation.

Investigations

The mainstay of the diagnosis is a good clinical examination by a skilled health professional.  However, investigations can be used to augment the clinical diagnosis and they may include x-rays to confirm whether or not there is any calcification together with any associated arthritis.  Imaging modalities such as ultrasound or MRI can also be used to look at the continuity of the rotator cuff and whether or not there is any tear as well as sizing it and deciding whether or not it is a full thickness tear or only involving a partial thickness of the tendon itself.

Treatment

The mainstay of management after the completion of the assessment consists of modification of activities of daily living, rest, physiotherapy, injections and finally surgery.  The physiotherapy concentrates on stabilising the shoulder and in particular in relation to the shoulder blade.  Patients often find it surprising that whilst the primary problem is in the shoulder tendon (rotator cuff), a great deal of effort is made to correct the shoulder blade movement.  Over and above the physiotherapy, injections can be considered and dependent on the type of change within the tear these can be repeated although there are contraindications for repeated injections which can have a deleterious effect.  Ultimately, if these non-interventionist measures do not solve the problem then the next port of call would be an arthroscopic (keyhole) intervention which decompresses the rotator cuff (subacromial decompression).  This involves the use of fine modern equipment which is introduced by means of small keyhole and the purpose of this is to deal with the soft tissue and the bony element which are causing the impingement/painful arc/tendonitis/bursitis.

Recovery

In cases where surgery is required, the quoted chances of success for subacromial decompression without a tear are in the order of 85-95%.  We usually say that it is an excellent procedure for pain but it is OK for power and range of movement.  It takes 6-9 months for the ultimate plateau of recovery to come through and it requires the patient to be committed to the postoperative therapy regime.  It is our experience that patients hit what we call a “brick wall” at between 8-12 weeks such that the original rate of progress may not be sustained and feel as though they are going backwards. This is due to the fact that the physiotherapy exercises are stepped up at this stage. This phase  usually settles down and patients then continue to make to improve.  If the procedure is combined with a rotator cuff tear then the chances of success are revised downwards from 85-90%.  Again the same criteria apply in that the surgery is very good for pain although the results with regards to power and range of movement would then depend on the size of the tear, its reparability and the quality of the tissue.  There is good evidence in the medial literature and also supported by our personal experience that in patients over 60 – 65, certain rotator cuff tears are no longer reparable.  When a rotator cuff tear repair is undertaken there is a small increase in the  risk of wound infections which is less than 1%.

It is not uncommon for patients who have had an arthroscopic procedure to notice some bruising tracking down the arm.  The reason for this is that some blood stained fluid used during arthroscopy can track downwards and give the impression of bruising.  This always settles down quite nicely and disappears very soon.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

“Efficient sympathetic and very competent”

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Shoulder Rotator Cuff Tendonitis

This is a painful disorder whereby pain and weakness occur  in the mid arc of elevation which comes about either due to repetitive injuries or occasionally following one single injury. Broadly speaking the older the patient is the more likely this will occur.   The likelihood of an associated rotator cuff tear occurring is also proportionate to the age of the patient.  The older the patient is then less and less force is required to produce more and more symptoms. Patients complain of pain and discomfort when reaching for a seat belt, hanging clothes, turning onto the affected side at night time, reaching for an object behind them, putting hands in the back pocket, putting hands on the steering wheel, changing gearstick, moving suddenly, lifting something from a shelf at the mid height.  The vast majority of impingement syndromes are self-limiting and never make it either to general practice or to see a shoulder specialist.  A small proportion of such presentations do go on to require a referral to general practice and subsequently on to a shoulder specialist.

Features on the History

There is pain in the mid arc of elevation made worse on resisted activity with relative relief on passive elevation.  Movements which involve internal and external rotation in elevation are painful and we went through some of his daily activities, which were quite typical.  The symptoms are also problematic nocturnally and certain fine and powered activities have been significantly affected.

“I can say that I was given first class service in every way. The procedure was fully explained in a calm and informative manner at the consultation, and I was given the opportunity to ask any questions or concerns that I may have had. ”

Shoulder Arthroscopy, Shoulder Pain

Features on Examination

The signs on examination consist of typical tenderness and crepitus over the greater tuberosity; positive thumbs up and positive thumbs down and positive cross adduction impingement test.  These tests are designed to stress the rotator cuff in varying degrees of internal/external rotation whilst the shoulder is in the mid-arc of elevation.

Investigations

The mainstay of the diagnosis is a good clinical examination by a skilled health professional.  However, investigations can be used to augment the clinical diagnosis and they may include x-rays to confirm whether or not there is any calcification together with any associated arthritis.  Imaging modalities such as ultrasound or MRI can also be used to look at the continuity of the rotator cuff and whether or not there is any tear as well as sizing it and deciding whether or not it is a full thickness tear or only involving a partial thickness of the tendon itself.

Shoulder Arthroscopy

Treatment

The mainstay of management after the completion of the assessment consists of modification of activities of daily living, rest, physiotherapy, injections and finally surgery.  The physiotherapy concentrates on stabilising the shoulder and in particular in relation to the shoulder blade.  Patients often find it surprising that whilst the primary problem is in the shoulder tendon (rotator cuff), a great deal of effort is made to correct the shoulder blade movement.  Over and above the physiotherapy, injections can be considered and dependent on the type of change within the tear these can be repeated although there are contraindications for repeated injections which can have a deleterious effect.  Ultimately, if these non-interventionist measures do not solve the problem then the next port of call would be an arthroscopic (keyhole) intervention which decompresses the rotator cuff (subacromial decompression).  This involves the use of fine modern equipment which is introduced by means of small keyhole and the purpose of this is to deal with the soft tissue and the bony element which are causing the impingement/painful arc/tendonitis/bursitis.

“I have had minor surgery on a few occasions so I would just like to say I have never felt more at ease or more valued as a patient Mr Yanni was amazing and I would definitely recommend his brilliant work and his superb manor. Thank you.”

Shoulder Arthroscopy, Shoulder Pain

Recovery

In cases where surgery is required, the quoted chances of success for subacromial decompression without a tear are in the order of 85-95%.  We usually say that it is an excellent procedure for pain but it is OK for power and range of movement.  It takes 6-9 months for the ultimate plateau of recovery to come through and it requires the patient to be committed to the postoperative therapy regime.  It is our experience that patients hit what we call a “brick wall” at between 8-12 weeks such that the original rate of progress may not be sustained and feel as though they are going backwards. This is due to the fact that the physiotherapy exercises are stepped up at this stage. This phase  usually settles down and patients then continue to make to improve.  If the procedure is combined with a rotator cuff tear then the chances of success are revised downwards from 85-90%.  Again the same criteria apply in that the surgery is very good for pain although the results with regards to power and range of movement would then depend on the size of the tear, its reparability and the quality of the tissue.  There is good evidence in the medial literature and also supported by our personal experience that in patients over 60 – 65, certain rotator cuff tears are no longer reparable.  When a rotator cuff tear repair is undertaken there is a small increase in the  risk of wound infections which is less than 1%.

It is not uncommon for patients who have had an arthroscopic procedure to notice some bruising tracking down the arm.  The reason for this is that some blood stained fluid used during arthroscopy can track downwards and give the impression of bruising.  This always settles down quite nicely and disappears very soon.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

“I just wanted to commend Mr Dimitri Yanni, for everything he has provided me to date. From my initial consultation, extremely informative, professional, yet informal and with a manner to put one instantly at ease and instil confidence that my issue was indeed fixable. Then for the expert care, professionalism, manner and attention to detail, both pre and post-operative, for my shoulder arthroscopic decompression and other issues requiring attention (not to mention the skill required to successfully resolve my issues during the procedure). I cannot recommend you more highly and it is with my sincerest gratitude and thanks, that I feel like I have my shoulder and the ‘active’ part of my life back, after 14 years of pain and pain management. I am still under Mr Yanni’s care, such as the attention to detail, to ensure my post-operative rehab remains on track (it is) to full recovery. I feel extremely fortunate to have been referred to you in the first instance and of course to be under your care. Kind Regard”

Shoulder Arthroscopy, Shoulder Pain

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Bursitis of the Shoulder

This is a painful disorder whereby pain and weakness occur in the mid arc of elevation which comes about either due to repetitive injuries or occasionally following one single injury. Broadly speaking the older the patient is the more likely this will occur. The likelihood of an associated rotator cuff tear occurring is also proportionate to the age of the patient. The older the patient is then less and less force is required to produce more and more symptoms. Patients complain of pain and discomfort when reaching for a seat belt, hanging clothes, turning onto the affected side at night time, reaching for an object behind them, putting hands in the back pocket, putting hands on the steering wheel, changing gearstick, moving suddenly, lifting something from a shelf at the mid height.

Bursitis of the Shoulder

The vast majority of impingement syndromes are self-limiting and never make it either to general practice or to see a shoulder specialist.  A small proportion of such presentations do go on to require a referral to general practice and subsequently on to a shoulder specialist.

Features on the History

There is pain in the mid arc of elevation made worse on resisted activity with relative relief on passive elevation.  Movements which involve internal and external rotation in elevation are painful and we went through some of his daily activities, which were quite typical.  The symptoms are also problematic nocturnally and certain fine and powered activities have been significantly affected.

“Dr Yanni has been delightful from start to finish, I actually look forward to seeing him! He answered all my questions and was also very patient with me being very nervous about the procedure. A highly recommended doctor overall.”

Features on Examination

The signs on examination consist of typical tenderness and crepitus over the greater tuberosity; positive thumbs up and positive thumbs down and positive cross adduction impingement test.  These tests are designed to stress  the rotator cuff in varying degrees of internal/external rotation whilst the shoulder is in the mid-arc of elevation.

Investigations

The mainstay of the diagnosis is a good clinical examination by a skilled health professional.  However, investigations can be used to augment the clinical diagnosis and they may include x-rays to confirm whether or not there is any calcification together with any associated arthritis.  Imaging modalities such as ultrasound or MRI can also be used to look at the continuity of the rotator cuff and whether or not there is any tear as well as sizing it and deciding whether or not it is a full thickness tear or only involving a partial thickness of the tendon itself.

Treatment

The mainstay of management after the completion of the assessment consists of modification of activities of daily living, rest, physiotherapy, injections and finally surgery.  The physiotherapy concentrates on stabilising the shoulder and in particular in relation to the shoulder blade.  Patients often find it surprising that whilst the primary problem is in the shoulder tendon (rotator cuff), a great deal of effort is made to correct the shoulder blade movement.  Over and above the physiotherapy, injections can be considered and dependent on the type of change within the tear these can be repeated although there are contraindications for repeated injections which can have a deleterious effect.  Ultimately, if these non-interventionist measures do not solve the problem then the next port of call would be an arthroscopic (keyhole) intervention which decompresses the rotator cuff (subacromial decompression).  This involves the use of fine modern equipment which is introduced by means of small keyhole and the purpose of this is to deal with the soft tissue and the bony element which are causing the impingement/painful arc/tendonitis/bursitis.

Recovery

In cases where surgery is required, the quoted chances of success for subacromial decompression without a tear are in the order of 85-95%.  We usually say that it is an excellent procedure for pain but it is OK for power and range of movement.  It takes 6-9 months for the ultimate plateau of recovery to come through and it requires the patient to be committed to the postoperative therapy regime.  It is our experience that patients hit what we call a “brick wall” at between 8-12 weeks such that the original rate of progress may not be sustained and feel as though they are going backwards. This is due to the fact that the physiotherapy exercises are stepped up at this stage. This phase usually settles down and patients then continue to make to improve.

If the procedure is combined with a rotator cuff tear then the chances of success are revised downwards from 85-90%.  Again the same criteria apply in that the surgery is very good for pain although the results with regards to power and range of movement would then depend on the size of the tear, its reparability and the quality of the tissue.  There is good evidence in the medial literature and also supported by our personal experience that in patients over 60 – 65, certain rotator cuff tears are no longer reparable.  When a rotator cuff tear repair is undertaken there is a small increase in the  risk of wound infections which is less than 1%.

It is not uncommon for patients who have had an arthroscopic procedure to notice some bruising tracking down the arm.  The reason for this is that some blood stained fluid used during arthroscopy can track downwards and give the impression of bruising.  This always settles down quite nicely and disappears very soon.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

“My 2nd operation under the care of Dimitri Yanni and yet again the care and attention was superb from start to finish.”

Shoulder Arthroscopy, Shoulder Pain

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

One of the best surgeons I have met. Amazing customer service with a clear understanding of individual needs and delivering with extreme professionalism, yet ensuring a very relaxed manner.. Very very happy with my surgery. Thank you

Hand Surgery

Shoulder Painful Arc

This is a painful disorder whereby pain and weakness occur in the mid arc of elevation which comes about either due to repetitive injuries or occasionally following one single injury. Broadly speaking the older the patient is the more likely this will occur. The likelihood of an associated rotator cuff tear occurring is also proportionate to the age of the patient. The older the patient is then less and less force is required to produce more and more symptoms.

“Dr Yanni has been delightful from start to finish, I actually look forward to seeing him! He answered all my questions and was also very patient with me being very nervous about the procedure. A highly recommended doctor overall.”

Patients complain of pain and discomfort when reaching for a seat belt, hanging clothes, turning onto the affected side at night time, reaching for an object behind them, putting hands in the back pocket, putting hands on the steering wheel, changing gearstick, moving suddenly, lifting something from a shelf at the mid height. The vast majority of impingement syndromes are self-limiting and never make it either to general practice or to see a shoulder specialist. A small proportion of such presentations do go on to require a referral to general practice and subsequently on to a shoulder specialist.

Features on the History

There is pain in the mid arc of elevation made worse on resisted activity with relative relief on passive elevation. Movements which involve internal and external rotation in elevation are painful and we went through some of his daily activities, which were quite typical. The symptoms are also problematic nocturnally and certain fine and powered activities have been significantly affected.

“Dr Yanni has been delightful from start to finish, I actually look forward to seeing him! He answered all my questions and was also very patient with me being very nervous about the procedure. A highly recommended doctor overall.”

Features on Examination

The signs on examination consist of typical tenderness and crepitus over the greater tuberosity; positive thumbs up and positive thumbs down and positive cross adduction impingement test.  These tests are designed to stress  the rotator cuff in varying degrees of internal/external rotation whilst the shoulder is in the mid-arc of elevation.

Investigations

The mainstay of the diagnosis is a good clinical examination by a skilled health professional.  However, investigations can be used to augment the clinical diagnosis and they may include x-rays to confirm whether or not there is any calcification together with any associated arthritis.  Imaging modalities such as ultrasound or MRI can also be used to look at the continuity of the rotator cuff and whether or not there is any tear as well as sizing it and deciding whether or not it is a full thickness tear or only involving a partial thickness of the tendon itself.

Treatment

The mainstay of management after the completion of the assessment consists of modification of activities of daily living, rest, physiotherapy, injections and finally surgery.  The physiotherapy concentrates on stabilising the shoulder and in particular in relation to the shoulder blade.  Patients often find it surprising that whilst the primary problem is in the shoulder tendon (rotator cuff), a great deal of effort is made to correct the shoulder blade movement.

Over and above the physiotherapy, injections can be considered and dependent on the type of change within the tear these can be repeated although there are contraindications for repeated injections which can have a deleterious effect.  Ultimately, if these non-interventionist measures do not solve the problem then the next port of call would be an arthroscopic (keyhole) intervention which decompresses the rotator cuff (subacromial decompression).  This involves the use of fine modern equipment which is introduced by means of small keyhole and the purpose of this is to deal with the soft tissue and the bony element which are causing the impingement/painful arc/tendonitis/bursitis.

Recovery

In cases where surgery is required, the quoted chances of success for subacromial decompression without a tear are in the order of 85-95%.  We usually say that it is an excellent procedure for pain but it is OK for power and range of movement.  It takes 6-9 months for the ultimate plateau of recovery to come through and it requires the patient to be committed to the postoperative therapy regime.  It is our experience that patients hit what we call a “brick wall” at between 8-12 weeks such that the original rate of progress may not be sustained and feel as though they are going backwards.

This is due to the fact that the physiotherapy exercises are stepped up at this stage. This phase usually settles down and patients then continue to make to improve.  If the procedure is combined with a rotator cuff tear then the chances of success are revised downwards from 85-90%.  Again the same criteria apply in that the surgery is very good for pain although the results with regards to power and range of movement would then depend on the size of the tear, its reparability and the quality of the tissue.  There is good evidence in the medial literature and also supported by our personal experience that in patients over 60 – 65, certain rotator cuff tears are no longer reparable.

When a rotator cuff tear repair is undertaken there is a small increase in the risk of wound infections which is less than 1%.

It is not uncommon for patients who have had an arthroscopic procedure to notice some bruising tracking down the arm.  The reason for this is that some blood stained fluid used during arthroscopy can track downwards and give the impression of bruising.  This always settles down quite nicely and disappears very soon.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

“Very kind and understanding Great at explaining what’s going on with my treatment and answering any questions I had”

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Frozen Shoulder

Frozen shoulder is a condition which affects the range of movement of the shoulder and which causes pain and stiffness within the shoulder itself.  The causes for it are often unidentified.  It can be brought about by innocent trauma often forgotten by the patient.  There is an increased incidence in insulin dependent diabetics as well as patients who suffer with Dupuytren’s contracture in the hand.  The literature has previously described associations with a variety of other causes but the majority of frozen shoulder patients do not have any association with any other identifiable pathological condition.  The course of the condition runs over 2 years and the purpose of treatment is to diminish the pain and improve the range of movement and thereby accelerating the treatment timeframe.  Broadly speaking, it starts with painful phase which can last for up to 12-14 months.  Then comes the phase of stiffness and loss of range of movement which typically can spread from 6-18 months.  Finally it resolves and that can take up to 24 months.  Dependent upon where the patient is in the various phases of the history, patients have subtle differences in their presentation.  In the early phases this is a painful condition and patients have difficulty sleeping and during most activities of daily living.  As the stiffness and loss of range of movement set in patients become aware of difficulties in activities of daily living eg personal hygiene, hanging an item of clothing on a coat hanger, reaching for a seat belt, scratching the back, reaching for an object on a shelf, putting the hand into the sleeve of a jacket …….

In essence the primary anatomical pathology in frozen shoulder is that the capsule becomes inflamed and it contracts down thereby ultimately reducing the range of movement of the shoulder.

Nuggets of Wisdom

SHOULDER AND ELBOW REPLACEMENTS:

Shoulder and elbow replacements as an option for arthropathies in the upper limb have advanced greatly in the last 20 years.  There are many options, ranging from re-surfacing, total shoulders and reverse polarity shoulder replacements for rotator cuff deficient shoulders.

“Charming, very professional in delivering what he intends and believes will be beneficial to my problem.”
Hand Surgery

Features on Examination

Dependent on where the patient is in the various phases of the frozen shoulder presentation the features are those of pain during certain stress manoeuvres of the shoulder and also loss of range of movement especially in internal and external rotation.

Investigations

Investigations consist of x-rays and an MRI scan and in particular to look at the continuity of the rotator cuff as to whether or not there is a tear and most importantly at the degree of the capaciousness of the capsule and whether or not it has contracted.

Treatment

Treatment consists of symptomatic relief through non-steroidal anti-inflammatories to control the pain particularly in the early phases of the presentation of a frozen shoulder together injections as well.  Physiotherapy is always a mainstay of treatment and it probably is the most important element of management.  If the problem persists and shoulder stiffness sets in then a variety of options can be considered after the option of physiotherapy has been exhausted.  These consist of capsular hydro distension (also known as distension capsuloplasty) whereby a quantity of water exceeding the actual volume of the capsule is injected slowly so as to stretch the capsule thereby freeing it further and allowing the patient a greater range of movement.  This is always combined with intensive physiotherapy afterwards.

Recovery

The recovery of frozen shoulder can be a protracted one and it can take up to 24 months for the full cycle to run its course.  In general the earlier we intervene to treat it then the more likely we are to shorten the natural history.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

“Mr Yanni is an excellent surgeon who is extremely caring and thorough. Having used his expertise in 2012 on my left shoulder, I had no hesitation in returning to him for my right shoulder in 2020.”
Hand Surgery

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Calcification in the Rotator Cuff

The causes for this are very often non-identifiable.  It is very rarely indeed associated with any systemic disorder.  In some instances it can be regarded as a manifestation of shoulder impingement/tendonitis/bursitis ie an internal scar of inflammation though that is not always the case.

Calcification in the Rotator Cuff

“Mr Yanni was very welcoming and put me at ease. After explaining the results of my scan he referred me to a physiotherapist and I am very pleased with my progress from the original diagnosis. I would be happy to recommend Mr Yanni.”
Hand Surgery

Presentation

This condition can be very painful.  The mainstay of treatment is to keep the shoulder moving thereby preventing loss of range of movement and stiffness.  Most presentations settle of their own accord and the early milky calcification which develops often settles down and becomes like dry toothpaste thereby reducing the symptoms.

Features on history

There is pain in the mid arc of elevation made worse on resisted activity with relative relief on passive elevation.  Movements which involve internal and external rotation in elevation are painful and we went through some of his daily activities, which were quite typical.  The symptoms are also problematic nocturnally and certain fine and powered activities have been significantly affected.

Features on Examination

The typical  signs include tenderness and crepitus over the greater tuberosity; positive thumbs up/ positive thumbs down and positive cross adduction impingement tests.

Investigations

Both x-rays and ultrasound/MRI scan are considered to identify the lesion.

Treatment

Initial treatment consists of non-steroidal anti-inflammatories and physiotherapy to keep the shoulder moving.  If things do not settle down then the next port of call is to consider aspiration (or barbotage).  This in essence consists of needling the calcification and then milking it out by an aspiration.  It is usually more successful in the early stages when the calcification is still fluid whereas when they dry up it becomes much more difficult to aspirate.

Recovery

The vast majority of patients tend to settle down without any ill effect.  In a minority of cases there is extensive calcification which renders the rotator cuff brittle and thereby causing rotator cuff tear.  There are instances when an arthroscopic (keyhole) intervention is required to decompress the rotator cuff and also decompress the calcification/repair the associated rotator cuff as well.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

“Mr Yanni has been tremendous. He keeps me fully informed all the time and is very sympathetic to the pain I am experiencing. He is realistic in his expectations and ensures that I fully understand the complexities of the surgery and the possible outcomes. I feel very reassured and comforted being treated by Mr Yanni.”

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Rotator Cuff Tears

The older the patient the commoner rotator cuff tears occur. The management of rotator cuff tears is tailored according to the needs of the patients, their fitness, expectations of level of activity, as well as their age.  Thus in a patient aged 40 with a full thickness tear, we would always operate , whereas in a patient of 80, also with a full thickness tear, we would virtually never operate.

In the older age groups tears are extremely common and a good majority of such patients are never aware of the presence of a rotator cuff tear ie the condition is completely asymptomatic. The causes of rotator cuff tears depend on a variety of factors.  In a younger patient a considerable amount of force is required to bring about a tear whereas with increasing age less and less force is required to produce a full thickness discontinuity within the cuff.  There is often a spectrum of changes in the rotator cuff ranging from partial thickness tear which if extended can become full thickness tears.  Many factors contribute to the development of full thickness tears such as trauma, repetitive activities, impingement, problems with the blood supply to the tendon.  Once the full thickness tear has occurred it can never repair on its own accord .  The tendon is where the muscles of the shoulder insert into the bone.  The fact that a full thickness tendon tear has developed does not necessarily mean that surgery is needed.  Especially in the older groups where the vast majority of such tears are managed symptomatically quite well. In a proportion of patients shoulder arthritis in the glenohumeral joint (the ball and socket joint) can develop as a sequel to a rotator cuff tear which had occurred many years prior to the symptomatic presentation.

Nuggets of Wisdom

ROTATOR CUFF TEARS:

The management of rotator cuff tears is tailored according to the needs of the patient, their expectation of physical activity, general health and age. Broadly speaking the younger the patient is the more likely we are to intervene.  The corollary of this being that in the older patient we tend to leave full thickness rotator cuff tears without surgery as the patients can adapt well.  With modern advances the majority of rotator cuff tears are now repaired arthroscopically.

“Mr Yanni, I had the pleasure of meeting you earlier this year where I was fortuitous to have you as my surgeon. I just wanted to say since my surgery back when the world was a bit normal in March, my road of recovery since then has been a revelation. I have recently been doing a lot of gardening which required digging and lifting and I have been totally pain free which is something I had not experienced in the last two years since my injury. A big thank you to you and your team, I know I am still recovering and still doing physio, but I can see how well you have corrected the damage my body had suffered. Hope you and your family are well Best regards”

General philosophy of management

The management of rotator cuff tears is tailored according to the needs of the patient, their fitness, activity and level of activity, as well as their age.  Thus in a patient aged 40 with a full thickness tear, we would always consider operating, whereas in a patient of 80, also with a full thickness tear, we would virtually never operate.

There is an intermediate group and here the most important element is the physical examination and the history by a trained specialist, which is always augmented by imaging.

Features on history

There is pain in the mid arc of elevation made worse on resisted activity with relative relief on passive elevation.  Movements which involve internal and external rotation in elevation are painful and pain during activities of daily living e.g. during sleep, putting on a jacket, reaching for a seatbelt etc…. as well as weakness and inability to do sustained tasks. The severity of the symptoms is proportionate to the extent of the tear.  The symptoms are also typically problematic at night and certain fine and powered activities can been significantly affected.  Dependent on the size of the tear and the degree of compensation which has occurred from the other muscles around the shoulder, there is varying weakness during various activities such as lifting objects, powered activities in the mid arc of elevation, handling items of clothing, putting on a seat belt, scratching the back, etc .

Features on Examination

The signs consist of typical tenderness and crepitus over the greater tuberosity; positive thumbs up and positive thumbs down and positive cross adduction impingement test.

Dependent of the size of the tear there is weakness during certain challenge tests.  The greater the tear is the weaker the shoulder is.  In large rotator cuff tears the patient has to hitch the shoulder up to get any movement as the act of elevating the shoulder is impossible to initiate.

Investigations

Investigations consist of x-rays and ultrasound/MRI.

Treatment

Initial treatment is essentially symptomatic in the older age groups. The management of rotator cuff tears is tailored according to the needs of the patient, their fitness, level of activity, as well as their age.  Thus in a patient aged 40 with a full thickness tear, we would always operate, whereas in a patient of 80, also with a full thickness tear, we would virtually never operate.

Where repair is needed it consists of reattaching the shoulder tendons back to where they belong on the bony element in the humeral head (the ball part of the ball and socket joint).  Over the last two decades,  excellent new technology has been developed for reattaching the tendons with the use of modern anchors which have excellent pull out strengths and are routinely utilised in the surgery of this condition.

Recovery

Once the rotator cuff has been repaired there is a graduated mobilisation regime which involves intensive physiotherapy.  The management is tailored according to the size of the tear, the age of the patient, fitness etc.  Broadly speaking, as a guide, a patient can expect 4 weeks in the harness where the shoulder is immobilised.  Following on from that there is a period of around 4-6 weeks of passive elevation where the shoulder is moved with the help of either gravity or the opposite limb or through the support of the physiotherapy.  The purpose of this is to maintain the range of movement.  After about 8-12 weeks a graduated mobilisation regime commences which consists of active movements.  These will vary according to the size of the tear/ the quality of the tissues and will be adapted according to the patient.  It can take up to 2 years for the full benefit of a rotator cuff repair to come through.

As in any surgical intervention there are small risks in relation to intervention, the type of anaesthesiae and those specific to the procedure.

The rotator cuff is a series of tendons, which are involved in the moving of the shoulder.  They extend from the front to the top and all the way to the back.

The management of rotator cuff tears is tailored according to the needs of the patient, their expectations of physical activity and the debility that the rotator cuff is causing. The cuff is attached to the bald humeral head, which is part of the ball and socket articulation of the joint.  When it comes off it can be due a combination of reasons, which include poor blood supply, attritional damage, longstanding wear and tear or major force.  These are but a few factors that bring about rotator cuff tears.  The effect of this is that once a full thickness tear has occurred it does not heal of its own accord.  To repair the tendon involves re-suturing back to where it pulled off from, namely the rim of the humeral head. This usually involves preparation of the bony surface where the tendon is to be repaired on to and with the insertion of some anchors to allow the repair to hold.  The arrival of modern anchors into shoulder surgery has allowed us the ability to repair rotator cuff tears with better results than was previously the case.

In large rotator cuff tears the tendon has to be mobilised from where it has retracted to.  Once that is achieved it is repaired on to the bone. However, this does not mean that the patient can start mobilising gradually. Much time is required for the tendon to heal up. Up to 18 months is required for the ultimate plateau of recovery to come through. The tendon has to heal to where it has been repaired on to and the shoulder re-educated through physiotherapy to move in a co-ordinated fashion so as to unlearn the poor patterns of movement previously brought about by the tear.

Broadly speaking, the younger the patient is and the smaller the size of the full thickness element of the tear then the better the results are.  It is estimated that something like 30% of patients will have irreparable rotator cuff tears.  Through modern imaging and detailed clinical examination, we hope to pre-select this group beforehand, thus not putting these patients through unnecessary surgery. However, there are some instances when a complete repair is not