Kickas.org Forums Ankylosing Spondylitis General Discussion #1 AS Web Support Group Function Of Shoulder After Rotator Cuff Surgery

Arm straight out Sue. IF you bend the arm, not nearly so much leverage. Straight out in front, across the body - using different point/s of the compass?

See IF I can find illustrations for this'un.

Another point. Warning: don't bring arm out to the back of you, whether arm is bent or straight. This will do a lot of damage to an already damaged rotator cuff! And steer well clear of overhead stuff. Even taking items off high shelves; stand on a kitchen stool or summat. But ensure that the stool is one of those safety ones, with a bar in front, to grab and steady. (Don't want you guys falling forwards/backwards off stools!)

Rotator Cuff - lot of information here. This is the best site bar none, for shoulder information.

Rotator Cuff Tears :-http://www.shoulderdoc.co.uk/article.asp?section=22

Now,, you will read that corisone injections are mentioned, but, will post on the Hyaluronic Acid (Osternil) aspect wehn I have picked it up from THIS site itself...Prof Funk, BTW is a renowned internation expert on shoulders. And he is an amazing teacher.

Will use this response to add *relevant sections as I pick them up from the site. OK?

Shoulder Anatomy :-
http://www.shoulderdoc.co.uk/article.asp?section=3&article=1

"The shoulder is one of the most sophisticated and complicated joints of the body:

"It has the greatest range of motion of any joint in the body allowing complete global movement allowing you to position the hand anywhere in space.
The coordinated activity of numerous muscles working together in set patterns is required to produce this motion
It is made up of FOUR joints and FIVE linked bone groups which are related and work together.
To allow so much movement the joints need to be 'free' to move, therefore the shoulder should be unstable; However a series of complex ligaments and muscle keep it in joint." (more...)

Shoulder Tendons :-
http://www.shoulderdoc.co.uk/article.asp?article=1180&section=857

Partial thickness cuff tears :-
http://www.shoulderdoc.co.uk/article.asp?article=1368&section=22

Latest news :- (this is very informative and worth picking out salaient areas of interest.)http://www.shoulderdoc.co.uk/latest.asp?region=products&section=82

Shoulder Injections - important. You'll see why it is crucial for the person doing the procedure to use ultrasound or imaging to assist in doing the shoulder injection. It should NEVER be done without such aids - as can cause damage...! (coming up, more on this 'Shoulder Injections' aspect.)

Intra-articular injection of the acromioclavicular joint
(snip...) "Intra-articular punctures and injections are performed routinely on patients with injuries to and chronic diseases of joints, to release an effusion or haemarthrosis, or to inject drugs. The purpose of this study was to investigate the accuracy of placement of the needle during this procedure." (and) "Correct positioning of the needle in the joint should be facilitated by fluoroscopy, thereby guaranteeing an intra-articular injection."

Corticosteroids Reduce the Tensile Strength of Isolated Collagen Fascicles
http://www.shoulderdoc.co.uk/article.asp?article=969
(snipped...) "Clinical Relevance: Corticosteroids may weaken specific regions of the injected tendon and leave it more prone to rupture. This weakening effect is manifested in the individual collagen fascicles that constitute the tendon."

Hyaluronans in the Shoulder
http://www.shoulderdoc.co.uk/article.asp?article=82
HA does not have the know detrimental effects on tendons that corticosteroids have (14) (See Shoulder Injections ) and therefore is an attractive alternative to corticosteroids around the sensitive rotator cuff.

Shibata et al [8] prospectively compared HA and steroid injections in patients with rotator cuff tears. There was no difference with respect to the pain relief experienced, range of motion and surgical requirements between the two groups. However, biopsies from the rotator cuff stumps were examined from patients who underwent surgery and showed that the collagen fibres from those injected with HA pre-operatively were significantly denser than those treated with steroid. HA injected patients were more responsive to rotator cuff repair with better outcomes. There was also a link between the number of steroid injections and the outcome of surgery. Repeated steroid injections may cause severe local destruction. They concluded that although local steroid injection is often used for pain, since it has a good analgesic effect, repeated injections are associated with a softer residual cuff, and poor surgical results may be due to the giving way of this soft tissue (7)." (more...)
(snip...) "Our clinical experience after one year is that (HA)it is a useful alternative to corticosteroids and provides similar pain relief, without the concern of complications such as rotator cuff damage and fat necrosis."

Here is the biggie :-

Shoulder Injections
http://www.shoulderdoc.co.uk/article.asp?section=56&article=101

(snip...) "there is little overall evidence to guide treatment and subacromial corticosteroid injections for rotator cuff disease may be beneficial, although their effect may be small and not well-maintained"

(snip...) "Adverse Effects of Corticosteroid Injections

The accuracy of injecting corticosteroid into the subacromial bursa is at best 70% in the hands of an experienced shoulder surgeon [6,7]. Thus in 30% of cases corticosteroid is being injected into the surrounding tissues including the rotator cuff tendon and muscle.

Nelson et al. reviewed the use of corticosteroid injections in primary care [11]. They noted the local complications of corticosteroid injection include tendon and ligament weakening, bacterial infections of joints and related structures, and subcutaneous tissue atrophy. Systemic complications were rare but included hyperglycemia and adrenal axis suppression.

A number of studies have expressed concerns that steroids injected into the tendons and muscles can significantly weaken the collagen fibres and precipitate rotator cuff ruptures when injected for subacromial impingement[2-5,16]. Corticosteroids damage the ultrastructure of collagen molecules, reduce collagen density [8], as well as inhibiting the reparative properties of tendon by inhibiting tendon cell migration [9] and synovial fibroblast proliferation [10].

Due to the clinical complications of steroid injections into tendons, Fredberg in 1997 stated that the injection of corticosteroid inside the tendon has a deleterious effect on the tendon tissue and should be unanimously condemned [12].

Corticosteroids injected into the subcutaneous tissues can cause lipodystrophy and soft tissue infections. This is more common following repeated injections and in immunocompromised and rheumatoid patients [3,8,14].

Due to the nature of rheumatoid arthritis and the disease process effects on tendons, repeated corticosteroid injections compound the tissue damaging effects and make any surgical repair of these tissues more difficult and more likely to fail [8,13,14].

Hyaluronans
Subacromial injection is an important part of the management of impingement syndrome, therefore are there safer substances to use instead of steroids?

Hyaluronan (HA) injections have been proven to be as effective as corticosteroids for the treatment of impingement syndrome and rotator cuff disease [8,15], without the complications associated with corticosteroids.

At present, we are prospectively comparing a Hyaluronan (Ostenil) with corticosteroid (Depomedrone) for impingement syndrome and selected cases of arthritis (unfit for surgery).

Our early experience is that Ostenil is as effective as corticosteroids with regard to pain relief and range of motion. Click here for more.
Also See:
- Hyaluronans - Basic Science
- Hyaluronans in the Shoulder

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There is MORE information available on the shoulderdoc.co.uk website. (In fact, enough information of TRUE *excellence, to keep even a top orthopaedic surgeon going for a year, let alone *ESSENTIAL information for the rheumatologist and GP - and for the patient who needs to be very well informed before letting anyone loose on their shoulder!)

Molly, good article and discussion, especially since there are so many AS'ers with shoulder problems. Yes cortisone injections can be a tough call unless you know you have a OS that is a specialist in shoulder injuries and AS. Any injury that involves the connective tissues is going to be hard to heal in patients with AS due to the direct imflamation to those tissues normally but especially after an injury. If there are Hyloronic acid is best for those with joint deterioration from Osteoarthritis. If patients with connective tissue injuries want temorary relief they should consult their OS about the possibility of Marcaine injections to decrease the pain so they can get range of motion back. Shoulders are a big problem with AS patients and simple stretching and strengthening should be done on a daily basis and avoid repetative movements that will cause imflamation.

Cindy

Yea Cindy - Thank you for that. I feel that ALL ASers should have this printed out and kept to the forefront of their folders...

Yes, Professor Funk speaks of the Marcaine injections, and also in using Marcaine in conjunction 'with' the HA. Facinating. (He sure is filled with consternation at the damage those corisone shots do, and to the free use of such shots by rheumatologists and doctors, and that is excluding orthopods use of cortisone shots in the shoulders...! )

Again, my thanks for joining the thread with your expert physio input.

Take care - Go well -

Molly C (France)
Keeping on Keeping on

wow, this thread is just what I needed. My shoulder injury just will not heal. I'm going to absorb all this info and re-think my strategy. thanks!!!

I've been avoiding cortisone shots in my shoulders for these very reasons. Haven't had one yet but there've been times when I've been tempted.

I have had several, over a period of 20 years. In both shoulders. My shoulders are one of my biggest pain problems. This is not good news for me, as the cortisone injections really helped.
Donna

AS and steroid injections not a good mix. I've had so many injections in both shoulders over the years, I'm a prime example of what not to do. I have torn rotator cuff and Labial tears in both shoulders and right biceps tendon ruptured and the left biceps is about 50% torn. I really works against people with AS. Steroids weaken the very ligaments and tendons that the AS imflames, only makes sence when you think about it.
Cindy