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. ”
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.”
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”
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.”
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
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.”
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.”
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.”
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 possible.
The rehabilitation usually involves extensive physiotherapy, which usually starts with passive movements and gradually builds up to active and then resisted active movement. Whilst a rotator cuff tear would never give the patient a shoulder that was the same as they had in their youth, nevertheless we would always hope to achieve significant improvement on the function of the shoulder compared to the set of symptoms that were present when the full thickness rotator cuff tear was problematic.
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
“Mr Yanni has been extremely helpful, with good explanations throughout. I cannot praise him enough.”
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
Shoulder Tendon Tear
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 i.e. 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.
Shoulder Tendon Tear
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.
“I saw Mr Yanni about a full-tear rotator cuff injury. I had great confidence in Mr. Yanni from the first consultation, and I was not disappointed. Early indications following my surgery are that he has achieved an excellent outcome for me, with a near 100% recovery of utility expected. He provided frank and pragmatic prognosis, directed my pre and post-surgery physiotherapy, and has continually monitored my progress. I have nothing but praise and gratitude for Mr. Yanni. For his surgical skill, empathy, and total commitment to his patients.”
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 possible.
The rehabilitation usually involves extensive physiotherapy, which usually starts with passive movements and gradually builds up to active and then resisted active movement. Whilst a rotator cuff tear would never give the patient a shoulder that was the same as they had in their youth, nevertheless we would always hope to achieve significant improvement on the function of the shoulder compared to the set of symptoms that were present when the full thickness rotator cuff tear was problematic.
“Very good doctor and explanation of the procedure very thorough and after care is exceptional”
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
I felt at ease and confident . Mr Yanni is very competent and was able to diagnose and treat my injury. His manner towards me was very pleasant and he explained all the options open to me.
Acromioclavicular Joint (ACJ) Arthritis
The acromioclavicular joint is constituted by the outer end of the collar bone (clavicle) as it comes to join the shelf of bone above the humeral head (the ball element of the ball and socket joint). This shelf of bone is known as the acromion and hence the name acromioclavicular joint(ACJ). This joint is held together by ligaments around the joint and also ligaments distant to the joint itself which keep it aligned with the acromion. Arthritic changes within this joint are extremely common and are age related. Thus if we were to check on the shoulders of patients over 40 we would find that a majority would have arthritic changes within the acromioclavicular joint but would be completely unaware of it. Consequently, treatment is only directed towards the small-sub group of patients where this arthritis is symptomatic.
With the advent of modern imaging, which includes MRI we very frequently identify degenerative changes in the ACJ. This does not mean that they are always symptomatic, nor does it always mean that the patient requires surgery. Broadly speaking if we were to take MRI scans of 100 non-symptomatic patients aged 40 or above, a significant majority would have degenerative changes in their ACJ’s yet they would be completely unaware of this. The purpose of offering treatment for the ACJ arthritis is when this is symptomatic. That is determined through the history and physical examination, which are augmented by the imaging, rather than the imaging being the sole reason for making the decision. Surgery for the ACJ, when confirmed on the history and physical signs involves excision of the joint leaving a space to avoid the irregular surfaces from rubbing and therefore stopping the patient’s symptoms. This is undertaken arthroscopically(keyhole surgery)
It can take up to 9 months before the ultimate plateau of recovery comes through. This procedure can be combined with subacromial surgery if indicated. When this is the case the rehabilitation can be prolonged to up to a year. Attendance at physiotherapy is essential.
“Mr Yanni is a wonder. I felt in excellent hands through my surgery and beyond which was great as I was a nervous 1st timer. My shoulder’s on the mend and there’s barely a scar to be seen, all thanks To Mr Yanni.”
Features on history
Patients complain of pain on the outer range of elevation ie at the top end of lifting of the arm together with cross adduction ie when the shoulder and upper limb are moved across to the opposite shoulder at mid height. Patients can also complain of pain when lying on the affected shoulder during their sleep.
Features on Examination
There is usually tenderness over the acromioclavicular joint to pressing it up and down (ballottement) as well as cross adduction and when it is lifted up towards the outer range.
Investigations
Investigations consist of x-rays together with ultrasound/MRI scan to check whether or not there is associated subacromial pathology such as impingement or rotator cuff tear as the two can coexist.
Treatment
Treatment essentially consist of heat, ultrasound, physiotherapy and modification of activities of daily living. Should these measures fail then injections into the acromioclavicular joint can be considered. Where these measures have failed then surgery is undertaken arthroscopically (keyhole).
Recovery
Where simple measures like injection and physiotherapy are used patients can expect a recovery within a matter of weeks. Where such measures have failed and the treatment progresses onto an arthroscopic (keyhole) excision of the acromioclavicular joint then that requires a longer rehabilitation. It can take 6-9 months before the ultimate plateau of recovery comes through. Patients usually go through a graduated mobilisation regime and the physiotherapy programme afterwards is altered according to the findings at the time as often other conditions can exist involving the rotator cuff. There are small risks of wound infection, pain and stiffness and neurovascular damage but these are extremely rare.
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
“I simply can’t recommend him highly enough. Simply the best. After 2 shoulder surgeries I would not have anyone else. The most caring and thorough surgeon I have ever met. Thank you Mr yanni”
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
Acromioclavicular Joint (ACJ) Instability/Dislocation
The acromioclavicular joint is constituted by the outer end of the collar bone (clavicle) as it comes to join the shelf of bone above the humeral head (the ball element of the ball and socket joint). This shelf of bone is known as the acromion and hence the acromioclavicular joint. This joint is held together by a joint together with ligaments around the joint and also ligaments distant to the joint itself which keep it aligned with the acromion. The acromioclavicular joint is stabilised by multiple structures which consist of the capsule, the ligaments around the joint as well ligaments distant to the joint. Trauma can occur following a fall onto the point of the shoulder or during contact sports quite typically in a scrum at rugby. Dependant on the extent of the damage to the soft tissues and ligaments around the joint, varying degrees of dislocation can occur in the acromioclavicular joint.
Acromioclavicular Joint (ACJ) Instability/Dislocation
“This excellent surgeon operated on my right shoulder in 2019 and again in 2020 on my left shoulder. This man is totally brilliant in his chosen profession and I would recommend him to any of my colleagues and friends. He is wonderful.”
Features on history
Patients complain of pain and discomfort particularly on the outer range of elevation, cross adduction ie reaching across to the opposite shoulder and along the acromioclavicular joint itself.
Features on Examination
There is pain on ballottement of the ACJ and varying degrees of prominence depending upon the extent of the soft tissue damage. Where this is mild there is hardly any prominence other than the swelling which ensues. In cases where the whole stabilising structures have been damaged then the diagnosis is usually made on inspection with a prominent area over the acromioclavicular joint whereby the collar bone (clavicle)is riding high which in its own right can cause pain by tenting the skin upwards.
Investigations
The mainstay of investigation here is an MRI scan to define the extent of the soft tissue damage and this augments the clinical examination. The MRI also serves to identify whether or not any other damage to the shoulder has occurred ie the same force which caused the damage to the ACJ may have caused other problems in the shoulder itself.
Treatment
The majority of acromioclavicular joint dislocations are managed conservatively and patients rarely have any long term sequelae. Broadly speaking, the more disruption there is the more likely the patient is to require intervention. Treatment usually consists of repairing the ligament or augmenting it with an artificial ligament. In a sub-group of patients where the dislocation occurred many years previously there is a combination of soft tissue transfer of a coracoclavicular ligament together with augmentation with a ligament.
Recovery
Where surgery is not required the vast majority of these injuries settle within 6 weeks. Physiotherapy is always required and some early modification to activity of daily living. If surgery is indicated that can take longer. The majority of patients do not require intervention and the question of who to operate on is in general related to the extent to which the patient is symptomatic, proportionate to the demands of their daily lives. The extent of the soft tissue damage is an important consideration as well. The risks which are attached to surgery include wound infection, the risk of recurrence, wound infection, and it can take up to 6-9 months for the ultimate plateau of recovery to come through. The need for commitment to a postoperative therapy regime is crucial.
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
“Full 5 star rating for Mr Yanni, could not fault anything in my procedure at the Sloane Hospital.”
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
Shoulder Instability/Dislocation
If one were to compare the shoulder with its equivalent joint in the lower limb ie the hip one would find that in the hip the stability of the joint depends in large measure on the ball and socket arrangement of the joint. The soft tissues do play a role but the anatomical shape of the socket seating the head of the hip is the most important one to maintain instability. This is not the case in relation to the shoulder. Instead of the socket there is a shallow bony saucer (the glenoid)around which there is a rim of cartilage surround by the capsule and muscles. Consequently the stability of the shoulder depends upon the quality of the soft tissues and the strength of the capsule around it. Equally important is the strength of the muscle and the movement of the shoulder blade on the thoracic wall. It is for this reason that the shoulder is much more frequently dislocated than the hip. Multiple factors contribute to the instability of a shoulder. It is a complex topic with multiple inputs but broadly speaking cases can be separated into two broad groups. There are those where the shoulder has been “born loose” due to inherited background ligamentous laxity and those where the shoulder has been “torn loose” and that is following on from a trauma.
“Great Service Very Happy Thanks very Much to you and your team”
Features on history
It is important to establish what type of trauma brings about the dislocation such as raising the hand and externally rotating it or reaching across and internally rotating it as there are very important clues in the direction of instability. Enquiry into whether or not the patient suffers with ligamentous laxity is crucial as well as it can play a role in the rehabilitation. The frequency of the dislocation is also an important determinant feature and the amount of force required.
Features on Examination
The clinical examination consists of a series of stress manoeuvres to determine which position causes the patient to feel that the shoulder is about to dislocate (‘apprehension’ tests). From this it can be determined whether or not the instability is in all directions (ie ‘multidirectional’ or ‘unidirectional’) The vast majority are dislocations toward the front and downwards. There are however posterior dislocations as well as multi-directional ones as well.
Investigations
The investigation consists of x-rays as well as an MRI scans to determine the amount of disruption in the bony and soft tissue elements surrounding the shoulder.
Treatment
Rehabilitation for a first time dislocator always involves physiotherapy. There are a variety of modalities of rehabilitation regimes which can be used. If the patient has ligamentous laxity then that will be factored in. Ultimately, surgery is indicated if all such measures have failed. The purpose of surgery is to reconstruct the damaged bony elements along the front of the glenoid (the shallow saucer which seats the humeral head) as well as the capsule and the disc of cartilage around the glenoid itself.
Recovery
A majority of patients do not require intervention and the question of who to operate on is in general related to the extent to which the patient is symptomatic, proportionate to the demands of their daily lives,work and sporting activities. Broadly speaking , the purpose of surgery is to repair and tighten the damaged structures which have been damaged. This is undertaken arthroscopically in the majority of patients. The labrum is repaired and the capsule is tightened thus reducing the looseness in the shoulder. Defects in the bone need to be dealt with in some patients.
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
“I have had previous experience with Mr Yanni and I am absolutely happy to recommend his services, I have had two shoulder surgerys both open and keyhole surgery, I have experienced very little pain or discomfort.”
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
I had an excellent experience with Mr Yanni, there was a very quick turnaround from consultation to procedure and I at no point felt like I wasn’t being looked after.
Shoulder Arthritis of The Gleno-Humeral Joint
This is reference to the glenohumeral arthritis ie the ball the socket joint of the shoulder. The causes of this are multiple. In some instances there is no apparent cause but in others it can be related to a previous rupture of the rotator cuff, inflammatory conditions which give arthritis throughout the body (eg rheumatoid arthritis) or previous trauma/fracture in the shoulder which lead to arthritis. In the definition of the term arthritis it is a loss of the lining of the joint the so called articular cartilage. In so doing the surfaces become irregular and in advanced cases bone upon bone contact occurs thus resulting in pain during movement and at rest.
“Mr Yanni made my whole experience very comfortable and made me at ease with it all I would 100% recommend him to anyone”
Features on history
Patients complain of a loss of movement as well as pain. Pain at rest can be a dominant feature especially when it is at its worst at night time.
Features on Examination
Clinical examination will consist of identifying the range of movement and how painful it is as well as assessing the patient’s ability to undertake various manoeuvres.
Investigations
These usually consist of x-rays and/or ultrasound/MRI to identify the extent of the arthritis and just importantly the integrity of the soft tissues around the shoulder joint and in particular the rotator cuff which would play a role in the choice of treatment.
Treatment
Treatment usually starts with simple measures which include physiotherapy, anti-inflammatory tablets and steroid injections. There is a very narrow role for shoulder arthroscopy to debride the joint ultimately shoulder replacement is the treatment where all non-interventionist treatments have failed. The technology underpinning shoulder replacement has progressed in a very dramatic fashion over the last 20 years with varying types of shoulder replacement available appropriate to the circumstances of the patient.
Recovery
Patients suffering of early arthritis recover quite well following on from physiotherapy and modification of activity of daily living and it is by no means a certainty that the symptoms will progress. However, there is a small sub group of patients in whom the patients do progress and should that be the case they require a shoulder replacement. It can take the best part of 9 months before the ultimate plateau of recovery comes through and there are some associated risks as with any intervention which include infection, dislocation and very rarely thrombosis in the upper limb.
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
“Very well looked after, before, during and after my shoulder surgery”
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
Cervical Spine Problems in the Context of Upper Limb Presentations
The neck and the shoulder are in close anatomical proximity and are separated by about 4 fingers breadth. It is therefore to be expected that what affects one will always have some implications on the other. The purpose of the clinical examination by a specialist is to try and determine which of the neck and the shoulder is the more dominant contributor to the sum total of the symptoms.
Changes in the cervical spine are universal above the age of 35 to 40. Thus if we were to take MRI scans of patients above this age cut off, a significant proportion of these would have wear and tear changes in the neck. This does not mean that these are causing symptoms and it is the history and physical examination, which determines the extent to which the cervical spine is contributing to the sum total of the picture. The older the patient the more likely the cervical spine is causing problems.
“I consider Mr Yanni to be the ultimate professional with his excellent “bedside manner” and undoubted surgeon’s skills. He repaired my left rotator cuff some 17 years ago with near one hundred percent success. He has recently repaired a bad tear in my right rotator cuff. I am confident that, with his skill, care and attention, I will achieve a similar result this time despite being “17 years less young” ( his words ! ). Many thanks.”
Consequently cervical problems often co-exist with upper limb problems, such as carpal tunnel syndrome, shoulder problems or even elbow problems(via referred pain). Thus if there is compression of the nerve roots as they come out of the neck, these symptoms may mimic carpal tunnel syndrome by causing numbness, tingling and weakness. Equally they may add to the clinical picture and both carpal tunnel and the neck problems can co-exist in the same patient as both are age-related. Just as importantly, the same occurs with shoulder problems. It is not always very easy to decide where the shoulder ends and where the neck begins. The two musculoskeletal areas of the shoulder and the neck are in close anatomical proximity and thus affects one area will have an effect on the other. It is the history ,the physical examination and the imaging which clarify the diagnosis.
In general once it is established that the peripheral problem (for example the carpal tunnel or shoulder problem amongst others) is considered to be the most dominant contributor to the sum total of the symptoms, then the philosophy is to remove that by dealing with that with which we can deal with the more predictably and easily. Once that has been undertaken, post-op review will determine whether or not the neck is responsible for any residual symptoms. Where the neck remains a significant contributor to the sum total of the clinical picture then attention is given to the neck as a first line of treatment and this could involve the support of colleagues in the pain clinic or very infrequently spinal surgery.
Features on history
Enquiry will be focused on two main areas; the first being the amount of pain patients are getting and their range of movement and the second being the amount of compromise that has occurred in the nerves which emerge from the spinal cord and supply the limbs. Patients may describe a neuralgic (toothache like) pain affecting the arm and the shoulder. Dependant on the anatomical distribution of the symptoms important clues can be gained as to which part of the spine is involved.
Features on Examination
Physical examination will consist of examining the musculoskeletal element of the neck to look at the range of movement as well as the neurological element of the upper limb to check on the reflexes, the sensation and the power.
Investigations
Will consist of x-rays and MRI.
Treatment
The purpose of assessing the neck is to determine whether or not it is a lead contributor to the sum total of the symptoms or whether it is the shoulder which is the more dominant contributor. If there are any issues with the neck then this usually involves some physiotherapy to work on posture, stretching and improving the muscle tone around the neck. In very small instances surgery is indicated but the vast majority of patients with problems in the neck do not require it.
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
“Mr Yanni is very personable, professional and diligent. From my initial consultation to my ultimate discharge he dealt with my shoulder treatment with the utmost care, professionalism and diligence. He was also very detailed in his explanations as to what the issue was, what the next steps were and assured me that he would be able to support me to a full recovery. Thank you Mr Yanni.”
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123