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Shoulder Problems

Cartilage problems

Damaged cartilage

Overview:

The ends of bones join up to form joints. The glenoid of the scapula joins the humeral head to form the glenohumeral joint. In the same way the clavicle joins up with the acromion process to forms the acromioclavicular joint and in the elbow joint it is the distal humerus that joins with the radius head and the ulna proximal end to form the elbow joint.

Joint surfaces are covered with firm, smooth particular cartilage. Healthy cartilage absorbs shock, protects the underlying bone and allows for smooth movement with nearly no friction. Damage to the articular cartilage can occur through the different types of arthritis on a biological basis or through trauma that takes place over the joint on a mechanical basis.

Causes

Osteo-arthritis and rheumatoid arthritis is two of the most common conditions that can damage cartilage. The impact of trauma over a joint can break loose pieces of cartilage with or without bone.

These types of injuries can take place during contact sports, accidents or fall from heights. The shock absorbing properties of the cartilage is exceeded and a tear type of injury takes place in the cartilage. This type of damage is usually limited to a specific area of the joint whereas arthritic type of lesions is wide spread damage to the articular cartilage.

Symptoms

It includes a vague, continuous pain and can progress to an acute pain, joint stiffness, swelling and limited range of motion.

Classification

Classification of cartilage damage is based on the degree of cartilage thinning, the appearance of the cartilage as well as the distribution of involvement of the cartilage.

Treatment

Treatment for non-arthritic cartilage damage depends on the area of the injury, the size thereof and the degree of injury. Analgesics, rest, anti-inflammatory medication and immobilisation is used in the early stages. Rehabilitation in the form of exercises to promote range of motion and strength around the joint is employed for the more chronic cases.

Removal of loose pieces of cartilage and surgically smoothening of unstable cartilage edges with a release of the joint capsule is some times performed in the later stages of the condition. In advanced cases the joint surfaces can be replaced.

Download Damaged cartilage document.

Loose bodies

Overview:

The ends of bones that make out the different joints in the body is covered with firm smooth tissue called cartilage. The humerus head and the glenoid join to form the shoulder joint and the distal end of the humerus and the proximal ulna and radius form the elbow joint. Articular cartilage absorb shock, allow for smooth movement and protects the underlying bone. When joint cartilage is damaged due to arthritis or small pieces break off due to trauma these pieces move freely around the joint and receives its nutrition through joint fluid. Small pieces of bone can come loose with the cartilage and especially during mechanical injury of the joint. These loose pieces that float around in the joint are called loose bodies.

Causes

Injury to or gradual degeneration of cartilage from arthritis causes small pieces to break off from the cartilage surface. Another source of loose bodies can be osteophytes that break loose and drift around in the joint. Osteophytes is bony outgrowth on the edges of the joint that occurs as a result of osteo-arthritis. Cells which become active during osteo-arthritis and are responsible for imflammatory reaction in the bone causes new bone to be deposited of the edges on the joint that eventually becomes osteophytes.

These types of injuries can take place during contact sports, accidents or fall from heights. The shock absorbing properties of the cartilage is exceeded and a tear type of injury takes place in the cartilage. This type of damage is usually limited to a specific area of the joint whereas arthritic type of lesions is wide spread damage to the articular cartilage.

Bone and cartilage fragments can also break loose where there is blood supply to the subcondral bone (osteo condritis desicants). Connective tissue structures that developed during bleeding in the joint or damage to soft tissue in the joint can also cause loose bodies.

Symptoms

Most loose bodies do not cause symptoms. When they do it is usually acute sharp pain that is experienced during episodes of locking or clicking of the joint and there is also a feeling of instability of the joint. Swelling of the joint can occur due to the irritating nature of these loose bodies. A grating feeling called crepitis may be felt of heard during joint movement.

Classification

Loose bodies are classified by what they consist of, whether they are free in the joint or whether they are partially attached to the surrounding soft tissue. There are cartliginous loose bodies from cartilage, fibris loose bodies from connective tissue origin and osteocondral loose bodies that contains bone and cartilage. Some cartilage loose bodies can calcify and like osteochondral loose bodies be visible on x-rays. Stable loose bodies are usually attached to the synovial membrane.

Treatment

Loose bodies that causes symptoms must usually be removed. Smaller loose bodies can be removed by arthroscopic techniques through grabbing instruments or suction where with larger loose bodies a small incision will be necessary. Loose bodies can also be removed by burring or breaking it up in smaller pieces. In some cases where large enough pieces brake loose from previously normal joint surfaces these loose bodies can be re-attached in their original position through surgery.

Download Loose bodies document.

Osteo-arthritis

Overview:

The bone ends that constitute a joint are covered with a firm smooth cartilage. In the shoulder joint it involves a humeral head and glenoid process. At the acromioclavicular joint it involves the lateral end of the clavical and the acromion process and at the elbow it involves the distal humerus and the proximal end of the radius and ulna. The articular cartilage eliminates friction nearly completely, protects the underlying cartilage against damage and allows for smooth sliding motion between bone ends. Wear and tear of the articular cartilage leads to osteo-arthritis also called degenerative arthritis. This is the most common type of arthritis that occurs in the shoulder and elbow.

Causes

The process of osteo-arthritis takes place over time. It might be caused by wear and tear over a period of years, repeated strain on the joint, previous injuries, mal-alignment, metabolic defects or genetic conditions. In weight-bearing joints being overweight also plays a part. Osteo-arthritis in shoulder and elbow is more common in patients over 50 years of age but younger patients can develop this after dislocation of the joint or in people with a genetic tendency to develop osteo- arthritis.

Symptoms

It causes a dull aching pain that alternates with acute pain episodes, stiffness and swelling of the joint and limited range of motion. Bony outgrowth or osteofytes develop over time together with gradual erosion of the articular cartilage. It may cause symptoms in the soft tissue like swelling or stiffness. Pain is typically centered over the posterior aspect of the shoulder and elbow but in the acromio-clavicular joint it is usually on top or in front of the shoulder. Osteo-arthritis can occur simutaniously in joints lying close together like the acromio-clavicular and glenohumeral joints.

Classification

When no specific cause can be identified or when it occurs due to genetic or metabolic factors it is called primary osteo-arthritis. In the case of trauma with an underlying defect of the cartilage or bone, secondary osteo-arthritis will develop. Specific diseases of cartilage can also influence the classification.

Treatment

Pain relief and improvement of function is the aim of treatment. Analgesic medication, anti-imflammatory medication and adjustment of physical activities are first line of treatment. Exercises to improve range of motion and to strenghten of surrounding muscle groups might be of help.

Surgical debridement might be indicated for patients that are not candicates for more extensive surgery.

Severe acromio-clavicular joint involvement may require complete removal of the acromio- clavicular joint which will lead to development of scar tissue in place of the diseased joint. For advanced osteo-arthritis of the glenohumeral joint replacement of the humeral head and glenoid provides good pain relief. Joint replacement of the elbow is performed less often.

Download Osteo-arthritis document.

 

More info: http://orthoinfo.aaos.org/topic.cfm?topic=A00222