Upper Limb Degenerations
Shoulder Degenerations
Rotator cuff Degeneration
The Rotator Cuff is a group of muscles and their tendons which lie over the top of the shoulder joint and contribute to lifting the arm. While there are several muscles in this group the most commonly affected structure is the tendon of the supraspinatous muscle. Typically it is this tendon which is gradually damaged before finally tearing, partially or completely.
This tendon can degenerate in one of three ways:
- It can be gradually damaged by a repetitive strain of the tendon as a result of the way the arm is used, either during an occupational or sporting activity.
- It can occur as a result of the bone on the under surface of the acromion becoming arthritic and irregular. This damaged area then rubs on a portion of the tendon as it moves backward and forward during movement of the arm.
- It can occur in older individuals as a result of a gradual impairment of its blood supply causing it to atrophy and break down.
While one or more of the tendons of the Rotator Cuff degenerates the shoulder may become painful, both at rest and during movement. Typically, the pain occurs while moving the arm, which limits its use. In addition, some grating may be experienced in the shoulder as the arm is used.
The ‘painful arc syndrome’ is the classical picture of a damaged rotator cuff . This is demonstrated when the arm initially moves freely outward for a few degrees but then the shoulder becomes painful as the arm comes up to the level of the shoulder, only to subside again as the arm is raised further. This is due to the damaged portion of the tendon passing under the acromion process which rubs on it for a portion of its length, causing the discomfort.
In the early stages the painful Rotator Cuff can be treated with effect using analgesics and physiotherapy. In addition, when the tendon is still intact, an injection of a steroid solution into the joint can be very helpful.
If this is not feasible and/or the tendon is shown to be ruptured surgery is usually the only effective course if it is causing functional impairment. This can be done as either an open or an arthroscopic procedure through a minimally invasive approach. During this procedure it is usual to repair the injured or ruptured tendon, if possible, as well as performing an ‘acromioplasty’ (smoothing of the irregular under surface of the acromion. If the tear of the subscapularis tendon is found to be irreparable there is a technique to transfer the tendon of the nearby Pectoralis major muscle, although tissue engineering techniques are being investigated for these types of injury.
Calcification of the supraspinatous tendon (Calcific Tendonitis)
In a relatively small number of people calcification occurs within the tendon of the supraspinatus tendon and occurs predominantly among middle-aged women. The condition is frequently associated with degeneration of the supraspinatous tendon (degenerative calcific tendonitis) but in others there is no degeneration and the underlying cause of the condition is unknown.
In some the calcification may be symptomless but in others the condition is associated with pain which, at times, is excruciatingly severe and accompanied by marked loss of function of the affected shoulder. Clinically the condition can be mistaken for other degenerative conditions of the shoulder but a radiograph or MRI scan is usually diagnostic.
In many people the pain and disability as well as the calcification will settle spontaneously, although physiotherapy and anti-inflammatory tablets can be very helpful. If the pain and disability is severe a local injection of a steroid solution into the calcification can bring about a rapid improvement. Similarly transcutaneous shock-wave therapy can help to break down the calcification and bring about an early resolution of the problem. For people with severe pain surgical decompression with physical removal of the calcific deposit can also relieve the condition.
Upper Arm Degenerations
Rupture of the biceps tendons
The biceps muscle lies in the front of the arm. Generally only two of its three tendons may rupture – the one attatched near to the shoulder (the long head of biceps) and the one attached to the radius bone near the elbow . Rupture of these tendons is not a common injury. They occur most commonly in men. Smoking and steroid medication are predisposing factors, as are shoulder conditions. The rupture of one of these tendons usually with a ‘pop’ during lifting a heavy weight and is accompanied by pain and weakness of the arm, particularly with rupture of the distal bicipital tendon. The biceps muscle bulges when trying to bend the elbow, giving the characteristic ‘Poppye’ sign. Over the next few days bruising and swelling in the upper or lower arm may occur.
Rupture of the long head of biceps usually results in only a relatively small loss of function and, as it usually occurs in the elderly man who may accept a mild functional incapacity, the affected individual may accept the condition and not wish surgery. Rupture of the distal tendon (near the elbow) often results in a much greater loss of function and often occurs in a younger man. If this is the case there is generally a much greater indication and desire for surgery to fix the torn tendon to the relevant bone although it is unlikely that the arm will ever regain its full, pre-injury strength.
Degenerations in the Hand
Dupuytren’s contracture
The skin of the palm of the hand is a very specialised structure to compensate for the large shearing forces which act upon it when the hand holds various items. If the skin were lax, as in other parts of the body, it could stretch during grip and the item slip out of the hand. To prevent this the skin in the palm is attached to a strong sheet of fibrous fascia, the palmer fascia, which underlies the skin in the palm and is attached by fibrous strips to the bones of the hand.
Occasionally this normally pliable sheet of fibrous tissue develops a thickening in line with
one or more of the rays of the hand. This thickening may take several years to develop but as it does so it contracts and shrinks causing puckering of the skin along its length. If this contracture crosses into a finger it will cause it to be pulled slowly into the palm, which will ultimately cause a functional impairment of the hand.
This condition is more common in males and is found almost exclusively in Caucasian people originating in the Northern hemisphere. It is common for the condition to run in families and usually arises with no obvious precipitating event. Some factors, however, are associated with the condition and may contribute to its onset. These include diabetes, smoking, excessive alcohol ingestion, epilepsy.
The only effective treatment is surgical. During the procedure the thickened tissue under the skin is excised, along with its extensions into the finger. Mostly the results of this operation are satisfactory but problems can arise. The nerves to the finger are often tied up in the thickened tissue and can be injured during the operation. In this event an area of numbness in the finger can result. Occasionally there can be problems with healing of the wound. As an infrequent event, the contracture can recur. In these instances further surgery may be necessary.
Ganglion cysts
Ganglions are benign fluid filled cysts arising in association with tendons and joints, particularly around the wrist. The cause for these cysts is not clear but it is felt that, in some cases, herniation of the lining membrane from the joint is responsible. This possibly occurs following a localised injury to the joint capsule.
The cyst often varies in size. This, in itself, is not serious. Problems, however, can arise from the pressure effects such a swelling on the surrounding tissues and it is usually these which prompt people to seek medical attention. As the cyst increases in size it can become painful. A large tense cyst can interfere with the movement of an associated joint. Occasionally pressure of the cyst on a nerve can cause neurological symptoms.
Ganglion cysts can be injected with various sclerosing substances, after removal of the fluid, but this technique is associated with a relatively high rate of recurrence. The rate of recurrence is much lower with surgical excision and, while there is a small chance of damage to the small nerves in the skin in the area, this is considered the best form of treatment for this condition.