Mr Amar Malhas

The acromioclavicular ( AC) joint is located in your shoulder, at the point where the collarbone (clavicle) meets the acromion process of the shoulder blade. The AC joint is used most when you lift your arms above shoulder height or lift a heavy weight.  

AC joint arthritis is a degenerative disease of the AC joint. It is very common and almost everybody who has done any type of contact sport or has fallen off a bike will normally have a degree of arthritis in their collar bone joint.

In the majority of cases, the AC joint itself does not become sore and so it is not a problem people are aware of. In other cases, people can get pain in the AC joint, sometimes quite severe. This tends to be most common in people who are either high-level sportsmen (such as weightlifters) or people who do a lot of work with their arms above their head, like mechanics and roofers.

Symptoms

The main symptom is pain or discomfort, specifically over the AC joint (i.e. at the end of the collarbone). This pain may be fairly mild or quite severe, depending on the extent of the arthritis in the joint. Most people find their pain becomes worse when they lift their arm above their head.

When I see you for a consultation, I will examine your shoulder and move your arm into various positions to help me assess the severity of the problem. I may need to arrange further diagnostic tests for you, such as X-ray, MRI or CT, to confirm diagnosis and to give an accurate view of the extent of your AC joint arthritis.

This consultation is also your chance to ask any questions and raise any concerns you may have. Nobody knows the joint pain you are experiencing better than you, and it is important you tell me the different ways it is affecting you so that I can ensure any treatment options I advise are right for you.

Treatment options

As a shoulder specialist, many of the conditions I treat are a result of trauma or injury to the shoulder. AC joint arthritis is different to most other shoulder conditions, as its not caused by trauma or injury but rather a degenerative disease.

While there is currently no 'cure' for arthritis, there are non-surgical treatment options to help manage the pain and surgical options if needed in more severe cases.

The first treatment I normally suggest is a corticosteroid injection directly into the AC joint. This often relieves the pain significantly and the effects can last a reasonable time.  I would also recommend physiotherapy to work on posture and shoulder strengthening to try and take the pressure off the joint.

If you still have AC joint pain, or the arthritis has progressed to the point where non-surgical treatments are no longer effective, I can carry out a special type of surgery known as arthroscopy to help clear out the joint and relieve the pain you're experiencing.

Arthroscopy is a type of keyhole surgery. Using only tiny cuts into the shoulder, I'll insert a thin tube known as an arthroscope into the joint. The arthroscope has a light and a camera and gives me a really good view of the joint. Once I have assessed the health of the AC joint, I will insert small surgical tools through the arthroscope and shave a few millimeters of the collarbone joint to stop the arthritic surfaces from rubbing. This will help to relieve the pain that was being caused by your arthritis.  

Recovery

Shoulder arthroscopy will usually improve your pain, but it's important to be aware that it will take a good couple of months to fully settle down. The operation itself is carried out as a day case procedure and you will be wearing a sling for a few days afterwards, but other than that, it is important to give the joint time to rest and fully recover. Physiotherapy is important, helping with your recovery and ensuring you don't lose mobility in your shoulder as you recover. We can work with your therapist or provide therapy at Circle.

Why me?

During my training as an orthopaedic surgeon, I developed a particular interest in shoulder and elbow surgery. After my initial training, I completed two year-long fellowships specialising in shoulder and elbow surgery (firstly, at the Glasgow Royal Infirmary and then at the internationally renowned Wrightington Orthopaedic Hospital in its prestigious Upper Limb Unit).

During my years working as a shoulder and elbow specialist, I have been privileged to see the difference good, effective treatment makes to people's lives. For people struggling with AC joint arthritis, it can mean the difference between having to stop their favourite sport or to be able to carry on. It may just mean that getting dressed in the morning is now pain-free.

If you have pain or discomfort in your shoulder, a consultation will help us find out exactly what the problem is. Once we know the cause of your pain, we will be able to talk through treatment options so that you can make an informed decision. It's easy to schedule an appointment with me here at Circle, my private secretary will be delighted to help you book a time and day that is convenient for you.

The rotator cuff refers to a group of tendons and muscles in the shoulder that hold the shoulder ball (head of humerus) firmly in the joint. If you didn't have a rotator cuff, your shoulder would just keep on dislocating, with the humeral head dropping out of the socket; a bit like a golf ball dropping repeatedly off the tee.

The rotator cuff holds the joint in position so that the larger muscles can move the shoulder around as needed. If the rotator cuff is damaged, it can cause weakness and pain when moving the arm as the other muscles have to compensate.  

Why would I need a rotator cuff repair?

Rotator cuff tears become more common as we age. As we get older, our muscles can start to tear, causing instability in the joint. We may notice this first as pain, weakness and the shoulder getting tired very quickly.

As the joint moves abnormally (or “wobbles”), it gets sore. Depending on the size and extent of the rotator cuff tear, the pain you feel may be reasonably mild or severe. Over time, pain in the shoulder can slowly translate to weakness, itself leading to loss of movement in the shoulder and possible arthritis.

Rotator cuff repair surgery is an operation to fix the problem and to get you out of pain.

Smaller tears are easier to fix and have a better outcome than bigger tears, small tears can get bigger with time, so earlier treatment is more effective.

When I see you for a consultation, I will examine your shoulder and carefully move your arm into various positions to help me assess the severity of the problem. I will also usually arrange for you to have an X-ray and ultrasound scan of the shoulder as these are really good ways of identifying rotator cuff tears.

This consultation is also your chance to ask any questions and raise any concerns you may have. Nobody knows the pain and discomfort you are experiencing better than you, and it is important you tell me the different ways it is affecting you so that I can ensure any treatment options I advise are right for you.

Treatment options

As a shoulder specialist, many of the conditions I treat are a result of trauma or injury to the shoulder. Rotator cuff tears are no different, although they can also occur as a result of the aging process.

There are non-surgical treatment options to help manage the pain and a surgical repair option if needed for more painful or extensive tears.

Not all tears will need to be repaired. Some people can compensate and are very happy with their shoulder despite having a tear. Others will struggle and need further treatment. Physiotherapy can be really helpful, although people do sometimes find it is quite painful. We can work with your physiotherapist or our Circle physiotherapists will be able to show you suitable exercises.

Painkillers, such as paracetamol, taken when needed can often help to manage the pain well.

When I think it would be helpful, I may advise you to consider a corticosteroid injection into the shoulder. This often relieves the pain significantly and the effects can last a reasonable time.  Often, this period of relief allows you to really work with the physiotherapists to build up the rest of the shoulder muscles.

If you're still struggling with pain or loss of movement, I can carry out a special type of surgery known as arthroscopy to help repair the tear and relieve the pain you're experiencing.

Arthroscopy is a type of keyhole surgery. Using only tiny cuts into the shoulder, I'll insert a thin tube known as an arthroscope into the joint. The arthroscope has a light and a camera and gives me a really good view of the joint. Once I have assessed the rotator cuff, I will insert small surgical tools through the arthroscope and repair the tear.

Recovery

Shoulder arthroscopy will usually improve your pain, but it's important to be aware that it will take a good couple of months to fully recover from a rotator cuff repair. The operation itself is carried out as a day case procedure and you will be wearing a sling for around three weeks afterwards, but other than that, it is important to give the shoulder time to rest and fully recovery. Most people will feel maximum benefits around 6 months after the surgery, following our structured rehabilitation protocol.

Why me?

I decided fairly early on in my orthopaedic training that I wanted to specialise in treating shoulder and elbow problems. During my years working as a shoulder and elbow specialist, I have been privileged to see the difference good, effective treatment makes to people's lives.

If you have pain or discomfort in your shoulder, a consultation will help us find out exactly what the problem is. Once we know the cause of your pain, we will be able to talk through treatment options so that you can make an informed decision.

It's easy to schedule an appointment with me here at Circle, my private secretary will be delighted to help you book a time and day that is convenient for you.

Your shoulder is a ball and socket joint. I always describe it to people as being like a golf ball on a tee. With this picture in mind, if something causes the shoulder to dislocate, it can damage the lip of the golf tee. This damage can make it more likely that further dislocations will occur in the future as it reduces the stability of the shoulder.

Shoulder stabilisation surgery is carried out in order to repair this 'lip', give the shoulder more structural integrity and reduce the risk of recurrent dislocations.

Why would I need shoulder stabilisation surgery?

There are different types of shoulder dislocation. The classic one, and the one I most often see here at Circle, is the type experienced by many a rugby player. They're involved in a tackle and the impact forces their shoulder to pop out of the socket (dislocation). Other common injuries include falling on the arm from standing or at speed (falls from bikes, horses or while skiing).

Often a quick trip to their nearest A&E will see the joint put back in the right place (reduced). The shoulder will often need to be in a sling for a period of time and physiotherapy is helpful to get the shoulder going.  Once over the initial injury, it is often useful to have the full extent of the damage assessed to choose the right treatment.

Other people can experience instability due to having very mobile joints (called “hyperlaxity”) or subtle instabilities. This can often cause the feeling of the joint dropping out of position (or “subluxing”) and clicking back.

Once you've had a shoulder dislocate, the odds are high that you will have more in the future.

Assessment

Most people come to see me a couple of weeks after their initial dislocation. Current national guidelines advise that all first-time shoulder dislocations should see a shoulder surgeon to assess them. The main question I'm trying to answer at this stage is whether they are likely to re-dislocate or not. To make things more challenging for me(!), most young sporting people have a very high chance of the joint popping out again, although this risk does decrease with age. However, over the age of 45, there is an increased chance of tearing some of the important muscles of the shoulder (called the rotator cuff muscles), so it is important to rule this out.

When I see you for a consultation, I'll talk with you about your previous dislocation to get a good understanding of what caused it and the type of damage you may have to the shoulder. I will also examine your shoulder, carefully moving your arm into various positions to help me assess any pain or weakness in the joint.

I may arrange for you to have additional diagnostic scans like an X-ray, CT or MRI scan if this would help to assess the best treatment options.

Once we know the extent of the damage to your shoulder, we'll be able to talk through treatment options with you. Many people can be successfully treated with physiotherapy alone and I can refer to you for therapy. If surgery would be helpful, I'll explain the procedure and give you all the information you need in order to make an informed choice about whether to have surgery or not.

Shoulder stabilisation surgery

If you have had a number of dislocations, suggesting an inherent weakness in the joint, surgery can be of help and can often be done arthroscopically.

Arthroscopy is a type of keyhole surgery. Using only tiny cuts into the shoulder, I'll insert a thin tube known as an arthroscope into the joint. The arthroscope has a light and a camera and gives me a really good view of the joint. Once I have assessed the joint, I will insert small surgical tools through the arthroscope in order to repair any damage and to help stabilise the joint.  

For people who have severe damage in the shoulder, or have previously had a repair but have dislocated again, a normal or “open operation” may be the best option.

Recovery

The most common question I'm asked by people before this stabilisation surgery is, "how soon can I play rugby again?". Rugby players are 'below shoulder' athletes, as they don't often need to move their arms above their heads. This helps with recovery from shoulder surgery, as the shoulder tends to be at more risk when the arms are raised above shoulder height.

Rugby players tend to be able to return to competitive play around 3 - 6 months after surgery, whereas 'above shoulder' athletes like swimmers and tennis players may need 6 - 9 months. Shoulder stabilisation surgery is said to have a 90% success rate. It can reduce your risk of dislocation to probably about 10% over 10 years, which is a big difference.

Why me?

I decided fairly early on in my orthopaedic training that I wanted to specialise in treating shoulder and elbow problems. During my years working as a shoulder and elbow specialist, I have been privileged to see the difference good, effective treatment makes to people's lives. I have a particular interest in the effective management and treatment of sports injuries, so if you are a keen sportsperson keen to get back to playing again at the highest levels, I can help.

Your initial consultation will help us find out exactly what the problem is. We'll then be able to talk through the treatment options so that you can make an informed decision.

It's easy to schedule an appointment with me here at Circle, my private secretary will be delighted to help you book a time and day that is convenient for you.

Your shoulder is a ball and socket joint. I always liken it to a golf ball sitting on a golf tee.  Holding the ball in the joint is a “sock” or “cuff” of muscles (called the rotator cuff). The job of the rotator cuff is to hold the ball in place so that the bigger muscles (deltoid, pectorals, lat dorsi etc.) can move the shoulder. Above the joint is an arch of bone where the collarbone connects to the shoulder (it's just under the skin and you can feel it on your own shoulder).

In a healthy shoulder, there is enough room for movement of the joint and cuff muscles under the arch of bone without rubbing.  However, if the space is reduced or the muscles are not working well, the muscles can start to rub under the arch, causing pain and discomfort.  In some people, this is due to tightness in the joint itself. In others it is due to the bony arch drooping after many years of loadbearing. There are some people where it is a combination of factors.

Where non-surgical treatments have not been as effective as hoped for, an operation called a subacromial decompression may help to resolve the problem and get you out of pain.

Who?

Shoulder impingement commonly affects people aged 40 - 60. Rather than causing specific areas of pain, it tends to give a more generalised shoulder pain, hard to pinpoint precisely. The pain will often become worse when the arm is lifted above shoulder height or made worse on trying to raise and arm above shoulder height.

These symptoms are fairly common for a number of shoulder conditions, so it's important that other causes of shoulder problems ( e.g. muscle tears, arthritis) are always excluded before any treatment is started.

When I see you for a consultation, I will examine your shoulder and carefully move your arm into various positions to help me assess the severity of the problem and to see where it is most painful. I may arrange for you to have additional diagnostic tests, such as an X-ray, ultrasound, MRI or CT scan of the shoulder if they would help with the diagnosis.

This consultation is also your chance to ask any questions and raise any concerns you may have. Nobody knows the joint pain you are experiencing better than you, and it is important you tell me the different ways it is affecting you so that I can ensure any treatment options I advise are right for you.

Treatment

The good news is that physiotherapy is really effective in the majority of cases and will often be all that is needed. Many people have a degree of tightness within the shoulder that settles with stretching and muscle strengthening exercises. We can liaise with your physiotherapist or provide therapy at Circle. Only a few patients will need to have surgery.

Should physiotherapy not be as effective as hoped, I can give a corticosteroid injection directly into the shoulder joint. This often relieves the pain very quickly and the effects can last a reasonable time.

If you still have shoulder pain, I can carry out a subacromial decompression to widen the space around the rotator cuff so that it no longer rubs or catches on nearby tissues or bone. People who have developed a tight space between the bony arch and the muscles tend to be those that do not respond to therapy.

Arthroscopy is a type of keyhole surgery. Using only tiny cuts into the shoulder, I'll insert a thin tube known as an arthroscope into the joint. The arthroscope has a light and a camera and gives me a really good view of the joint. Once I have assessed things, I will insert small surgical tools through the arthroscope and carry out the decompression. This will stop your shoulder pain.

Recovery

Subacromial decompression will usually improve your pain, but it's important to be aware that it will take time to fully settle down and for you to feel the full benefits.

The operation itself is carried out as a day case procedure and you will be wearing a sling for a few days afterwards, but other than that, it is important to give the joint time to rest and fully recovery. The Circle physiotherapy team can also help with your recovery and to ensure you don't lose mobility in your shoulder during your recovery.

Of course, if you have any queries or concerns during your recovery, it's easy to contact me here at Circle and I am always happy to help.

Why me?

I decided fairly early on in my orthopaedic training that I wanted to specialise in treating shoulder and elbow problems. During my years working as a shoulder and elbow specialist, I have been privileged to see the difference good, effective treatment makes to people's lives. Although not a commonly known procedure to most people, a subacromial decompression can be a very helpful operation for the small number of people who don't improve with physiotherapy and/or corticosteroid injections.

Your initial consultation will help us find out exactly what the problem is. We'll then be able to talk through the treatment options so that you can make an informed decision.

It's easy to schedule an appointment with me here at Circle, my private secretary will be delighted to help you book a time and day that is convenient for you.