The shoulder joint is designed to give a large amount of movement to enable us to swing and throw with relative ease and with great force. It is often described as a golf ball on a tee peg and is a ball and socket joint, with the ball much larger than the socket. This results in greater mobility but the price to pay for greater flexibility is reduced stability. Therefore support from the ligaments and muscles is essential. Connecting the shoulder girdle to the trunk is the acromioclavicular joint, which is a relatively rigid joint. Around the shoulder joint lies a group of muscles known as the rotator cuff which moves the shoulder up against gravity.

The golf swing requires the shoulder to go through a wide range of motion, which is usually more than 90 degrees. At the top of the backswing, the leading shoulder (left shoulder for a right hander) is turned towards your body while the trailing shoulder is turned away. As the golf swing progresses, the two shoulders rotate and swap position. The golf swing is thus very demanding on the shoulders and factor in 250 to 300 swings per game and you can appreciate that shoulder injuries are usually from overuse. The leading shoulder is more commonly injured with the acromioclavicular joint accounting for 50% of the cases. Many of these injuries are a result of sprains and strains, which recovers with adequate rest and appropriate treatment. This treatment usually involves anti-inflammatory medication and physiotherapy. Appropriate and adequate stretching as well as proper golfing technique can go a long way in preventing injuries from occurring. The common shoulder problems related to golfing injuries encountered in our daily practice include

AC joint

1. Acromioclavicular joint strain and arthritis.

2. Subacromial impingement

3. Shoulder instability

4. Rotator-cuff tear

Subacromion

Arthroscopic Shoulder Surgery

Arthroscopy has revolutionized the treatment of these shoulder problems. Most primary procedures are suitable for keyhole surgery and the shoulder joint is one of the commonest joints where arthroscopic procedures are performed. Advantages of the arthroscopic method include less tissue damage, less blood loss, less post-surgery pain, being done as day case surgery with shorter period of time off work, better cosmesis and less stiffness.

Shoulder Key Hole Procedure

Acromioclavicular Joint Arthritis and Arthroscopic Decompression of AC Joint

The acromioclavicular joint or ACJ is situated at the outer end of the collarbone. As the ACJ is relatively stiff, it is subjected to high forces. This result in overuse injury and may progress to ACJ arthritis. A typical presentation is a sharp pain over the bump of the golfer’s left shoulder at the top of his back swing, with almost immediate relief upon lowering the arm. Treatment includes anti-inflammatory medication, physiotherapy and steroid injection into the joint. Swing modifications include shorter backswing and recruiting the pectoralis and latissimus dorsi in the downswing.

In advanced arthritis, surgical decompression of the joint will bring relief to the golfer. The surgery done through keyholes, involves shaving 1 to 1.5 centimeters of the outer end of the collarbone.

Subacromial Impingement and Arthroscopic Subacromial Decompression

The subacromial area lies between the top of the humerus and acromion. A muscle and bursa lies between the humerus and the acromion. With certain positions these structures can become pinched and inflamed. The pain that you have been experiencing is caused by this pinching and is typically felt on movements such as reaching and putting your arm into a jacket sleeve. The golfer experiences pain when the trailing shoulder is at the end of the backswing. A shorter and flatter swing can help moderate the pain.

If medication and physiotherapy fail to eliminate the pain, surgical decompression is necessary. The operation is done by ‘key hole surgery’; usually through two 5mm puncture wounds. It involves shaving away part of the acromion bone. This increases the size of the subacromial area and reduces the pressure on the muscle and bursa allowing them to heal.

Burring the hook with an arthroscopic burr

x-ray showing a hooked acromion

Shoulder Instability and Arthroscopic Stabilisation Of The Unstable Shoulder

Instability of the shoulder joint frequently results from previous trauma unrelated to golf. The golfer may feel that the shoulder is loose or weak at the extreme point of shoulder motion. Physiotherapy where the rotator cuff muscles are strengthened can help stabilize the joint. If instability persists after physiotherapy, surgical stabilization will be necessary. For the past two decades, open repair is the standard surgical procedure for failed conservative management of shoulder instability. With the advent of key-hole surgery, repair of the torn ligaments had been performed arthroscopically using Suture anchors.

Torn shoulder ligament Repaired ligament

Rotator Cuff Tear and Arthroscopic Rotator Cuff Repair

The rotator cuff consists of four muscles and their tendons. These surround the ball of the shoulder joint. The muscles fine tune the movements of the shoulder joint and assist other large muscles in moving the arm. The tendons run under the acromion (part of the shoulder blade) where they are very vulnerable to being damaged. This can lead to a tear resulting in a painful, weak shoulder.

Not all rotator cuff tears can be treated arthroscopically. Large tears, which cannot be mobilized sufficiently to its insertion, should be treated with open technique. Smaller tears of less than 1.5 cm retraction are the ideal candidates for arthroscopic repair. The technique and equipments used is similar to that for arthroscopic shoulder stabilisation with the use of suture anchors.

Conclusion

With the development of better implants and techniques, arthroscopic surgery has revolutionized the management of shoulder injuries. Results of treatment are similar and in certain instances, superior to open procedures, enabling the patient to return to normal function early. Many professional sportsmen and women are able to resume training within one to two weeks of an arthroscopic procedure. Good post surgery physiotherapy is essential and gradual return to training is important to protect any reconstruction.

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