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Sternoclavicular Joint Problems

A Patient’s Guide to Sternoclavicular Joint Problems

Introduction

The sternoclavicular (SC) joint is important because it helps support the shoulder. The SC joint links the bones of the arms and shoulder to the vertical skeleton.

Most SC joint problems are relatively minor. However, certain types of injuries require immediate medical attention.

This document will help you understand

what the SC joint is
what kinds of problems can develop at the SC joint
what treatments are available

Anatomy

What does the SC joint look like?

The SC joint connects your clavicle (collarbone) to your sternum, which is the large bone down the middle of your chest. This attachment is the only bony joint linking the bones of the arm and shoulder to the main part of the skeleton.

Like most joints, the SC joint is made up of two bones covered with a material called articular cartilage. Articular cartilage is a white, smooth material that covers the ends of bones in a joint. Articular cartilage allows the bones of a joint to rub together without much friction.

Only a small section of the SC joint actually connects to the sternum. This makes the bony connection somewhat unstable. However, extra ligaments cross the SC joint to give it more stability. Ligaments attach bones to other bones.

It seems like this construction would make SC joint dislocation common, but a dislocation is actually very rare. The ligaments surrounding the SC joint are extremely strong. These ligaments are very effective at preventing dislocations. Four different types of ligaments hold the joint in place.

The intra-articular disc ligament attaches to the first rib and divides the joint into two separate spaces. This ligament is very thick and fibrous.
The costoclavicular ligament is short and strong. It attaches underneath the clavicle to the first rib just below. It helps steady the SC joint during certain motions.
The interclavicular ligament supports the ends of both clavicle bones near the SC joint. It passes over the top of the sternum, connecting one clavicle to the other.
The capsular ligament reinforces the capsule that surrounds the SC joint. This ligament keeps the sternum end of the clavicle from pointing up as the other end of the clavicle drops down.

A part of the clavicle called the physis does not turn into bone until you are about 25 years old. The physis is a section of cartilage near the end of the clavicle. Bone growth occurs at a physis, which is also called a growth plate. Between age 20 and 25, the cartilage physis fuses into bone. Injuries to the physis in people under 25 may look like an SC joint dislocation. But sometimes the injury is actually a fracture through the growth plate.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

What causes SC joint injuries?

The SC joint is one of the least commonly dislocated joints in the body. Car accidents cause nearly half of all SC dislocations. Sports injuries cause about 20 percent. Falls and other types of accidents cause the rest. These sorts of traumatic injuries can also cause injuries to the physis in people under 25 years old.

Indirect force causes most injuries to the SC joint. Indirect force involves something hitting the shoulder very hard. The shoulder is pushed in and rolled either forward or backward, affecting the SC joint.

When the SC joint is dislocated, it is usually an anterior dislocation. This means that the clavicle is pushed forward, in front of the sternum. Dislocating in the opposite direction is less common because the ligaments on the back side of the joint are so strong.

Direct force against the front of the clavicle can push the end of the clavicle behind the sternum, into the area between the lungs. This is called a posterior dislocation. It takes a lot of force to cause a posterior dislocation due to the strength of the ligaments behind the joint.

Posterior dislocations can be very dangerous, because the area behind the sternum contains vital organs and tissues. The heart and its large vessels, the trachea, the esophagus, and lymph nodes can all be seriously damaged in a posterior dislocation of the SC joint. This can cause life-threatening injuries to the heart and lungs. Immediate medical help is required to get the SC joint back into position after a posterior dislocation.

Symptoms

What does an SC joint injury feel like?

Different SC joint problems have different symptoms.

Dislocation

You will know immediately if your SC joint has dislocated. Dislocation causes severe pain that gets worse with any arm movements.In anterior dislocation, the end of the clavicle juts out near the sternum. This causes a hard bump in the middle of the chest. In posterior dislocation, a bump is usually not obvious. The joint will feel different to your doctor. Posterior dislocations can cause difficulty breathing, shortness of breath, or a feeling of choking. Some patients have trouble swallowing or have a tight feeling in their throats.

Sprains

Sometimes force may only sprain the SC joint. Mild sprains cause pain, but the joint is still stable. In moderate sprains, the joint becomes unstable.

Ligament Injury

In rare cases, patients have a stable joint but a painful clicking, grating, or popping feeling. This indicates an injury to the intra-articular disc ligament. This type of injury causes pain and problems moving the SC joint.

Degenerative Arthritis

Osteoarthritis is a type of degenerative arthritis that tends to get worse with age. Injury to a joint can result in the development of osteoarthritis. Osteoarthritis eventually causes pain and stiffness. Usually these symptoms go away with anti-inflammatory medications, rest, and heat. If the symptoms last for six to 12 months, some type of surgical treatment may eventually be needed.

Diagnosis

What tests will my doctor run?

Diagnosis begins with a complete history and physical examination. Usually the doctor is suspicious of an injury to the SC joint when there is pain and swelling over the joint. The joint may look deformed.

You will need to get an X-ray. Special X-rays can show your doctor both the clavicles and SC joints. Your doctor may also want to get a computerized tomography (CT) scan. CT scans show bones and soft tissues such as ligaments and tendons. CT scans are more precise than X-rays. They can help your doctor more clearly see the problem in your SC joint.

Treatment

What treatment options are available?

Nonsurgical Treatment

The treatment your doctor recommends will depend on the type of injury to your joint.

Sprains

A mild sprain usually gets better by resting the joint for two to three days. Ice packs can be placed on the sore joint for 15 minutes at a time during the first few days after the injury.

Moderate sprains may require some help to get the joint back into position. A figure-eight strap wraps around both shoulders to support the SC joint. Patients with a moderate sprain may need to wear this type of strap for four to six weeks. The strap protects the joint from another injury and lets the injured ligaments heal and become strong again.

Anterior Dislocation

Doctors have different ways of treating anterior dislocation. Some feel that surgery is needed when the dislocation is severe. Most doctors treat the anterior dislocation by letting it heal where it is or by performing a closed reduction.

Closed reduction involves pulling, pushing, and moving the clavicle until it pops back into joint. It can be very painful. Most patients are given general anesthesia before the procedure, or at least some form of muscle relaxant. The intense pain and muscle spasms caused by the dislocation can make reduction almost impossible without some form of anesthesia.

After closed reduction for anterior dislocation, your SC joint will need to be held perfectly still. Moving the SC joint will cause pain and may even dislocate the joint again. Your doctor will probably recommend that you take pain medication and wear a figure-eight strap for at least six weeks.

Posterior Dislocation

If your doctor suspects posterior dislocation, you will need to have a complete physical examination right away. A series of X-rays and CT scans will be needed. It is important that your doctor have as much information as possible about what organs may be affected by the dislocation.

Doctors almost always use closed reduction to treat posterior dislocations. This requires general anesthesia, because of the pain and muscle spasms. The most common type of closed reduction involves lying on your back, with your dislocated joint near the edge of the table. The arm is pulled out and then brought back into place. You can usually hear the clavicle pop back into joint. Sometimes doctors need to grab the clavicle and pull it out from behind the sternum. If this doesn’t work, a special kind of clip is used to pull the clavicle out.

A figure-eight strap is used for at least six weeks after closed reduction for a posterior dislocation of the SC joint.

Sometimes closed reduction for a posterior dislocation does not work, or SC joint problems become chronic. In these cases, adult patients may need surgery. The risk of harm to your heart, lungs, and other organs behind the sternum is too high. Posterior dislocation has been known to cause a ruptured esophagus, laceration of major veins, and pressure on major arteries, among other complications. These problems can kill you. Posterior dislocation has also been known to cause hoarseness, a sudden onset of snoring, and voice changes with arm movement.

Most of the time the goal of surgery is to stabilize the SC joint. When the ligaments are too severely damaged, the clavicle is surgically attached to the rib instead of the sternum. The joint will still probably be unstable, but the displaced clavicle no longer compresses the organs behind the sternum.

Growth Plate Injuries

Injuries to the growth plate of the clavicle usually heal without treatment. (As mentioned earlier, the growth plate is a section of cartilage near the end of the clavicle where bone growth occurs.) Only rare cases require surgery. In younger children, the growth of the bone will remodel the fractured bone. Remodeling actually causes the collarbone to straighten as the child grows. In young adults, there is less of this straightening effect because their bone growth is nearly complete.

Osteoarthritis

Osteoarthritis of the SC joint usually responds to treatments such as rest, ice, physical or occupational therapy, and anti-inflammatory medications. If the symptoms of osteoarthritis do not respond to basic treatment over six to 12 months, surgery may be needed.

Surgery

If nonsurgical measures fail to relieve your pain, you may need surgery.

Resection Arthroplasty

The most common procedure for SC joint osteoarthritis is resection arthroplasty. A resection arthroplasty involves removing the surface of the clavicle next to the sternum. This keeps the arthritic bone surfaces from rubbing on one another. The remaining end of the clavicle eventually attaches to the rib with scar tissue. This stops the end of the clavicle from moving around when you move your arm.

Graft Method

Your surgeon will try to keep from disturbing the ligaments around the SC joint. But if the ligaments are damaged and loose, a tendon graft may be used to tighten the connection between the end of the clavicle and the first rib. Surgeons use a piece of tendon taken from the wrist or a piece of fascia taken from the thigh. These are referred to as tendon grafts or fascia grafts. The graft is then sewn through the end of clavicle and connected to the first rib.

Surgeons prefer not to use metal pins or wire to fix an unstable SC joint. These implants could puncture the vital organs behind the SC joint.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

If you don’t need surgery, you should start range-of-motion exercises as pain eases, followed by a program of strengthening. At first, exercises are done with the arm below shoulder level. The program advances to include strength exercises for the rotator cuff and shoulder blade muscles. The goal is to get your shoulder moving smoothly. Your physical or occupational therapist will give you tips on controlling your symptoms, which may include using tape to help hold the SC joint in place. You will probably progress to a home program within four to six weeks.

After Surgery

Your surgeon may have you wear a sling to support and protect the shoulder for a few days. A physical or occupational therapist will probably direct your recovery program. The first few therapy treatments will focus on controlling the pain and swelling from surgery. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy can progress safely and quickly after a simple arthroscopic resection. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You need to avoid doing too much, too quickly.

Therapy goes slower after surgeries that require a tissue graft. Your arm is usually placed in a sling to prevent shoulder movement for several weeks. After this time, you’ll begin with passive exercises. During passive exercises, the shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy starts four to six weeks after graft surgery. Active range-of-motion exercises help you regain shoulder movement using your own muscle power. You might begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing joint.

At about six weeks, you will start more active strengthening. These exercises focus on improving strength and control of the rotator cuff muscles and the muscles around the shoulder blade.

Some of the exercises you’ll do are designed to get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Snapping Scapula Syndrome

A Patient’s Guide to Snapping Scapula Syndrome

Introduction

The scapulothoracic joint is located where the shoulder blade (also called the scapula) glides along the chest wall (the thorax). When movement of this joint causes feelings or sounds of grating, grinding, popping, or thumping, doctors call it snapping scapula syndrome.

Snapping scapula syndrome is fairly rare. When it happens, the soft tissues between the scapula and the chest wall are thick, irritated, or inflamed. Snapping scapula syndrome can also happen if the bones of the shoulder blade or rib cage grate over one another.

This guide will help you understand

what causes snapping scapula syndrome
how doctors treat this condition

Anatomy

What parts of the body are involved in this condition?

The shoulder is made up of three bones: the humerus (upper arm bone), the clavicle (collarbone), and the scapula (shoulder blade). Two large muscles attach to the front part of the scapula where it rests against the chest wall. One of them, called the subscapularis muscle, attaches over the front of the scapula where it faces the chest wall. The serratus anterior muscle attaches along the edge of the scapula nearest the spine. It passes in front of the scapula, wraps around the chest wall, and connects to the ribs on the front part of the chest.

A bursa is a fluid-filled sac that cushions body tissues from friction. A bursa sits between the two muscles of the scapula. There is also a bursa in the space between the serratus anterior muscle and the chest wall. When bursa sacs become inflamed, the condition is called bursitis.

Scapulothoracic bursitis refers to inflammation in the bursa under the shoulder blade. This type of bursitis is most common in the upper corner of the scapula nearest the spine. It also occurs under the lower tip of the scapula. In either case, it can cause the sounds and sensations of snapping scapula syndrome. A person can have bursitis in the joint without any grinding or popping.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

What causes this condition?

Snapping scapula is caused by problems in the soft tissues or bones of the scapula and chest wall. It can start when the tissues between the scapula and shoulder blade thicken from inflammation. The inflammation is usually caused by repetitive movements. Certain motions of the shoulder done over and over again, such as the movements of pitching baseballs or hanging wallpaper, can cause the tissues of the joint to become inflamed.

In other cases, the muscles under the scapula have shrunk (atrophied) from weakness or inactivity. The scapula bone then rides more closely to the rib cage. This means the scapula bumps or rubs on the rib bones during movement.

Changes in the alignment or contour of the bones of the scapulothoracic joint can also cause snapping scapula. When a fractured rib or scapula isn’t lined up just right, it can cause a bumpy ridge that produces the characteristic grind or snap as the scapula moves over the chest wall.

Grinding and snapping can also happen if there are any abnormal curves, bumps, or ledges on the upper edge of the scapula closer to the center of the back. (These abnormalities are called Luschka’s tubercles.) Any time there is an abnormality in the bone, one of the body’s possible responses is to form a bursa. The new bursa may then become inflamed, causing the symptoms of bursitis.

Symptoms

What symptoms does snapping scapula cause?

Grating, grinding, or snapping may be heard or felt along the edge or undersurface of the scapula as it moves along the chest wall. These grinding sensations are also called crepitus. Sometimes the joint pops or thumps during movement. Often, these sensations cause no pain.

Scapulothoracic bursitis, on the other hand, is painful whether or not there is any crepitus in the joint. The sore bursa is usually tender to the touch, and the tissue in the sore area often feels thick.

Diagnosis

What tests will the doctor run?

Your doctor will ask many questions about your medical history. The goal is to find out if you’ve had similar problems in the past, if you’ve injured your scapula, and if any of your activities require repetitive shoulder movements.

Your doctor will also do a physical exam. He or she will check the alignment of the scapula. Your doctor may listen with a stethoscope while you move your shoulder and scapula. You may feel pain as you move, but it is important that your doctor knows exactly where your problem is coming from. By feeling the tissues around the scapula, your doctor can find out if the bursa is tender or thickened from inflammation.

Your doctor may order an X-ray to see between the scapula and rib cage. An X-ray image can show abnormalities in the bone, such as a rib or scapular fracture. In cases where there may be a problem with the bones, your doctor may order a computed tomography (CT) scan to get a more detailed look. If bursitis is suspected, a magnetic resonance imaging (MRI) may be used to locate the bursa and see how big it is. MRI scans use magnetic waves to show the soft tissues of the body in slices.

Treatment

What treatment options are available?

Nonsurgical Treatment

Most doctors prescribe nonsurgical treatments for patients with snapping scapula. These types of treatments are generally successful, especially when the problem is coming from soft tissues. Doctors may start by prescribing nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen. Rest and ice also help reduce inflammation and ease pain. Some patients benefit by working with a physical or occupational therapist.

If pain and inflammation don’t go away with these treatments, your doctor may recommend one or two injections of cortisone into the bursa. Cortisone is a steroid that effectively reduces inflammation.

Surgery

Doctors usually recommend surgery only if nonsurgical treatments have failed. Surgery may be needed if the problem is caused by a bone abnormality. In the most common surgery for snapping scapula, the surgeon takes out a small piece of the upper corner of the scapula nearest to the spine.

Bone Resection

To remove a small piece of the scapula, an incision is made just below the bone’s top edge. The surgeon pulls aside the tissues to show the prominent section of the bone, called the spine of the scapula. The tissues that attach muscles to the upper part of the scapula are carefully detached and moved out of the way. Then the surgeon uses a special tool to remove the corner of the scapula. Drill holes are made into the spine of the scapula. Then the ends of the upper scapular muscles are sewn back onto the spine of the scapula, and the incision is closed up.

Arthroscopic Bursectomy

Surgeons sometimes do arthroscopic surgery to take out an inflamed scapulothoracic bursa. Removing a bursa is called bursectomy. Small incisions allow the surgeon to insert a small TV camera, called an arthroscope, into the joint. Through another small incision, the surgeon uses special instruments to remove the inflamed bursa while the arthroscope shows what is happening.

Rehabilitation

What can I expect after treatment?

Nonsurgical Rehabilitation

For patients undergoing nonsurgical treatment, physical or occupational therapy may be part of the rehabilitation plan. Your therapist may help treat your pain and inflammation. Therapists also evaluate posture to make sure the spine and shoulder bones are in their best alignment. A strengthening program to bulk up the muscles under the scapula may help pad and cushion the soft tissues between the scapula and rib cage.

After Surgery

Therapy is more involved after surgery. Patients wear a sling following scapula surgery. Passive shoulder movements can begin soon after surgery. But there should be no active exercises for about eight weeks, to make sure the muscles are firmly healed where they were sewn back into the drill holes in the scapula. People usually start doing resistive exercise and activities after 12 weeks. Your surgeon will probably recommend that you work with a physical or occupational therapist during your rehabilitation.

Rotator Cuff Tears

A Patient’s Guide to Rotator Cuff Tears

Introduction

The shoulder is an elegant and complex piece of machinery. Its design allows us to reach and use our hands in many different positions. However, while the shoulder joint has great range of motion, it is not very stable. This makes the shoulder vulnerable to problems if any of its parts aren’t in good working order.

The rotator cuff tendons are key to the healthy functioning of the shoulder. They are subject to a lot of wear and tear, or degeneration, as we use our arms. Tearing of the rotator cuff tendons is an especially painful injury. A torn rotator cuff creates a very weak shoulder. Most of the time patients with torn rotator cuffs are in late middle age. But rotator cuffs tears can happen at any age.

This guide will help you understand

what the rotator cuff is
how it can become torn
what treatments are available for a torn rotator cuff

Anatomy

What is the rotator cuff, and what does it do?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

The rotator cuff connects the humerus to the scapula.

The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm.

As the arm is raised, the rotator cuff also keeps the humerus tightly in the socket of the scapula. The upper part of the scapula that makes up the roof of the shoulder is called the acromion.

A bursa is located between the acromion and the rotator cuff tendons. A bursa is a lubricated sac of tissue that cuts down on the friction between two moving parts. Bursae are located all over the body where tissues must rub against each other.

In this case, the bursa protects the acromion and the rotator cuff from grinding against each other.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

What causes the rotator cuff to tear?

The rotator cuff tendons have areas of very low blood supply. The more blood supply a tissue has, the better and faster it can repair and maintain itself. The areas of poor blood supply in the rotator cuff make these tendons especially vulnerable to degeneration from aging.

The degeneration of aging helps explain why the rotator cuff tear is such a common injury later in life. Rotator cuff tears usually occur in areas of the tendon that had low blood supply to begin with and then were further weakened by degeneration.

This problem of degeneration may be accelerated by repeating the same types of shoulder motions. This can happen with overhand athletes, such as baseball pitchers. But even doing routine chores like cleaning windows, washing and waxing cars, or painting can cause the rotator cuff to fatigue from overuse.

Excessive force can tear weak rotator cuff tendons. This force can come from trying to catch a heavy falling object or lifting an extremely heavy object with the arm extended. The force can also be from a fall directly onto the shoulder. Sometimes injuries that tear the rotator cuff are painful, but sometimes they aren’t. Researchers estimate that up to 40 percent of people may have a mild rotator cuff tear without even knowing it.

The typical patient with a rotator cuff tear is in late middle age and has had problems with the shoulder for some time. This patient then lifts a load or suffers an injury that tears the tendon. After the injury, the patient is unable to raise the arm. However, these injuries also occur in young people. Overuse or injury at any age can cause rotator cuff tears.

Symptoms

What does a rotator cuff tear feel like?

Rotator cuff tears cause pain and weakness in the affected shoulder. In some cases, a rotator cuff may tear only partially. The shoulder may be painful, but you can still move the arm in a normal range of motion. In general, the larger the tear, the more weakness it causes.

In other cases, the rotator cuff tendons completely rupture. A complete tear makes it impossible to move the arm in a normal range of motion. It is usually impossible to raise the arm away from your side by yourself.

Most rotator cuff tears cause a vague pain in the shoulder area. They may also cause a catching sensation when you move your arm. Most people say they can’t sleep on the affected side due to the pain.

Diagnosis

What tests will my doctor run?

Your doctor will ask questions about your medical history, your injury, and your pain. Your doctor will then do a physical examination of the shoulder. The physical exam is most helpful in diagnosing a rotator cuff tear. A complete tear is usually very obvious. If your doctor can move the arm in a normal range of motion, but you can’t move the arm yourself, you most likely have a torn rotator cuff.

X-rays won’t show tears in the rotator cuff. However, your doctor may want you to have a shoulder X-ray to see if there are bone spurs, a loss of joint space in the shoulder, or a down-sloping (hooked) acromion. These findings are associated with tears in the rotator cuff. An X-ray can also show if there are calcium deposits in the tendon that are causing your symptoms, a condition called calcific tendonitis.

Your doctor will probably also want to do an arthrogram test. An arthrogram involves injecting dye into the shoulder joint and taking several X-rays. If the dye leaks out of the shoulder joint, there is probably a tear in the rotator cuff.

Your doctor may ask you to have a magnetic resonance imaging (MRI) scan.

An MRI scan is a special imaging test that uses magnetic waves to create pictures of the shoulder in slices. The MRI scan shows tendons as well as bones. This test is painless and requires no needles or injections.

Treatment

What treatment options are available?

Nonsurgical Treatment

Your doctor’s first goal will be to help control your pain and inflammation. Initial treatment is usually rest and anti-inflammatory medication, such as aspirin or ibuprofen. This medicine is used mainly to control pain. Your doctor may suggest a cortisone injection if you have trouble getting your pain under control. Cortisone is a very effective anti-inflammatory medication.

Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. At first, treatments such as heat and ice focus on easing pain and inflammation. Hands-on treatments and various types of exercises are used to improve the range of motion in your shoulder and the nearby joints and muscles.

Later, you will do strengthening exercises to improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This will help your shoulder move smoothly during all of your activities.

You may need therapy treatments for six to eight weeks. Most patients are able to get back to their activities with full use of their arm within this amount of time.

Surgery

A complete rotator cuff tear will not heal. Complete ruptures usually require surgery if your goal is to return your shoulder to optimal function. The exception is in elderly patients or patients who have other diseases that increase the risks of surgery. There is some evidence that repairing the rotator cuff within three months of the injury results in a better outcome. You will need to work with your surgeon to determine when is the best time to do the surgery.

Certain types of partial rotator cuff tears may not require surgical repair. If you have a partial tear, your surgeon will most likely want to further evaluate the situation and determine how much the tendon is torn and where the tendon is damaged. This information will be used to decide whether surgery should be recommended or whether you may want to consider non-surgical care for the partial tear of the tendon.

Today, the MRI scan is the most common test used to evaluate the shoulder and determine whether surgery is necessary. Your surgeon will be looking for details of your rotator cuff tear and checking for other problems. As mentioned earlier, a tear usually doesn’t occur unless the rotator cuff is already weakened by some other problem. Other potential problems include acromioclavicular (AC) joint osteoarthritis and impingement syndrome. Your surgery may need to address these conditions as well.

Arthroscopic Repair

In the past,

repair of the rotator cuff tendons usually required an open incisionthree or four inches in length. As surgeons have become more comfortable using the arthroscope to work in and around the shoulder joint, things have changed. Today, it is much more common to repair tears of the rotator cuff using the arthroscope.

An arthroscope is a special type instrument designed to look into a joint, or other space, inside the body. The arthroscope itself is a slender metal tube smaller than a pencil. Inside the metal tube are special strands of glass called fiberoptics. These small strands of glass form a lens that allows one to look into the tube on one end and see what is on the other side – inside the space. This is similar to a microscope or telescope. In the early days of arthroscopy, the surgeon actually looked into one end of the tube. Today, the arthroscope is attached to a small TV camera. The surgeon can watch the TV screen while the arthroscope is moved around in the joint. Using the ability to see inside the joint, the surgeon can then place other instruments into the joint and perform surgery while watching what is happening on the TV screen.

The arthroscope lets the surgeon work in the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery. If your surgery is done with the arthroscope, you may be able to go home the same day.

To perform the rotator cuff repair using the arthroscope, several small incisions are made to insert the arthroscope and special instruments needed to complete the procedure. These incisions are small, usually about one-quarter inch long. It may be necessary to make three or four incisions around the shoulder to allow the arthroscope to be moved to different locations to see different areas of the shoulder.

A small plastic, or metal, tube is inserted into the shoulder and connected with sterile plastic tubing to a special pump. Another small tube allows the fluid to be removed from the joint. This pump continuously fills the shoulder joint with sterile saline (salt water) fluid. This constant flow of fluid through the joint inflates the joint and washes any blood and debris from the joint as the surgery is performed.

There are many small instruments that have been specially designed to perform surgery in the joint. Some of these instruments are used to remove torn and degenerative tissue. Some of these instruments nibble away bits of tissue and then vacuum them up from out of the joint. Others are designed to burr away bone tissue and vacuum it out of the joint. These instruments are used to remove any bone spurs that are rubbing on the tendons of the shoulder and smooth the under surface of the acromion and AC joint.

Once any degenerative tissue and bone spurs are removed, the torn rotator cuff tendon can be reattached to the bone. Special devices have been designed to reattach these ligaments. These devices are called suture anchors.

Suture anchors are special devices that have been designed to attach tissue to bone. In the past, many different ways were used to attach soft tissue (such as ligaments and tendons) to bone. The usual methods have included placing stitches through drill holes in the bone, special staples and screws with special washers – all designed to hold the tissue against the bone until healing occurred. Most of these techniques required larger incisions to be able to see what was going on and to get the hardware and soft tissue in the right location.

Today, suture anchors have simplified the process and created a much stronger way of attaching soft tissue to bone. These devices are small enough that the can be placed into the appropriate place in the bone through a small incision using the arthroscope. Most of these devices are made of either metal or a special plastic-like material that dissolves over time. This is the “anchor” portion of the device. The anchor is drilled into the bone where the surgeon wished to attach the soft tissue. Sutures are attached to the anchor and threaded through the soft tissue and tied down against the bone.

Open Repair

In some instances, open surgery is necessary. In open surgery, the surgeon gets to the rotator cuff tendon by cutting through muscles and tissues on the front of the shoulder. After repairing the tendon, the muscle on the front is reattached to the bone.

Graft Method

It is not possible to repair all rotator cuff tears. Sometimes the tendon has been torn for too long a period of time. The tendons and muscles become contracted and can’t be stretched enough to be reattached. In these cases, the surgeon may use a length of tendon graft to span the distance from the tendon stump of the torn rotator cuff to the humerus.

Salvage Procedure

In other cases, the tendon tissue has simply worn away, and the remaining tendon is not strong enough to hold the necessary stitches. In these instances, simply removing all the torn tissue and fixing any other problems in the shoulder may reduce your pain. But this will probably not increase the strength or motion of your shoulder. It may actually decrease your range of motion.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Even if you don’t need surgery, you may need to follow a program of rehabilitation exercises. Your doctor may recommend that you work with a physical or occupational therapist. Your therapist can create an individualized program to help you regain shoulder function. This includes tips and exercise for improving posture and shoulder alignment. It is also very important to improve the strength and coordination in the rotator cuff and shoulder blade muscles. Your therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems.

After Surgery

Rehabilitation after rotator cuff surgery can be a slow process. You will probably need to attend therapy sessions for two to three months, and you should expect full recovery to take up to six months. Getting the shoulder moving as soon as possible is important. However, this must be balanced with the need to protect the healing tissues.

Your surgeon will most likely have you wear a sling to support and protect the shoulder for several weeks (generally four to six weeks) after surgery. Ice and electrical stimulation treatments may be used during your first few therapy sessions to help control pain and swelling from the surgery. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy can progress quickly after arthroscopic procedures. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You just need to be careful about doing too much, too quickly.

Therapy goes slower after surgeries where the front shoulder muscles have been cut. Exercises begin with passive movements. During passive exercises, your shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy usually starts six weeks after surgery. You use your own muscle power in active range-of-motion exercises. You may begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing tissues. Formal strengthening exercises will be delayed until 12 weeks.

Exercises focus on improving the strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus firmly in the socket. This helps your shoulder move smoothly during all your activities.

If all of these efforts to improve your shoulder condition fail, there are a few other options. Tendon grafts and muscle transfers, for example, may help you regain use of your shoulder. However, these procedures are very complex and are rarely necessary.

Labral Tears

A Patient’s Guide to Labral Tears

Introduction

Since orthopedic surgeons began using a tiny TV camera called an arthroscope to diagnose and treat shoulder problems, they have discovered several conditions that no one knew existed. One of these conditions is an injury to a small structure in the shoulder called the labrum. A labral tear can cause pain and a catching sensation in the shoulder. Labral tears can be very difficult to diagnose.

This document will help you understand:

where and what the labrum is
what tests your doctor will run to diagnose the problem
what you can do to relieve your pain

Anatomy

What is the labrum?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

A part of the scapula, called the glenoid, makes up the socket of the shoulder. The glenoid is very shallow and flat. The labrum is a rim of soft tissue that makes the socket more like a cup. The labrum turns the flat surface of the glenoid into a deeper socket that molds to fit the head of the humerus.

The rotator cuff connects the humerus to the scapula. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm. As the arm is raised, the rotator cuff also keeps the humerus tightly in the glenoid of the scapula.

The soft labral tissue can be caught between the glenoid and the humerus. When this happens, the labrum may start to tear. If the tear gets worse, it may become a flap of tissue that can move in and out of the joint, getting caught between the head of the humerus and the glenoid. The flap can cause pain and catching when you move your shoulder. Several tendons and ligaments attach to the labrum that help maintain the stability of the shoulder. So when the labrum tears, the shoulder often becomes much less stable.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

What causes labral tears?

Labral tears are often caused by a direct injury to the shoulder, such as falling on an outstretched hand. The labrum can also become torn from the wear and tear of activity, a condition called overuse. An injured labrum can lead to shoulder instability. The extra motion of the humerus within the socket causes additional damage to the labrum. An extremely unstable shoulder may slip or dislocate. This can also cause the labrum to tear.

The biceps tendon attaches to the front part of the labrum. The biceps is the large muscle on the front of your upper arm. Sports can cause injuries to the labrum when the biceps tendon pulls sharply against the front of the labrum. Baseball pitchers are prone to labral tears because the action of throwing causes the biceps tendon to pull strongly against the top part of the labrum. Weightlifters can have similar problems when pressing weights overhead. Golfers may tear their labrum if their club strikes the ground during the golf swing.

Related Document: A Patient’s Guide to Biceps Tendonitis

Symptoms

What does a labral tear feel like?

The main symptom caused by a labral tear is a sharp pop or catching sensation in the shoulder during certain shoulder movements. This may be followed by a vague aching for several hours. At other times, the tear may not cause any pain. Shoulder instability from a damaged labrum may cause the shoulder to feel loose, as though it slips with certain movements.

Diagnosis

What tests will my doctor run?

Your doctor may suspect a labral tear based on your medical history. You will be asked questions about your pain and past injuries to your shoulder that may suggest labral damage.

In the physical examination, there are several shoulder movements that can bring on the symptoms. You may feel a catching sensation as your arm is raised, and there may be pain when the arm is held overhead. If your arm is held in front of your body, with the palm of the hand facing downward, you may feel pain when your doctor tries to push down on your arm.

Labral tears are difficult to see, even in a magnetic resonance imaging (MRI) scan. An MRI scan is a special imaging test that uses magnetic waves to show the tissues of the shoulder in slices. The MRI scan shows soft tissues such as tendons and ligaments as well as bones.

Labral tears may be seen using computed tomography (CT) scan and a special dye. A CT scan is an older test that uses computer-enhanced X-rays to show slices of the shoulder. The soft tissues do not show up in a CT scan, but the special dye does. The dye shows the outline of the labrum. If there is a tear, the dye may leak into it and show up on the CT scan.

However, MRI and CT scans are not very accurate in detecting labral tears. Confirming the diagnosis of a labral tear can be extremely difficult. A surgeon may need to look into your shoulder using an arthroscope. The arthroscope is a small TV camera that is inserted into the shoulder joint through a very small incision. The surgeon can then see pictures of the joint on a TV screen. This allows the surgeon to look directly at the labrum to see if it is torn.

Treatment

What treatment options are available?

Nonsurgical Treatment

Your doctor’s first goal will be to control your pain and inflammation. Initial treatment for pain control is usually rest and anti-inflammatory medication, such as aspirin or ibuprofen. Your doctor may suggest a cortisone injection if you have trouble getting your pain under control. Cortisone is a strong anti-inflammatory medication. It can provide good relief, although its effects are temporary.

Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. Your first therapy treatments will try to ease pain and inflammation by using such treatments as heat or ice. Hands-on treatment and various types of exercises are used to improve the range of motion in your shoulder and the nearby joints and muscles.

Later, you will do strengthening exercises to improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the glenoid. This will improve the stability of your shoulder and help it move smoothly during all your activities.

You may need therapy treatments for four to six weeks. Most patients are able to get back to their activities with full use of their arm within this amount of time.

Surgery

If your symptoms don’t go away, you may need surgery. Surgical treatment for this condition is still evolving. Surgeons have not known about the problem long enough to adequately evaluate the results of different treatments.

Labral Debridement

The arthroscope is commonly used to treat many labral tears. If the tear is small and is mostly getting caught as you move the shoulder, simply removing the frayed edges and any loose parts of the labrum may get rid of your symptoms. This is called labral debridement.

Labral Repair

If the tear is larger, the shoulder may also be unstable. If this is the case, the labral tear may need to be repaired, rather than simply removed. Several new techniques allow surgeons to place “anchors” into the bone around the shoulder joint and reattach the labrum using the arthroscope. There are many variations of these anchors, but most are drilled into the bone and have sutures (stitches) attached that are then used to tie the labrum down to the bone and enable the labrum to heal back in the appropriate position.

Open Procedure

Open procedures are rarely used today for repair of labral tears. The arthroscopic techniques have become increasingly refined and are today the preferred method of treatment.

If for some reason the tear is repaired open, the surgeon will need to make an incision in the front of the shoulder. The main drawback of making the larger incision is that it will probably take you longer to recover from surgery.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Even nonsurgical treatment requires a rehabilitation program. Some evidence suggests that shoulder instability may eventually make labral tears worse. The goal of therapy will be to strengthen the rotator cuff muscles to make the shoulder more stable. At first you will do exercises with the therapist. Eventually you will be put on a home program of exercise to keep the muscles strong and flexible. This should help you avoid future problems.

After Surgery

Rehabilitation after surgery is more complex. You will probably need to wear a sling to support and protect the shoulder for several weeks after surgery. A physical or occupational therapist will probably direct your recovery program. Depending on the surgical procedure, you will probably need to attend therapy sessions for one to two months, and you should expect full recovery to take up to four to six months if you are expecting to participate in athletics.

Getting the shoulder moving as soon as possible is important. However, this must be balanced with the need to protect the healing tissues. The first few therapy treatments will focus on controlling the pain and swelling from surgery. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy proceeds quickly after a simple arthroscopic surgery to clean up the frayed edges or loose parts of the labrum. Sessions start with range-of-motion exercises and gradually work into active stretching and strengthening. Overhand athletes start their sports gradually within four to six weeks. They can usually return to competition within three months.

After surgery to repair the labrum, therapists usually begin with passive exercises. In passive exercises, the shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may also be taught how to do passive exercises at home.

Active therapy starts about six weeks after repair surgery. Active range-of-motion exercises help you regain shoulder movement using your own muscle power. Light isometric strengthening exercises are started about this time. These exercises work the muscles without straining the healing joint.

By about the tenth week, you will start more active strengthening. Exercises will focus on improving strength and control of the rotator cuff muscles. They help tighten the ball of the humerus in the glenoid socket and can improve the stability of the shoulder. A stronger and more stable shoulder helps keep the ball of the humerus centered in the socket during all your activities.

Some of the exercises you will do are designed get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Impingement Syndrome

A Patient’s Guide to Impingement Syndrome

Introduction

The shoulder is a very complex piece of machinery. Its elegant design gives the shoulder joint great range of motion, but not much stability. As long as all the parts are in good working order, the shoulder can move freely and painlessly.

Many people refer to any pain in the shoulder as bursitis. The term bursitis really only means that the part of the shoulder called the bursa is inflamed. Tendonitis is when a tendon gets inflamed. This can be another source of pain in the shoulder. Many different problems can cause inflammation of the bursa or tendons. Impingement syndrome is one of those problems. Impingement syndrome occurs when the rotator cuff tendons rub against the roof of the shoulder, the acromion.

This guide will help you understand

what happens in your shoulder when you have impingement syndrome
what tests your doctor will run to diagnose this condition
how you can relieve your symptoms.

Anatomy

What part of the shoulder is affected?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

The rotator cuff connects the humerus to the scapula. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm.

As the arm is raised, the rotator cuff also keeps the humerus tightly in the socket of the scapula, the glenoid. The upper part of the scapula that makes up the roof of the shoulder is called the acromion.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

Why do I have problems with shoulder impingement?

Usually, there is enough room between the acromion and the rotator cuff so that the tendons slide easily underneath the acromion as the arm is raised. But each time you raise your arm, there is a bit of rubbing or pinching on the tendons and the bursa. This rubbing or pinching action is called impingement.

Impingement occurs to some degree in everyone’s shoulder. Day-to-day activities that involve using the arm above shoulder level cause some impingement. Usually it doesn’t lead to any prolonged pain. But continuously working with the arms raised overhead, repeated throwing activities, or other repetitive actions of the shoulder can cause impingement to become a problem. Impingement becomes a problem when it causes irritation or damage to the rotator cuff tendons.

Raising the arm tends to force the humerus against the edge of the acromion. With overuse, this can cause irritation and swelling of the bursa. If any other condition decreases the amount of space between the acromion and the rotator cuff tendons, the impingement may get worse.

Bone spurs can reduce the space available for the bursa and tendons to move under the acromion. Bone spurs are bony points. They are commonly caused by wear and tear of the joint between the collarbone and the scapula, called the acromioclavicular (AC) joint. The AC joint is directly above the bursa and rotator cuff tendons.

In some people, the space is too small because the acromion is oddly sized. In these people, the acromion tilts too far down, reducing the space between it and the rotator cuff.

Symptoms

What does impingement syndrome feel like?

Impingement syndrome causes generalized shoulder aches in the condition’s early stages. It also causes pain when raising the arm out to the side or in front of the body. Most patients complain that the pain makes it difficult for them to sleep, especially when they roll onto the affected shoulder.

A reliable sign of impingement syndrome is a sharp pain when you try to reach into your back pocket. As the condition worsens, the discomfort increases. The joint may become stiffer. Sometimes a catching sensation is felt when you lower your arm. Weakness and inability to raise the arm may indicate that the rotator cuff tendons are actually torn.

Related Document: A Patient’s Guide to Rotator Cuff Tears

Diagnosis

What tests will my doctor run?

The diagnosis of bursitis or tendonitis caused by impingement is usually made on the basis of your medical history and physical examination. Your doctor will ask you detailed questions about your activities and your job, because impingement is frequently related to repeated overhead activities.

Your doctor may order X-rays to look for an abnormal acromion or bone spurs around the AC joint. A magnetic resonance imaging (MRI) scan may be performed if your doctor suspects a tear of the rotator cuff tendons. An MRI is a special imaging test that uses magnetic waves to create pictures that show the tissues of the shoulder in slices. The MRI scan shows tendons as well as bones. The MRI scan is painless and requires no needles.

An arthrogram may also be used to detect rotator cuff tears. The arthrogram is an older test than the MRI, but it is still widely used. It involves injecting dye into the shoulder joint and then taking several X-rays. If the dye leaks out of the shoulder joint, it suggests that there is a tear in the rotator cuff tendons.

In some cases, it is unclear whether the pain is coming from the shoulder or a pinched nerve in the neck. An injection of a local anesthetic (such as lidocaine) into the bursa can confirm that the pain is in fact coming from the shoulder. If the pain goes away immediately after the injection, then the bursa is the most likely source of the pain. Pain from a pinched nerve in the neck would almost certainly not go away after an injection into the shoulder.

Treatment

What treatment options are available?

Nonsurgical Treatment

Doctors usually start by prescribing nonsurgical treatment. You may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Resting the sore joint and putting ice on it can also ease pain and inflammation. If the pain doesn’t go away, an injection of cortisone into the joint may help. Cortisone is a strong medication that decreases inflammation and reduces pain. Cortisone’s effects are temporary, but it can give very effective relief for up to several months.

Your doctor may also prescribe sessions with a physical or occupational therapist. Your therapist will use various treatments to calm inflammation, including heat and ice. Therapists use hands-on treatments and stretching to help restore full shoulder range of motion. Improving strength and coordination in the rotator cuff and shoulder blade muscles lets the humerus move in the socket without pinching the tendons or bursa under the acromion. You may need therapy treatments for four to six weeks before you get full shoulder motion and function back.

Surgery

If you are still having problems after trying nonsurgical treatments, your doctor may recommend surgery.

Subacromial Decompression

The goal of surgery is to increase the space between the acromion and the rotator cuff tendons. Taking pressure off the tissues under the acromion is called subacromial decompression. The surgeon must first remove any bone spurs under the acromion that are rubbing on the rotator cuff tendons and the bursa. Usually the surgeon also removes a small part of the acromion to give the tendons even more space. In patients who have a downward tilt of the acromion, more of the bone may need to be removed. Surgically cutting and shaping the acromion is called acromioplasty. It gives the surgeon another step to get pressure off (decompress) the tissues between the humerus and the acromion.

Resection Arthroplasty

Impingement may not be the only problem in an aging or overused shoulder. It is very common to also see degeneration from arthritis in the AC joint. If there is reason to believe that the AC joint is arthritic, the end of the clavicle may be removed during impingement surgery. This procedure is called a resection arthroplasty.

The most common procedure for AC joint osteoarthritis is resection arthroplasty. A resection arthroplasty involves removing a small portion of the end of the clavicle. This leaves a space between the acromion (the piece of the scapula that meets your shoulder) and the cut end of the clavicle, where the joint used to be. Your surgeon will take care not to remove too much of the end of the clavicle to prevent any damage to the ligaments holding the joint together. Usually only a small portion is removed, less than one cm (about three-eighths of an inch). As your body heals, the joint is replaced by scar tissue. Remember, the AC joint doesn’t move much, but it does need to be flexible. The scar tissue allows movement but stops the bone ends from rubbing together.

This procedure can be done in two ways. Today, it is more common to do this procedure using the arthroscope. An arthroscope is a slender tool with a tiny TV camera on the end. It lets the surgeon work in the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery.

Arthroscopic Procedure

Today, acromioplasty is usually done using an arthroscope.

An arthroscope is a special type instrument designed to look into a joint, or other space, inside the body. The arthroscope itself is a slender metal tube smaller than a pencil. Inside the metal tube are special strands of glass called fiberoptics. These small strands of glass form a lens that allows one to look into the tube on one end and see what is on the other side – inside the space. This is similar to a microscope or telescope. In the early days of arthroscopy, the surgeon actually looked into one end of the tube. Today, the arthroscope is attached to a small TV camera. The surgeon can watch the TV screen while the arthroscope is moved around in the joint. Using the ability to see inside the joint, the surgeon can then place other instruments into the joint and perform surgery while watching what is happening on the TV screen.

To perform the acromioplasty using the arthroscope, several small incisions are made to insert the arthroscope and special instruments needed to complete the procedure. These incisions are small, usually about one-quarter inch long. It may be necessary to make three or four incisions around the shoulder to allow the arthroscope to be moved to different locations to see different areas of the shoulder.

There are many small instruments that have been specially designed to perform surgery in the joint. Some of these instruments are used to remove torn and degenerative tissue. Some of these instruments nibble away bits of tissue and then vacuum them up from out of the joint. Others are designed to burr away bone tissue and vacuum it out of the joint. These instruments are used to remove any bone spurs that are rubbing on the tendons of the shoulder and smooth the under surface of the acromion and AC joint.

Open Procedure

In other cases, an open incision is made to allow removal of the bone. Usually an incision about three or four inches long is made over the top of the shoulder. The surgeon removes any bone spurs and a part of the acromion. The surgeon then smooths the rough ends of the bone. If necessary, the surgeon will do a resection arthroplasty on the AC joint. If you have open surgery, you may need to spend a night or two in the hospital.

View animation of bone spur removal

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

It is important to maintain the strength in the muscles of the rotator cuff. These muscles help control the stability of the shoulder joint. Strengthening these muscles can actually decrease the impingement of the acromion on the rotator cuff tendons and bursa. Your therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems.

After Surgery

Rehabilitation after shoulder surgery can be a slow process. You will probably need to attend therapy sessions for several weeks, and you should expect full recovery to take several months. Getting the shoulder moving as soon as possible is important. However, this must be balanced with the need to protect the healing muscles and tissues.

Your surgeon may have you wear a sling to support and protect the shoulder for a few days after surgery. Ice and electrical stimulation treatments may be used during your first few therapy sessions to help control pain and swelling from the surgery. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy can progress quickly after a simple arthroscopic procedure. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You just need to be careful to avoid doing too much, too quickly.

Therapy goes slower after open surgery in which the shoulder muscles have been cut. Therapists will usually wait up to two weeks before starting range-of-motion exercises. Exercises begin with passive movements. During passive exercises, your shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy starts four to six weeks after surgery. You use your own muscle power in active range-of-motion exercises. You may begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing tissues.

At about six weeks you start doing more active strengthening. Exercises focus on improving the strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This helps your shoulder move smoothly during all your activities.

Some of the exercises you’ll do are designed get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Calcific Tendonitis of the Shoulder

A Patient’s Guide to Calcific Tendonitis of the Shoulder

Introduction

Calcific tendonitis of the shoulder happens when calcium deposits form on the tendons of your shoulder. The tissues around the deposit can become inflamed, causing a great deal of shoulder pain. This condition is fairly common. It most often affects people over the age of 40.

This guide will help you understand

what happens in the shoulder with calcific tendonitis
what tests your doctor will run to diagnose this condition
what you can do to help relieve the pain.

Anatomy

Which part of the shoulder is affected?

Calcific tendonitis occurs in the tendons (tendons attach muscles to bones) of the rotator cuff. The rotator cuff is actually made up of several tendons that connect the muscles around your shoulder to the humerus (the larger bone of the upper arm).

Calcium deposits usually form on the tendon in the rotator cuff called the supraspinatus tendon.

There are two different types of calcific tendonitis of the shoulder: degenerative calcification and reactive calcification. The wear and tear of aging is the primary cause of degenerative calcification. As we age, blood flow to the tendons of the rotator cuff decreases. This makes the tendon weaker. Due to the wear and tear as we use our shoulder, the fibers of the tendons begin to fray and tear, just like a worn-out rope. Calcium deposits form in the damaged tendons as a part of the healing process.

Reactive calcification is different. Why it occurs is not clear. It doesn’t seem to be related to degeneration, though it is more likely to cause shoulder pain than degenerative calcification. Doctors think of reactive calcification in three stages. In the pre-calcific stage, the tendon changes in ways that make calcium deposits more likely to form. In the calcific stage, calcium crystals are deposited in the tendons. Then they begin to disappear. The body simply reabsorbs the calcium deposits. Ironically, it is during this stage that pain is most likely to occur. In the post-calcific stage, the body heals the tendon, and the tendon is remodeled with new tissue.

No one knows what triggers the body to reabsorb the deposits. But once this occurs and the tissue begins to be remodeled, the pain usually decreases or goes away altogether.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

Why did I develop calcific tendonitis?

No one really knows what causes calcific tendonitis. Severe wear and tear, aging, or a combination of the two are involved in degenerative calcification. Some researchers think that calcium deposits form because there is not enough oxygen to the tendon tissues. Others feel that pressure on the tendons can damage them, causing the calcium deposits to form.

Reactive calcification is even more of a mystery. This type of problem occurs in younger patients and seems to go away by itself in many cases.

Symptoms

What are the symptoms of this condition?

While the calcium is being deposited, you may feel only mild to moderate pain, or even no pain at all. For some unknown reason, calcific tendonitis becomes very painful when the deposits are being reabsorbed. The pain and stiffness of calcific tendonitis can cause you to lose motion in your shoulder. Lifting your arm may become painful. At its most severe, the pain may interfere with your sleep.

Diagnosis

What tests will my doctor run?

Your doctor will take a detailed medical history and do a thorough physical exam of your shoulder. The pain of calcific tendonitis can be confused with other conditions that cause shoulder pain. An X-ray is usually necessary to confirm the presence of calcium deposits. The X-ray will also help pinpoint the exact location of the deposits.

You will probably need to get several X-rays over time. This will help your doctor keep track of the changes in the amount of calcification. By following the changes in the calcium deposits, your doctor can determine whether the condition will heal by itself or perhaps require surgery.

Treatment

How can I get my pain under control?

Nonsurgical Treatment

Your doctor’s first goal will be to help control your pain and inflammation. Initial treatment is likely to be rest and anti-inflammatory medication, such as ibuprofen. The anti-inflammatory medicine is used mainly to control pain. Your doctor may suggest a cortisone injection if your pain stays severe even after trying other nonsurgical treatments. Cortisone is a very powerful steroid. Cortisone can be very effective at temporarily easing inflammation and swelling.

During the time when the calcium deposits are being reabsorbed, the pain can be especially bad. Your doctor may suggest trying to remove the calcium deposit by inserting two large needles into the area and rinsing with sterile saline. (Saline is simply a saltwater solution.) This procedure is called lavage. Sometimes lavage breaks the calcium particles loose. Then they can be removed with the needles. Getting rid of the calcium deposits can help speed up the healing. Even when lavage fails to remove calcium deposits, it may reduce pressure in the tendon, leading to less pain.

Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. At first, therapy focuses on easing your pain and inflammation. Treatments may include heat or ice. Therapists may apply ultrasound treatments. Ultrasound has shown some benefit in reducing the size of the deposit and in helping people have less pain and better arm function. However, to get the full benefit, ultrasound treatments must be repeated often (up to 24 times) in a six-week period.

Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. Patients generally receive the treatment once each week for up to three weeks. The impulses are thought to help break up the deposit so the body can more easily absorb it. Recent studies indicate that this form of treatment can help ease pain and reduce the size of the deposit.

Surgery

If the pain and loss of movement continue to get worse or interfere with your daily life, you may need surgery. Surgery for calcific tendonitis does not usually require patients to stay in the hospital overnight. It does require anesthesia.

Arthroscopic Resection

Most surgeries to correct calcific tendonitis of the shoulder are arthroscopic

surgeries. The arthroscope is a special TV camera that can be inserted into the shoulder joint through a small incision in the skin. Other small incisions allow the surgeon to insert small surgical instruments into the joint as well. The surgeon uses the arthroscope to locate the calcium deposit in the rotator cuff tendon. Once the deposit is found, the surgeon uses the small instruments to resect (remove) the calcium deposits and rinse the area. Loose calcium crystals must be removed. They can be very irritating to the surrounding tissues.

Open Resection

In rare instances, open surgery is necessary. In open surgery, the surgeon gets to the calcium deposit by cutting through muscles and other surrounding tissues. The tendon itself is cut to allow removal of the calcium deposits. The surgeon rinses the area to get rid of calcium crystals and then stitches the muscles and skin together.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Even if you don’t need surgery, you may need to follow a program of rehabilitation exercises. Your doctor may recommend that you work with a physical or occupational therapist for four to six weeks. Your therapist can create an individualized program of strengthening and stretching for your shoulder.

It is very important to strengthen the muscles of the rotator cuff, as these muscles help control the stability of the shoulder joint. Strengthening these muscles can actually decrease the pressure on the calcium deposits in the tendon. Your therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes. Simple changes in the way you sit or stand can ease pain and help you avoid further problems.

After Surgery

Rehabilitation after shoulder surgery can be a slow process. You will probably need to attend therapy sessions for six to eight weeks, and you should expect full recovery to take three to four months. Getting the shoulder moving as soon as possible is important. However, this must be balanced with the need to protect the healing tissues.

Therapy can progress quickly after a simple arthroscopic resection. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You just need to be careful to avoid doing too much, too quickly.

Therapy goes slower after open surgery, where the shoulder muscles have been cut. Therapists will usually wait up to two to three weeks before starting range-of-motion exercises. Exercises begin with passive movements. In passive exercises, your shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

At about six weeks you start doing heavier strengthening. Exercises focus on improving the strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This helps your shoulder move smoothly during all your activities.

Artificial Joint Replacement of the Shoulder

A Patient’s Guide to Artificial Joint Replacement of the Shoulder

Introduction

Shoulder joint replacement surgery (also called shoulder arthroplasty) is not as common as replacement surgeries for the knee or hip joints. Still, when necessary, this operation can effectively ease pain from shoulder arthritis. Most people experience improved shoulder function after this surgery.

This guide will help you understand

how the shoulder works
what parts of the shoulder are replaced in surgery
what to expect after shoulder replacement surgery

Anatomy

What parts make up the shoulder?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

The rotator cuff connects the humerus to the scapula. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm. As the arm is raised, the rotator cuff also keeps the humerus tightly in the socket. A part of the scapula, called the glenoid, makes up the socket of the shoulder. The glenoid is very shallow and flat.

The part of the scapula that connects to the shoulder is called the acromion. A bursa is located between the acromion and the rotator cuff tendons. A bursa is a lubricated sac of tissue that cuts down on the friction between two moving parts. Bursae are located all over the body where tissues must rub against each other. In this case, the bursa protects the acromion and the rotator cuff from grinding against each other.

The humeral head of the shoulder is the ball portion of the joint. The humeral head has several blood vessels, which enter at the base of the articular cartilage. Articular cartilage is the smooth, white material that covers the ends of bones in most joints. Articular cartilage provides a slick, rubbery surface that allows the bones to glide over each other as they move. Cartilage also functions as sort of a shock absorber.

The shoulder joint is surrounded by a watertight sac called the joint capsule. The joint capsule holds fluids that lubricate the joint. The walls of the joint capsule are made up of ligaments. Ligaments are connective tissues that attach bones to bones. The joint capsule has a considerable amount of slack, loose tissue, so that the shoulder is unrestricted as it moves through its large range of motion.

Related Document: A Patient’s Guide to Shoulder Anatomy

Rationale

What conditions lead to shoulder joint replacement?

The most common reason for undergoing shoulder replacement surgery is osteoarthritis. Osteoarthritis is caused by the degeneration of the joint over time, through wear and tear. Osteoarthritis can occur without any injury to the shoulder, but that is uncommon. Because the shoulder is not a weight-bearing joint, it does not suffer as much wear and tear as other joints. Osteoarthritis is more common in the hip and knee.

Most of the time osteoarthritis occurs many years after an injury to the shoulder. For example, a shoulder dislocation can result in an unstable shoulder. The extra movement or repeated dislocation of the unstable joint causes damage to the articular cartilage and other joint tissues. Over time, this damage leads to osteoarthritis.

Osteoarthritis is not the only type of arthritis that affects the shoulder joint. Systemic diseases, such as rheumatoid arthritis, may affect any joint in the body. Whatever the type or cause of the arthritis, the shoulder may become painful and difficult to use. If you and your doctor can’t find ways to control your pain, or if it becomes impossible to use your shoulder for daily tasks, your doctor may recommend shoulder replacement surgery.

Certain types of shoulder fractures can injure the blood vessels of the humeral head. The fracture may heal, but the blood vessels don’t. When the blood vessels are damaged, the humeral head no longer has any blood supply. This condition leads to a condition called aseptic necrosis.

In necrosis, parts of the joint surface actually die. Over time, necrosis of the shoulder joint can lead to arthritis. When fractures affect the humeral head, doctors may recommend a shoulder joint replacement. In some cases, the risk of developing necrosis is so high that it makes sense to replace the humeral head immediately.

In most cases, doctors see shoulder replacement surgery as the last option. Sometimes there is a benefit to delaying shoulder replacement surgery as long as possible. Your doctor will probably want you to try nonsurgical measures to control your pain and improve your shoulder movement, including medications and physical or occupational therapy.

Like any arthritic condition, osteoarthritis of the shoulder may respond to anti-inflammatory medications such as aspirin or ibuprofen. Acetaminophen (Tylenol®) may also be prescribed to ease the pain. Some of the newer medications such as glucosamine and chondroitin sulfate are more commonly prescribed today. They seem to be effective in helping reduce the pain of osteoarthritis in all joints. There are also new injectable medications that lubricate the arthritic joint. These medications have been studied mainly in the knee. It is unclear if they will help the arthritic shoulder.

Physical or occupational therapy may be suggested to help you regain as much of the motion and strength in your shoulder as possible before you undergo surgery.

An injection of cortisone into the shoulder joint may give temporary relief. Cortisone is a powerful anti-inflammatory medication that can ease inflammation and reduce pain, possibly for several months. Most surgeons only allow two or three cortisone shots into any joint. If the shots don’t provide you with lasting relief, your doctor may suggest surgery.

Preparation

What do I need to do to get ready for surgery?

Some severe degenerative problems of the shoulder may require replacement of the painful shoulder with an artificial shoulder joint. You and your surgeon should make the decision to proceed with surgery together. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

You may also need to spend time with the physical or occupational therapist who will be managing your rehabilitation after surgery. This allows you to get a head start on your recovery. One purpose of this pre-operative visit is to record a baseline of information. Your therapist will check your current pain levels, ability to do your activities, and the movement and strength of each shoulder.

A second purpose of the pre-operative visit is to prepare you for surgery. You’ll begin learning some of the exercises you’ll use during your recovery. And your therapist can help you anticipate any special needs or problems you might have at home, once you’re released from the hospital.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. Come prepared to stay in the hospital for several nights. The length of time you will spend in the hospital depends a lot on you.

Surgical Procedure

What happens during shoulder replacement surgery?

Before we describe the procedure, let’s look first at the artificial shoulder itself.

The Artificial Shoulder

There are two major types of artificial shoulder replacements: a cemented prosthesis and an uncemented prosthesis. A cemented prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone. An uncemented prosthesis has a fine mesh of holes on the surface. Bone grows into the mesh. Over time, this anchors the prosthesis to the bone.

Both types of artificial joints are widely used. Your surgeon may also use a combination of the two types. The surgeon determines the type of replacement joint based on your age, your lifestyle, and the surgeon’s experience.

Each prosthesis (artificial joint) is made up of two parts. The humeral component replaces the humeral head, or the ball of the joint. The glenoid component replaces the socket of the shoulder, which is actually part of the scapula.

The humeral component is made of metal. The glenoid component is usually made of two parts. A metal tray attaches directly to the bone, and a plastic cup forms the socket. The plastic is very tough and very slick, much like the articular cartilage it is replacing. In fact, you can ice skate on a sheet of this plastic without causing it much damage.

The Operation

Shoulder replacement surgery can be done in one of two ways. When the cartilage of both the humeral head (the ball) and the glenoid (the socket) is worn away, both parts of the joint must be replaced. This surgery is called arthroplasty, which is the term used for joint reconstruction.

If the glenoid still has some articular cartilage, your surgeon may replace only the humeral head. This procedure is known as a hemiarthroplasty. (Hemi means half.) The hemi-arthroplasty is most commonly used after a fracture of the shoulder where the blood supply to the ball portion (the humeral head) of the humerus is damaged. Research has shown that when the shoulder is being replaced for arthritis, the complete shoulder arthroplasty performs better. Patients have less pain immediately after surgery and in the long run have a better functioning shoulder with less complications and are less likely to need a second operation.

You will most likely need general anesthesia for shoulder replacement surgery. General anesthesia puts you to sleep. It is difficult to numb only the shoulder and arm in a way that makes such a major surgery possible.

Shoulder replacement surgery is done through an incision on the front of your shoulder. This is called an anterior approach. The surgeon cuts through the skin and then isolates the nerves and blood vessels and moves them to the side. The muscles are also moved to the side.

The surgeon enters the shoulder joint itself by cutting into the joint capsule. This allows the surgeon to see the joint.

At this point, the surgeon can prepare the bone for attaching the replacement parts. The ball portion of the humeral head is removed with a bone saw. The hollow inside of the upper humerus is prepared using a rasp. This lets your surgeon mold the space to anchor the metal stem of the humeral component inside the bone.

View animation of removing humeral head

View animation of reaming the humerus

If the glenoid will be replaced, it is prepared by grinding away any remaining cartilage on the surface. This is done with an instrument called a burr. The surgeon usually uses the burr to drill holes into the bone of the scapula. This is where the stem of the glenoid component is anchored.

View animation of preparing the glenoid

View animation of drilling the glenoid

Finally, the humeral component and the glenoid component are inserted and the humeral ball is attached.

View animation of inserting the humeral component

View animation of inserting the glenoid component

View animation of attaching the humeral ball

Once the joint is anchored, the surgeon tests for proper fit. When the surgeon is satisfied with the fit, the joint capsule is stitched together. The muscles are then returned to their correct positions, and the skin is also stitched up.

Your incision will be covered with a bandage, and your arm will be placed in a sling. You will then be woken up and taken to the recovery room.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following artificial shoulder replacement are

anesthesia
infection
loosening
dislocation
nerve or blood vessel injury

Anesthesia

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Infection following joint replacement surgery can be very serious. The chances of developing an infection following artificial joint replacement, however, are low (about one percent). Sometimes infections show up very early, before you leave the hospital. Other times infections may not show up for months, or even years, after the operation.

Infection can also spread into the artificial joint from other infected areas. Once an infection lodges in your joint, it is almost impossible for your immune system to clear it. You may need to take antibiotics when you have dental work or surgical procedures on your bladder and colon. The antibiotics reduce the risk of spreading germs to the artificial joint.

Loosening

The major reason that artificial joints eventually fail is that they loosen where the metal or cement meets the bone. A loose joint prosthesis causes pain. Once the pain becomes unbearable, another operation will probably be needed to fix the artificial joint.

There have been great advances in extending the life of artificial joints. However, most will eventually loosen and require another surgery. In the case of artificial knees, you can expect about 12 to 15 years, but artificial shoulder joints tend to loosen sooner.

Dislocation

Just like your real shoulder, an artificial shoulder can dislocate. A shoulder dislocation occurs when the ball comes out of the socket. There is a greater risk of dislocation right after surgery, before the tissues have healed around the new joint. But there is always a slightly increased risk of dislocation with an artificial joint. Your therapist will teach you how to avoid activities and positions that tend to cause shoulder dislocation. A shoulder that dislocates more than once may need another operation to make it more stable.

Nerve or Blood Vessel Injury

All of the large nerves and blood vessels to the arm and hand travel through the armpit. (This area is called the axilla.) Because shoulder replacement surgery takes place so close to the axilla, it is possible that the nerves or blood vessels may be injured during surgery. The resulting problems may be temporary if the injury was caused by stretching to hold the nerves out of the way. The nerves and blood vessels rarely suffer any kind of permanent injury after shoulder replacement surgery, but this type of injury can happen.

After Surgery

What happens after surgery?

After surgery, you’ll be transported to the recovery room. You will have a dressing wrapped over your shoulder that will need to be changed frequently over the next few days. Your surgeon may have inserted a small drainage tube into the shoulder joint to help keep extra blood and fluid from building up inside the joint. An intravenous line (IV) will be placed in your arm to give you needed antibiotics and medication.

Your shoulder may be placed in a continuous passive motion (CPM) machine immediately after surgery. CPM helps the shoulder begin moving and alleviates joint stiffness. The machine straps to the shoulder and continuously bends and straightens the joint. This motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint. You’ll use a shoulder sling to support your arm when you’re not using the CPM machine.

Rehabilitation

What will my recovery be like?

A physical or occupational therapist will see you the day after surgery to begin your rehabilitation program. Therapy treatments will gradually improve the movement in your shoulder. If you are using CPM, your therapist will check the alignment and settings. Your therapist will go over your exercises and make sure you are safe getting in and out of bed and moving about in your room.

When you go home, you may get home therapy visits. By visiting your home, your therapist can check to see that you are safe getting around in your home. Treatments will also be done to help improve your range of motion and strength. In some cases, you may require up to three visits at home before beginning outpatient therapy.

The first few outpatient treatments will focus on controlling pain and swelling. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain. Continue to use your shoulder sling as prescribed.

As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the shoulder’s strength and function.

Finally, a select group of exercises can be used to simulate day-to-day activities, like grooming your hair or getting dressed. Specific exercises may also be chosen to simulate work or hobby demands.

When your shoulder range of motion and strength have improved enough, you’ll be able to gradually get back to normal activities. Ideally, you’ll be able to do almost everything you did before. However, you may need to avoid heavy or repeated shoulder actions.

You may be involved in a progressive rehabilitation program for two to four months after surgery to ensure the best results from your artificial joint. In the first six weeks after surgery, you should expect to see your therapist two to three times a week. At that time, if everything is still going as planned, you may be able to advance to a home program. Then you will only check in with your therapist every few weeks.

Shoulder Anatomy

A Patient’s Guide to Shoulder Anatomy

Introduction

The shoulder is an elegant piece of machinery. It has the greatest range of motion of any joint in the body. However, this large range of motion can lead to joint problems.

Understanding how the different layers of the shoulder are built and connected can help you understand how the shoulder works, how it can be injured, and how challenging recovery can be when the shoulder is injured. The deepest layer of the shoulder includes the bones and the joints. The next layer is made up of the ligaments of the joint capsule. The tendons and the muscles come next.

In addition to reading this article, be sure to watch our Shoulder Anatomy Animated Tutorial Video.

This guide will help you understand

what parts make up the shoulder
how these parts work together

Important Structures

The important structures of the shoulder can be divided into several categories. These include

bones and joints
ligaments and tendons
muscles
nerves
blood vessels
bursae

Bones and Joints

The bones of the shoulder are the humerus (the upper arm bone), the scapula (the shoulder blade), and the clavicle (the collar bone). The roof of the shoulder is formedby a part of the scapula called the acromion.

There are actually four joints that make up the shoulder. The main shoulder joint, called the glenohumeral joint, is formed

where the ball of the humerus fits into a shallow socket on the scapula. This shallow socket is called the glenoid.

The acromioclavicular (AC) joint is where the clavicle meets the acromion. The sternoclavicular (SC) joint supports the connection of the arms and shoulders to the main skeleton on the front of the chest.

A false joint is formed where the shoulder blade glides against the thorax (the rib cage). This joint, called the scapulothoracic joint, is important because it requires that the muscles surrounding the shoulder blade work together to keep the socket lined up during shoulder movements.

Articular cartilage is the material that covers the ends of the bones of any joint. Articular cartilage is about one-quarter of an inch thick in most large, weight-bearing joints. It is a bit thinner in joints such as the shoulder, which don’t normally support weight. Articular cartilage is white and shiny and has a rubbery consistency. It is slippery, which allows the joint surfaces to slide against one another without causing any damage. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to make motion easier. We have articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate. In the shoulder, articular cartilage covers the end of the humerus and socket area of the glenoid on the scapula.

Ligaments and Tendons

There are several important ligaments in the shoulder. Ligaments are soft tissue structures that connect bones to bones. A joint capsule is a watertight sac that surrounds a joint. In the shoulder, the joint capsule is formed by a group of ligaments that connect the humerus to the glenoid. These ligaments are the main source of stability for the shoulder. They help hold the shoulder in place and keep it from dislocating.

Ligaments attach the clavicle to the acromion in the AC joint. Two ligaments connect the clavicle to the scapula by attaching to the coracoid process, a bony knob that sticks out of the scapula in the front of the shoulder.

A special type of ligament forms a unique structure inside the shoulder called the labrum. The labrum is attached almost completely around the edge of the glenoid. When viewed in cross section, the labrum is wedge-shaped. The shape and the way the labrum is attached create a deeper cup for the glenoid socket. This is important because the glenoid socket is so flat and shallow that the ball of the humerus does not fit tightly. The labrum creates a deeper cup for the ball of the humerus to fit into.

The labrum is also where the biceps tendon attaches to the glenoid. Tendons are much like ligaments, except that tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The biceps tendon runs from the biceps muscle, across the front of the shoulder, to the glenoid. At the very top of the glenoid, the biceps tendon attaches to the bone and actually becomes part of the labrum. This connection can be a source of problems when the biceps tendon is damaged and pulls away from its attachment to the glenoid.

The tendons of the rotator cuff are the next layer in the shoulder joint. Four rotator cuff tendons connect the deepest layer of muscles to the humerus.

Muscles

The rotator cuff tendons attach to the deep rotator cuff muscles. This group of muscles lies just outside the shoulder joint. These muscles help raise the arm from the side and rotate the shoulder in the many directions. They are involved in many day-to-day activities. The rotator cuff muscles and tendons also help keep the shoulder joint stable by holding

the humeral head in the glenoid socket.

The large deltoid muscle is the outer layer of shoulder muscle. The deltoid is the largest, strongest muscle of the shoulder. The deltoid muscle takes over lifting the arm once the arm is away from the side.

Nerves

The main nerves that travel into the arm run through the axilla under the shoulder. Three main nerves begin together at the shoulder: the radial nerve, the ulnar nerve, and the median nerve. These nerves carry the signals from the brain to the muscles that move the arm. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature. There is also an important nerve that travels around the back of the shoulder joint to supply sensation to a small area of skin on the outside of the shoulder and motor signals to the deltoid muscle. This nerve is called the axillary nerve.

Blood Vessels

Traveling along with the nerves are the large vessels that supply the arm with blood. The large axillary artery travels through the axilla.

If you place your hand in your armpit, you may be able to feel the pulsing of this large artery. The axillary artery has many smaller branches that supply blood to different parts of the shoulder. The shoulder has a very rich blood supply.

Bursae

Sandwiched between the rotator cuff muscles and the outer layer of large bulky shoulder muscles are structures known as bursae. Bursae are everywhere in the body. They are found wherever two body parts move against one another and there is no joint to reduce the friction.

A single bursa is simply a sac between two moving surfaces that contains a small amount of lubricating fluid.

Think of a bursa like this: If you press your hands together and slide them against one another, you produce some friction. In fact, when your hands are cold you may rub them together briskly to create heat from the friction. Now imagine that you hold in your hands a small plastic sack that contains a few drops of salad oil. This sack would let your hands glide freely against each other without a lot of friction.

Summary

As you can see, the shoulder is extremely complex, with a design that provides maximum mobility and range of motion. Besides big lifting jobs, the shoulder joint is also responsible for getting the hand in the right position for any function. When you realize all the different ways and positions we use our hands every day, it is easy to understand how hard daily life can be when the shoulder isn’t working well.

Adhesive Capsulitis

A Patient’s Guide to Adhesive Capsulitis

Introduction

Many adults (mostly women) between the ages of 40 and 60 years of age develop shoulder pain and stiffness called adhesive capsulitis. You may be more familiar with the term frozen shoulder to describe this condition. But frozen shoulder and adhesive capsulitis are actually two separate conditions.

This guide will help you understand

what causes adhesive capsulitis
what tests your doctor will do to diagnose it
how you can regain use of your shoulder.

Anatomy

What part of the shoulder is affected?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone). The joint capsule is a watertight sac that encloses the joint and the fluids that bathe and lubricate it. The walls of the joint capsule are made up of ligaments. Ligaments are soft connective tissues that attach bones to bones. The joint capsule has a considerable amount of slack, loose tissue, so the shoulder is unrestricted as it moves through its large range of motion.

The terms frozen shoulder and adhesive capsulitis are often used interchangeably. In other words, the two terms describe the same painful, stiff condition of the shoulder no matter what causes it. A more accurate way to look at this is to refer to true adhesive capsulitis (affecting the joint capsule) as a primary adhesive capsulitis.

As the name suggests, adhesive capsulitis affects the fibrous ligaments that surround the shoulder forming the capsule. The condition referred to as a frozen shoulder usually doesn’t involve the capsule. Secondary adhesive capsulitis (or true frozen shoulder) might have some joint capsule changes but the shoulder stiffness is really coming from something outside the joint. Some of the conditions associated with secondary adhesive capsulitis include rotator cuff tears, biceps tendinitis, and arthritis. In either condition, the normally loose parts of the joint capsule stick together. This seriously limits the shoulder’s ability to move, and causes the shoulder to freeze.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

Why did my shoulder freeze up?

The cause or causes of either primary adhesive capsulitis or secondary adhesive capsulitis (frozen shoulder) remain largely a mystery. Some of the risk factors for adhesive capsulitis include diabetes, thyroid dysfunction, and autoimmune diseases. Anyone who has had a heart attack, stroke, or been treated for breast cancer is also at increased risk for this condition. But a significant number of people develop adhesive capsulitis without any known trauma, medical history, or other risk factor.

In the case of secondary adhesive capsulitis (true frozen shoulder), the problem is really coming from something outside the joint. Some of the conditions associated with secondary adhesive capsulitis include rotator cuff tears, impingement, bursitis, biceps tendinitis, and arthritis.
For either type, an overactive immune response or an autoimmune reaction may be at fault. In an autoimmune reaction, the body’s defense system, which normally protects it from infection, mistakenly begins to attack the tissues of the body. This causes an intense inflammatory reaction in the tissue that is under attack.

No one knows why this occurs so suddenly. Pain and stiffness may begin after a shoulder injury, fracture, or surgery. It can also start if the shoulder is not being used normally. This can happen after a wrist fracture, when the arm is kept in a sling for several weeks. For some reason, immobilizing a joint after an injury seems to trigger the autoimmune response in some people.

Doctors theorize that the underlying condition may cause chronic inflammation and pain that make you use that shoulder less. This sets up a situation that can create adhesive capsulitis. With a primary adhesive capsulitis, treatment of any associated risk factors or underlying medical conditions may be needed before working to correct the tissues around the shoulder. In the case of secondary adhesive capsulitis, it may be necessary to treat the shoulder first in order to regain its ability to move before the underlying musculoskeletal problem can be addressed..

Related Document: A Patient’s Guide to Rotator Cuff Tears

Symptoms

What are the symptoms of adhesive capsulitis?

The symptoms of adhesive capsulitis (and frozen shoulder) are primarily shoulder pain and stiffness, resulting in a very reduced range of shoulder motion. The tightness in the shoulder can make it difficult to do regular activities like getting dressed, combing your hair, or reaching across a table.

Diagnosis

What tests will my doctor run?

The diagnosis of adhesive capsulitis is usually made on the basis of your medical history and physical examination. One key finding that helps differentiate adhesive capsulitis from a frozen shoulder is how the shoulder moves. With adhesive capsulitis, the shoulder motion is the same whether the patient or the doctor tries to move the arm. With a frozen shoulder, say from a tendinitis or rotator cuff tear, the patient cannot move the arm normally or through the full range of motion. But when someone else lifts the arm it can be moved in a nearly normal range of motion.

Simple X-rays are usually not helpful. An arthrogram may show that the shoulder capsule is scarred and tightened. The arthrogram involves injecting dye into the shoulder joint and taking several X-rays. In adhesive capsulitis, very little dye can be injected into the shoulder joint because the joint capsule is stuck together, making it smaller than normal. The X-rays taken after injecting the dye will show very little dye in the joint.

As your ability to move your shoulder increases, your doctor may suggest additional tests to differentiate between primary adhesive capsulitis and secondary adhesive capsulitis (from an underlying condition, such as impingement or a rotator cuff tear). Probably the most common test used is magnetic resonance imaging (MRI). An MRI scan is a special imaging test that uses magnetic waves to create pictures that show the tissues of the shoulder in slices. The MRI scan shows tendons and other soft tissues as well as the bones.

The final and most accurate diagnosis is made when an arthroscopic exam is done. The arthroscopic exam makes it possible to identify exactly which stage of disease you may be in. Tissue samples taken from inside and around the joint are examined under a microscope.

Four separate stages of primary adhesive capsulitis have been recognized from arthroscopic tissue sampling. Symptoms present at any given time usually correspond to the stage you are in. In the first stage, pain prevents full active shoulder motion (active motion means you move your own shoulder) but full passive motion (an examiner moves your shoulder without help from you) is still available. There are some inflammatory changes in the synovium but the capsular tissue is still normal.

In stage two (the freezing stage), pain is now accompanied by stiffness and you start to lose full passive shoulder motion. External rotation is affected first. The rotator cuff remains strong. These two symptoms differ from secondary adhesive capsulitis (what might otherwise be called a frozen shoulder). The condition referred to as a frozen shoulder is more often characterized by damage to the rotator cuff and loss of internal rotation first.

The pain during stage two of primary adhesive capsulitis is worse at night. Cellular changes continue to progress with increased blood flow to the synovium. There are early signs of scarring of the capsule from the inflammatory and repair processes.

By stage three of primary adhesive capsulitis (the frozen stage), there is less pain (mostly at the end range of motion) but more stiffness. There is a true loss of active and passive shoulder joint motion. Very little if any inflammation is seen in the tissue samples viewed under a microscope. Instead, the pathologist sees much more fibrotic (scar) tissue.

In the final (chronic) stage (stage four) you don’t have pain but instead there is profound stiffness and significant loss of motion. Both of these symptoms will gradually start to get better. The body is no longer attempting to repair or correct the problem. Enough scar tissue is present to make it difficult for the surgeon to see the joint during arthroscopic examination.

Treatment

What treatment options are available?

Treatment is based on any underlying causes (if known), any risk factors present, and the stage at the time of diagnosis. There isn’t a one-best-treatment known for adhesive capsulitis. Studies done so far just haven’t been able to come to a single evidence-based set of treatment guidelines for this problem.

Nonsurgical Treatment

Treatment of adhesive capsulitis can be frustrating and slow. Most cases eventually improve, but the process may take months. The goal of your initial treatment is to decrease inflammation and increase the range of motion of the shoulder. Your doctor will probably recommend anti-inflammatory medications, such as aspirin and ibuprofen.

During the early stage, your doctor may also recommend an injection of cortisone and a long-acting anesthetic, similar to lidocaine, to get the inflammation under control. Cortisone is a steroid that is very effective at reducing inflammation. Controlling the inflammation relieves some pain and allows the stretching program to be more effective.

Physical or occupational therapy treatments are a critical part of recovery and rehab. The first two goals are to reduce pain and interrupt the inflammatory cycle. Treatments are directed at getting the muscles to relax in order to help you regain the motion and function of your shoulder. This can be done with modalities such as electrical stimulation, joint mobilization, the use of cold, and iontophoresis. Iontophoresis is a way to push medications through the skin directly into the inflamed tissue.

Therapists use heat and hands-on treatments to stretch the joint capsule and muscle tissues of the shoulder. In some cases, it helps to inject a long-acting anesthetic with the cortisone right before a stretching session. This allows your therapist to manually break up the adhesions while the shoulder is numb from the anesthetic. You will also be given exercises and stretches to do as part of a home program. You may need therapy treatments for three to four months before you get full shoulder motion and function back.

During stage two, the therapist will address the capsular tightness and adhesions. Joint mobilization techniques are used to keep the joint sliding and gliding smoothly and to prevent scar tissue from forming. Keeping full shoulder and scapular (shoulder blade) motion is a priority. Special stretching techniques are used to prevent pain that could cause muscles around the shoulder to tighten even more.

Physical therapy throughout stages three and four continues in a similar fashion with added strengthening exercises.

Physical or occupational therapy treatments are a critical part of helping you regain the motion and function of your shoulder. Treatments are directed at getting the muscles to relax. Therapists use heat and hands-on treatments to stretch the joint capsule and muscle tissues of the shoulder. You will also be given exercises and stretches to do as part of a home program. You may need therapy treatments for three to four months before you get full shoulder motion and function back.

Surgery

Manipulation Under Anesthesia

If progress in rehabilitation is slow, your doctor may recommend manipulation under anesthesia. This means you are put to sleep with general anesthesia. Then the surgeon aggressively stretches your shoulder joint. The heavy action of the manipulation stretches the shoulder joint capsule and breaks up the scar tissue. In most cases, the manipulation improves motion in the joint faster than allowing nature to take its course. You may need this procedure more than once.

This procedure has risks. There is a very slight chance the stretching can injure the nerves of the brachial plexus, the network of nerves running to your arm. And there is a risk of fracturing the humerus (the bone of the upper arm), especially in people who have osteoporosis (fragile bones).

Arthroscopic Release

When it becomes clear that physical therapy and manipulation under anesthesia have not improved shoulder motion, arthroscopic release may be needed. This procedure is usually done using an anesthesia block to deaden the arm. The surgeon uses an arthroscope to see inside the shoulder. An arthroscope is a slender tube with a camera attached. It allows the surgeon to see inside the joint.

During the arthroscopic procedure, the surgeon cuts (releases) scar tissue, the ligament on top of the shoulder (coracohumeral ligament), and a small portion of the joint capsule. During the arthroscopic procedure a biopsy of the scar tissue is sent to the lab for evaluation to determine the stage of adhesive capsulitis. If shoulder movement is not regained or if the surgeon is unable to complete the surgery using the arthroscope, an open procedure may be needed. An open procedure requires a larger incision so the surgeon can work in the joint more easily.

At the end of the release procedure, the surgeon gently manipulates the shoulder to gain additional motion. A steroid medicine may be injected into the shoulder joint at the completion of the procedure.

Nerve Block

Numbing the suprascapular nerve to the shoulder is a newer technique used in some pain clinics. The procedure can be done on an outpatient basis, which means you’ll be in and out the same day. A single injection of a numbing agent combined with a steroid medication temporarily eliminates the pain signals. It’s like hitting a “reset” button. The nerve pathway sending continuous pain signals from the shoulder to the spinal cord and up to the brain is turned off. For a short time, the patient can move the arm fully without pain. Often, that’s enough to get the shoulder back on track for improved movement and function.

Hydrodilation

Another new technique called hyrdodilation or brisement is being used as an alternative to surgery. A fluid is injected into the joint causing the capsule to expand until it bursts. The result can be relief of pain and improved function. There haven’t been enough studies done yet to see how well this approach works. And there have been no studies comparing hydrodilation with manipulation or nerve block.

Rehabilitation

What can I expect after treatment?

Nonsurgical Rehabilitation

The primary goal of physical therapy is to help you regain full range of motion in the shoulder. If your pain is too strong at first to begin working on shoulder movement, your therapist may need to start with treatments to help control pain. Treatments to ease pain include ice, heat, ultrasound, and electrical stimulation. Therapists also use massage or other types of hands-on treatment to ease muscle spasm and pain.

When your shoulder is ready, therapy will focus on regaining your shoulder’s movement. Sessions may begin with treatments like moist hot packs or ultrasound. These treatments relax the muscles and get the shoulder tissues ready to be stretched. Therapists then begin working to loosen up the shoulder joint, especially the joint capsule. You can also get a good stretch using an overhead shoulder pulley in the clinic or as part of a home program.

If your doctor recommends an injection for your shoulder, you should plan on seeing your therapist right after the injection. The extra fluid from the injection stretches out the tissues of the joint capsule. An aggressive session of stretching right afterward can help maximize the stretch to the joint capsule.

After Surgery

After arthroscopic release, you’ll likely begin using a shoulder pulley on a daily basis. You’ll probably be encouraged to use the treated arm in everyday activities. Strengthening exercises are not begun for four to six weeks after the procedure. You might participate in physical or occupational therapy for up to two months after arthroscopic release.

After manipulation under anesthesia, your surgeon may place your shoulder in a continuous passive motion (CPM) machine. CPM is used after many different types of joint surgeries. You begin using CPM immediately after surgery. It keeps the shoulder moving and alleviates joint stiffness. The machine simply straps to the arm and continuously moves the joint. This continuous motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint.

Some surgeons apply a dynamic splint to the shoulder after manipulation surgery. A dynamic splint puts the shoulder into a full stretch and holds it there. Keeping the shoulder stretched gradually loosens up the joint capsule.

You’ll resume therapy within one to two days of the shoulder manipulation. Some surgeons have their patients in therapy every day for one to two weeks. Your therapist will treat you with aggressive stretching to help maximize the benefits of the shoulder manipulation. The stretching also keeps scar tissue from forming and binding the capsule again. Your shoulder movement should improve continually after the manipulation and therapy. If not, you may require more than one manipulation.

Once your shoulder is moving better, treatment is directed toward shoulder strengthening and function. These exercises focus on the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to help keep the ball of the humerus centered in the socket. This lets your shoulder move smoothly during all your activities.

The therapist’s goal is to help you regain shoulder motion, strength, and function. When you are well under way, regular visits to the therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Acromioclavicular Joint Separation

A Patient’s Guide to Acromioclavicular Joint Separation

Introduction

A shoulder separation is a fairly common injury, especially in certain sports. Most shoulder separations are actually injuries to the acromioclavicular (AC) joint. The AC joint is the connection between the scapula (shoulder blade) and the clavicle (collarbone). Shoulder dislocations and AC joint separations are often mistaken for each other. But they are very different injuries.

This guide will help you understand

what the AC joint is
what happens when the AC joint is separated
how an AC joint separation is treated.

Anatomy

What is the AC joint, and how does it work?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

The part of the scapula that makes up the top of the shoulder is called the acromion. The AC joint is where the acromion and the clavicle meet. Ligaments hold these two bones together.

Ligaments are soft tissue structures that connect bone to bone. The AC ligaments surround and support the AC joint. Together, they form the joint capsule.

The joint capsule is a watertight sac that encloses the joint and the fluids that bathe the joint. Two other ligaments, the coracoclavicular ligaments, hold the clavicle down by attaching it to a bony knob on the scapula called the coracoid process.

AC joint separations are graded from mild to severe, depending on which ligaments are sprained or torn. The mildest type of injury is a simple sprain of the AC ligaments. Doctors call this a grade one injury. A grade two AC separation involves a tear of the AC ligaments and a sprain of the coracoclavicular ligaments. A complete tear of the AC ligaments and the coracoclavicular ligaments is a grade three AC separation. This injury results in the obvious bump on the shoulder.

View animation of joint separation

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

How does AC joint separation happen?

The most common cause of an AC joint separation is falling on the shoulder. As the shoulder strikes the ground, the force from the fall pushes the scapula down. The collarbone, because it is attached to the rib cage, cannot move enough to follow the motion of the scapula. Something has to give. The result is that the ligaments around the AC joint begin to tear, separating (dislocating) the joint.

Symptoms

What symptoms does this condition cause?

Symptoms range from mild tenderness felt over the joint after a ligament sprain to the intense pain of a complete separation. Grade two and three separations can cause a considerable amount of swelling. Bruising may make the skin bluish several days after the injury.

In grade three separations, you may feel a popping sensation due to shifting of the loose joint. Grade three separations usually cause a noticeable bump on the shoulder.

Diagnosis

What tests will my doctor run?

Your doctor will need to get information about your injury and a detailed medical history. You will need to answer questions about past injuries to your shoulder. You may be asked to rate your pain on a scale of one to 10.

Diagnosis is usually made by the physical examination. Your doctor may move and feel your sore joint. This may hurt, but it is very important that your doctor understand exactly where your joint hurts and what movements cause you pain.

Your doctor may order X-rays. X-rays can show an AC joint disruption, and they may be necessary to rule out a fracture of the clavicle. In some cases, X-rays are taken while holding a weight in each hand to stress the joint and show how unstable it is.

Treatment

What treatment options are available?

Nonsurgical Treatment

Treatment for a grade one or grade two separation usually consists of pain medications and a short period of rest using a shoulder sling. Your rehabilitation program may be directed by a physical or occupational therapist.

The treatment of grade three AC separations is somewhat controversial. Many studies show no difference whether a person is treated with surgery or conservative treatment. Even with surgery, a bump may still be present where the separation occurred. And a significant portion of people who undergo surgery will need another operation later.

Several studies have looked at what happens to the AC joint after this injury. It appears that many people, whether they had the joint repaired surgically or not, will need an operation at some time in the future. The injured joint degenerates faster than normal. Over time it becomes arthritic and painful. This process may take years to develop, but sometimes it happens within one or two years.

Surgery

Some surgeons prefer to repair severe grade three AC separations, especially in high-level throwing athletes.

View animation of surgery

The surgery is usually done through a four-inch incision over the AC joint. The surgeon starts by putting the joint into its correct position. A screw or some other type of fixation may be used to hold the clavicle in place while the ligaments heal.

To fix the joint using a screw, the surgeon inserts the screw through the top of the clavicle and into the coracoid process.

Some surgeons use surgical tape to connect the clavicle and coracoid. A small drill hole is made in the clavicle and corocoid. The surgical tape is looped through each hole and pulled snugly.

In some cases, sutures are also used to repair and reinforce the torn coracoclavicular ligaments.

When a screw is used, it is usually removed six to eight weeks after the surgery. If it is not removed, the screw will probably break.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

If you don’t need surgery, range-of-motion exercises should be started as pain eases, followed by a program of strengthening. At first, exercises are done with the arm kept below shoulder level. The program advances to include strength exercises for the rotator cuff and shoulder blade muscles. In most cases, the pain goes away almost completely within three weeks. Full recovery can take up to six weeks for grade two separations and up to 12 weeks for grade three separations. Since there is little danger of making the condition worse, you can usually do whatever activities you can tolerate.

After Surgery

Therapists usually wait four weeks before starting range-of-motion exercises. You will probably begin with passive exercises. In passive exercises, the shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy starts six to eight weeks after surgery, giving the ligaments time to heal. Active range-of-motion exercises help you regain shoulder movement using your own muscle power. You might begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing joint.

After about three months, you will start more active strengthening. Exercises will focus on improving strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus centered in the socket. This helps your shoulder move smoothly during all your activities.

Recovery from shoulder surgery can take some time. You will need to be patient and stick to your therapy program. Some of the exercises you’ll do are designed get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Osteoarthritis of the Acromioclavicular Joint

A Patient’s Guide to Osteoarthritis of the Acromioclavicular Joint

Introduction

Some joints in the body are more likely to develop problems from normal wear and tear. Degeneration causes the cartilage that cushions the joint to wear out. This type of arthritis is called osteoarthritis. Doctors sometimes refer to this type of arthritis as arthrosis.

The acromioclavicular (AC) joint in the shoulder is a common spot for osteoarthritis to develop in middle age. Degeneration of the AC joint can be painful and can cause difficulty using the shoulder for everyday activities.

This guide will help you understand

what the AC joint is and how it works
the causes of pain and problems in the AC joint
the treatments used for this condition

Anatomy

What exactly is the AC joint?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

The part of the scapula that makes up the roof of the shoulder and connects with the clavicle is called the acromion.

The joint where the acromion and the clavicle join is the AC joint.

In some ways, the AC joint is like any other joint. It has two bones that need to connect but be flexible as well. The ends of the bones are covered with articular cartilage. Articular cartilage provides a slick, rubbery surface that allows the bones to glide over each other as you move. Cartilage also functions as sort of a shock absorber.

However, the AC joint is different from joints like the knee or ankle, because it doesn’t need to move very much. The AC joint only needs to be flexible enough for the shoulder to move freely. The AC joint just shifts a bit as the shoulder moves.

View animation of shoulder movement

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

Why does degeneration of the AC joint occur?

We use our shoulder constantly. The resulting strain makes AC joint osteoarthritis a common disorder. The AC joint is under constant stress as the arm is used overhead. Weightlifters and others who repeatedly lift heavy amounts of weight overhead tend to have an increased incidence of the condition, and often at a younger age.

AC joint osteoarthritis may also develop following an injury to the joint, such as an AC joint separation. This injury is fairly common. A separation usually results from falling on the shoulder. The shoulder does heal, but many years later degeneration causes the AC joint to become painful.

Symptoms

What are the symptoms of this condition?

In its early stages, AC joint osteoarthritis usually causes pain and tenderness in the front of the shoulder around the joint. The pain is often worse when the arm is brought across the chest, since this motion compresses the joint. The pain is vague and may spread to include the shoulder, the front of the chest, and the neck. If the joint has been injured in the past, there may be a bigger bump over the joint on the affected shoulder than on the unaffected shoulder. The joint may also click or snap as it moves.

Diagnosis

What tests will my doctor do?

Your doctor will want to get a detailed medical history, including questions about your condition and how it is affecting you. You will need to answer questions about past injuries to your shoulder. You may be asked to rate your pain on a scale of one to ten. Your doctor will also want to know how much your pain affects your daily tasks.

Diagnosis of AC joint osteoarthritis is usually made by physical examination. The AC joint is usually tender. A key finding is pain as the joint is compressed. To test for this, your arm is pulled gently across your chest. Your doctor may inject a local anesthetic such as lidocaine into the joint. If the AC joint is the problem, the injection will temporarily reduce the pain.

Your doctor may want to take X-rays of the AC joint. X-rays can show narrowing of the joint and bone spurs around the joint, which are signs of degeneration.

Treatment

What treatment options are available?

Nonsurgical Treatment

Initial treatment for AC joint osteoarthritis usually consists of rest and anti-inflammatory medications such as aspirin or ibuprofen. A rehabilitation program may be directed by a physical or occupational therapist. If the pain doesn’t go away, an injection of cortisone into the joint may help. Cortisone is a strong medication that decreases inflammation and reduces pain. Cortisone’s effects are often temporary, but it can give very effective relief in the short term.

Surgery

If nonsurgical measures fail to relieve your pain, your doctor may recommend surgery.

The most common procedure for AC joint osteoarthritis is resection arthroplasty. A resection arthroplasty involves removing a small portion of the end of the clavicle. This leaves a space between the acromion (the piece of the scapula that meets your shoulder) and the cut end of the clavicle, where the joint used to be. Your surgeon will take care not to remove too much of the end of the clavicle to prevent any damage to the ligaments holding the joint together.

Usually only a small portion is removed, less than one cm (about three-eighths of an inch). As your body heals, the joint is replaced by scar tissue. Remember, the AC joint doesn’t move much, but it does need to be flexible. The scar tissue allows movement but stops the bone ends from rubbing together.

The older open method of performing this operation is done by making a small incision, less than two inches long, over the AC joint. The AC joint is very close to the surface of the skin and can be easily reached through a small incision. The surgeon can then use a special saw or other instrument to shave off a small portion of the end of the clavicle.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

If you don’t need surgery, range-of-motion exercises should be started as pain eases, followed by a program of strengthening. At first, exercises are done with the arm kept below shoulder level. The program advances to include strength exercises for the rotator cuff and shoulder blade muscles. The goal is to get your shoulder moving smoothly and to learn how to control your symptoms. You will probably progress to a home program within four to six weeks.

After Surgery

Therapy goes slower after surgeries where an incision is made through the shoulder muscles. Therapists usually wait up to two weeks before starting range-of-motion exercises. You will begin with passive exercises. In passive exercises, the shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy starts after four to six weeks. Active range-of-motion exercises help you regain shoulder movement using your own muscle power. You might begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing joint.

At about six weeks, you will start more active strengthening. Exercises will focus on improving strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus centered in the socket. This helps your shoulder move smoothly during all your activities.

Revision Arthroplasty of the Knee

A Patient’s Guide to Revision Arthroplasty of the Knee

Introduction

Over the past 30 years, artificial knee replacement surgery has become increasingly common. Millions of people have gotten a new knee joint. The first time a joint is replaced with an artificial joint the operation is called a primary joint replacement. As people live longer and more people receive artificial joints, some of those joints begin to wear out and fail. When an artificial knee joint fails, a second operation is required to replace the failing joint. This procedure is called a revision arthroplasty.

This guide will help you understand

why revision surgery becomes necessary
what happens during the operation
what to expect during your recovery

Anatomy

What part of the knee is affected?

The knee joint is formed where the thighbone (femur) meets the shinbone (tibia). A slick cushion of articular cartilage covers the ends of both of these bones so that they slide against one another smoothly. The articular cartilage is kept slippery by joint fluid made by the joint lining (synovial membrane). The fluid is contained in a soft tissue enclosure around the knee joint called the joint capsule.

The kneecap (patella) is the moveable bone on the front of the knee. It is wrapped inside a tendon that connects the large muscles on the front of the thigh (the quadriceps muscles) to the tibia. The back of the patella is covered
with articular cartilage. The patella glides within a groove on the front of the femur.

Related Document: A Patient’s Guide to Knee Anatomy

Rationale

Why does a knee revision become necessary?

The most common reasons for knee revision arthroplasty are

mechanical loosening
infection in the joint
fracture of the bone around the joint
instability of the implant
wear of one or more parts of the implant
breakage of the implant

Mechanical Loosening

Mechanical loosening means that for some reason (other than infection) the attachment between the artificial joint and the bone has become loose. There are many reasons why this can occur. It may be that, given enough time, all artificial joints will eventually loosen. This is one reason that surgeons like to wait until absolutely necessary to put in an artificial joint. The younger you are when an artificial joint is put in, the more likely it is that the joint will loosen and require a revision. Mechanical loosening can occur in both cemented and uncemented artificial joints. (The different types of joints are described later.)

Infection

If an artificial joint is infected, it may become stiff and painful. It may also begin to lose its attachment to the bone. An infected artificial joint will probably have to be revised to try to cure the infection.

In the knee joint, operations to exchange the original implant (prosthesis) with a new one have a good chance of success. The decision to do a revision surgery depends in part on the type of bacteria that has infected the joint. In some uncommon cases, the type of bacteria is so harmful that a revision is not possible. In these unfortunate cases, the surgeon may suggest placing a cement spacer filled with antibiotics in the knee and having the patient wear a knee brace for support. In rare cases, the knee may need to be fused together, or possibly even amputated. In less aggressive infections, the infected artificial joint is removed at one operation. Antibiotics are given for up to three months until the infection is gone. Then a second operation is done to insert a new artificial knee.

Fracture

A fracture may occur near an artificial joint. It is sometimes necessary to

use a new artificial joint to fix the fracture. For example, if the femur (thighbone) breaks where the prosthesis attaches, it may be easier to replace the femoral part of the artificial joint with a new piece that has a longer stem that can hold the fracture together while it heals. This is similar to fixing the fracture with a metal rod.

Instability

Instability means that the artificial joint dislocates. This is very painful when it happens. It is unlikely that the knee joint will completely dislocate. However, it can happen. It is more common for the knee joint to be either too tight or too loose. If the knee joint is too loose, it can cause unsteadiness and pain. If the joint is too tight, the knee is usually painful and doesn’t have a good range of motion.

Wear

With the rise in knee joint replacements, surgeons have begun to see wear in the plastic parts of the artificial joints. In some cases, if the wear is discovered in time, the revision may only require changing the plastic part of the artificial joint. If the wear continues until the metal is rubbing on metal, the whole joint may need to be replaced.

Breakage

Finally, the metal of the artificial joint can break due to the constant stress that the artificial joint undergoes everyday. In weight-bearing joints like the knee, this is greatly affected by how much you weigh and how active you are.

Preparations

What happens before surgery?

Your surgeon will carefully plan the revision operation. Before the operation, many possible options and complications will have to be taken into account. Your surgeon will discuss these with you. Be sure to ask if there are parts of the procedure, your recovery, or the risks associated with a revision joint replacement that you have questions about.

Once the decision to proceed with surgery is made, several things may need to be done. Your orthopedic surgeon may suggest a complete physical examination by your medical or family doctor. This is to ensure that you are in the best possible condition to undergo the operation.

You may be scheduled for a bone scan so the surgeon can check for loosening of the artificial joint. When an artificial joint is loose, the bone around the joint reacts by trying to form new bone, a process called remodeling. The bone scan is done by injecting you with a weak radioactive chemical. Several hours later, a large camera is used to take a picture of the bone around the artificial joint. If the artificial joint is loose and there is remodeling going on, the picture will show a hot spot where the chemical has been added to the newly forming bone. The brighter the hot spot, the more likely it is that the artificial joint is loose.

If your surgeon suspects that the artificial knee is loose, other tests may be necessary to find out why the joint is loose. Before any plans are made to revise the artificial joint, most orthopedic surgeons will want to make sure that the knee is not loose because of infection. To check for infection, blood tests may be ordered. Your surgeon may also need to aspirate your knee. This involves inserting a needle into your knee joint, removing fluid, and sending the contents to the laboratory. Replacing any artificial joint that is infected is much more involved than replacing a noninfected, loose artificial joint. In some cases, infection will make a revision impossible.

Skin problems are common for people having knee revision arthroplasty. People who have low levels of lymphocytes (white blood cells that form antibodies to fight off infection) have an even greater risk of incision problems. Your surgeon may request a blood count before surgery to make sure you have adequate numbers of lymphocytes.

Past incisions in the knee can further complicate the planned revision procedure. People needing a knee revision will have at least one previous knee incision. Most surgeons who do knee revision surgery prefer to make an incision that runs down the center of the knee. This may not be possible due to previous knee incisions. The second choice is usually toward the outer (lateral) side of the knee. (Lateral is the side furthest from your other knee.) If the skin appears to be too tight for a planned incision to close, the risk of wound complications is high after the revision procedure. The orthopedic surgeon may need to consult with a plastic surgeon to ensure the best approach and result.

Another option is to use soft-tissue expanders. These are placed just under the skin next to where the revision incision will eventually go. The expanders stay in for up to eight weeks and are removed when you go in for the revision surgery. The idea is that the skin will have stretched enough so that, when the revision procedure is done, the edges of the skin can be closed and sutured together.

Before surgery, you may also need to spend time with the physical therapist who will manage your rehabilitation after the surgery. The therapist begins the teaching process before surgery to ensure that you are ready for rehabilitation afterwards. One purpose of the preoperative therapy visit is to record a baseline of information. This includes measurements of your current pain levels, functional abilities, and the available movement and strength of each knee. Any swelling in the artificial knee is noted.

A second purpose of the preoperative therapy visit is to prepare you for your upcoming surgery. You will begin to practice some of the exercises you will use just after surgery. You will also be trained in the use of either a walker or crutches. Finally, an assessment will be made of any needs you will have at home once you’re released from the hospital.

You may be asked to donate some of your own blood before the operation. This blood can be donated three to five weeks earlier. Your body will make new blood cells to replace the loss. If you need a blood transfusion during the operation, you will receive your own blood back from the blood bank.

Surgical Procedure

What happens during the operation?

Before describing the revision procedure, let’s look at the revision prosthesis itself.

The Revision Prosthesis

There are two major types of revision implants:

cemented prosthesis
uncemented prosthesis

A cemented prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone. An uncemented prosthesis has a fine mesh of holes on the surface that allows bone to grow into the mesh and attach the prosthesis to the bone.

Both are still widely used. In many cases a combination of the two types is used. The patellar (kneecap) portion of the prosthesis is commonly cemented into place. The decision to use a cemented or uncemented artificial knee is usually made by the surgeon based on your age, your lifestyle, and the surgeon’s experience.

Each prosthesis is made up of three main parts. The tibial component (bottom portion) replaces the top surface of the lower bone, the tibia. The stem of the tibial component used in revision surgery is usually much longer than the type used for primary knee replacements. This is because the bone of the tibia is usually not the same as when the initial replacement was done. The bone may be weaker, or there may be areas inside the tibia where bone is missing. A longer stem can reach further down the tibial canal and distribute your body weight better. It also gives the body a greater surface area for healing, which can improve fixation of the implant to the bone inside the tibia.

The femoral component (top portion) replaces the bottom surface of the upper bone (the femur) and the groove where the patella fits. Like the tibial component used in revision, the femoral component often has a long stem.

The patellar component (kneecap portion) replaces the surface of the patella where it glides in the groove on the femur.

The tibial component is usually made of two parts: a metal tray that is attached directly to the bone, and a plastic spacer that provides the slick surface. The femoral component is made of metal. In some types of knee implants, the patellar component is made of a combination of metal and plastic.

The Operation

To begin the procedure, the surgeon makes an incision down the front of the knee to allow access to the joint. The surgeon attempts to open the knee joint with the least amount of damage to the muscles and ligaments around the joint.

Next, the original artifical joint is removed. When the primary artificial joint was put in with cement, the cement has to be removed from inside the canal of the femur and the tibia. Because the bone is often fragile and the cement is hard, removing the cement can cause the femur or tibia to fracture during the operation. This is not unusual, and in most cases the surgeon will simply continue with the operation and fix the fracture as well.

Samples of bone and marrow tissue are usually removed during the surgery and sent to a laboratory to see if any infection is present. If an infection is present, a new artificial joint will probably not be put in (see below).

Revision joint replacements are much different from primary joint replacements. One reason that revision procedures are not routine is that there is almost always bone loss around the primary prosthesis. The surgeon deals with this problem by placing a bone graft or some other material around the artificial joint to reinforce the bone. This bone graft may come from your own body, such as bone taken from the pelvis during the same operation. This type of graft is called an autograft.

If the amount of bone needed is too large to take from your body, your surgeon may choose to use bone graft from the bone bank. This type of bone graft has been taken from someone else and placed in the bone bank. This type of transplant is called an allograft.

After application of bone and other materials to rebuild the tibia and/or femur, a new prosthesis is implanted. It is challenging to imitate the natural shape of the bones after rebuilding the bone, so a specially designed prosthesis is usually needed. All of this is carefully planned by the surgeon before the operation.

To get the best and sturdiest fit between the tibial and femoral components, the surgeon adjusts and balances the soft tissues that surround the knee joint. This may require cutting or tightening the ligaments on each side of the knee. Afterward, the surgeon checks the fit of the new knee components with the knee bent and then with the knee straightened. Further adjustment is made by changing out a thicker plastic portion of the tibial component. In the end, the surgeon tries to get the best fit so that the knee is stable through a full range of movement.

When the tibial and femoral components are in place and the soft tissues have been balanced, the surgeon will address the patella. In some cases, the patella may not need to be revised, especially when the surgeon sees good fixation of the original patellar implant. Sometimes the old patella component is simply removed, allowing the bone on the back of the patella to glide against the smooth surface on the front of the revision femoral component. In either case, the surgeon checks to see that the patella is lined up correctly and that it rides normally within the groove in the front of the femur.

Finally, the soft tissues of the knee are sewn back together, and metal staples or stitches are used to hold the skin incision together.

A revision joint replacement of the knee is more complex and unpredictable than a primary joint replacement. Since many factors can influence its longevity, your surgeon will not be able to say exactly how long your revision will last. Also, keep in mind that because revision surgery is more complicated than primary joint replacement, it may take up to a year to be able to perform your routine daily activities. Often people continue to need a walking aid because knee pain increases when they are on their feet for prolonged periods. There is also a greater chance that the knee will be tight and unable to bend all the way after knee revision surgery.

In some cases, if an artificial joint fails, it may not be possible to put another artificial joint back in. This can occur if the primary joint has failed because of an infection that cannot be controlled, if the bone has been destroyed so much that it will not support an artificial joint, or if your medical condition will not tolerate a major operation.

Sometimes a choice other than knee revision is best because a big operation might result in a failure, or even death. Removing the prosthesis and not replacing it doesn’t mean the patient can’t walk anymore. The surgeon may suggest fusing the joints of the knee, placing a spacer in the joint, or in some cases amputating the leg.

Complications

What might go wrong?

anesthesia complications
thrombophlebitis
infection
myositis ossificans
loosening
incision complications

Anesthesia Complications

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but it is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

pressure stockings to keep the blood in the legs moving
medications that thin the blood and prevent blood clots from forming

Infection

Infection can be a very serious complication following an artificial joint revision. Some infections may show up very early, even before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want to make sure that you take antibiotics when you have dental work or surgical procedures on your bladder and colon to reduce the risk of spreading germs to the joint.

The risk of infection is higher in revision arthroplasty than in primary joint replacement. In a primary knee replacement, the risk of infection is less than one percent. It goes up to two percent or more in revision cases. These figures are only an estimate and vary between different scientific studies.

Myositis Ossificans

Myositis ossificans is a curious problem that can affect the knee after both a primary knee replacement and a revision knee replacement. The condition occurs when the soft tissue around the knee joint begins to develop calcium deposits. Myositis means inflammation of muscle, and ossificans refers to the formation of bone. This can lead to a situation where new bone actually forms along the sides and top of the knee. This leads to stiffness and a loss of motion in the knee joint. It also causes pain.

Myositis ossificans is more common in people who have a long history of osteoarthritis with multiple bones spurs. Something about the genetic makeup in these people makes them more likely to produce bone tissue. Major reconstruction operations such as a knee revision seem to do more damage to the surrounding tissues than primary knee replacements. The operation is simply longer and harder to do. Calcium deposits are also more likely to form.

The treatment of myositis ossificans may actually begin before you get it. In cases where you are at high risk for developing this condition, your surgeon may recommend that you take medications such as indomethacin after surgery. This medication reduces the tendency for bone to form and may protect you from developing myositis ossificans.

A much more effective method that has been used a great deal to prevent the development of myositis ossificans involves radiation treatments immediately after surgery. These are the same type of radiation treatments used to treat cancer. Several short radiation treatments begun the day after surgery and continued for three to five days seem to drastically reduce the risk of developing myositis ossificans.

If myositis ossificans forms despite these precautions, treatment will depend on how much it affects your knee. Your surgeon will note how much pain it causes and how much it restricts motion. In some severe cases, you may choose to have a second operation to remove the calcified tissue that has formed. This is usually followed by radiation treatments to prevent the calcium deposits from returning.

Loosening

The major reason that artificial joints eventually fail continues to be from loosening where the metal or cement meets the bone. A loose revised prosthesis is a problem because it causes pain. Once the pain becomes unbearable, another revision surgery may be needed. The rate of loosening is higher after revision surgery than in primary arthroplasties.

Incision Complications

Poor healing of the incision is a fairly common complication of knee revision arthoplasty. This is because the tissue is often scarred and thinner than when the original knee replacement was done. The blood supply to the skin may not be normal due to damage to the blood vessels from one or more previous knee surgeries. As mentioned earlier, previous skin incisions can make it hard for the incision to close after knee revision surgery, leading to complications. When the incision doesn’t heal right, the chances of infection go up. The wound may continue to ooze, creating optimal conditions for bacterial growth.

Poor incision healing is more likely to occur in patients with one or more of the following factors:

anemia
obesity
past wound healing problems
weak immune system
tobacco habit
poor circulation
diabetes mellitus

Your surgeon’s goal is to prevent problems with the incision. If problems do happen, however, one or more additional surgeries will likely be needed.

After Surgery

What happens after surgery?

After surgery, your knee is covered with a padded dressing. Special boots or stockings are placed on your feet to help prevent blood clots from forming.

If a general anesthesia was used, a nurse or respiratory therapist will visit your room to guide you in a series of breathing exercises. You’ll use an incentive spirometer to improve breathing and avoid possible problems with pneumonia.

Several measures may be taken for patients who are at risk of incision problems. Some surgeons believe it is important to place a drain in the knee for a few days after surgery. The idea is that the drain will help keep swelling down. Too much swelling can pull the new incision apart and allow the wound to ooze. These factors place the knee at risk for infection. The practice of putting a drain in the knee is controversial, however, as some surgeons think that implanting the drain carries by itself an even bigger risk of infection.

A second measure to improve wound healing is to supply extra oxygen for three to four days through a nasal cannula. (A nasal cannula delivers oxygen through two small prongs placed into the nose.) The idea is that the added oxygen circulating in the blood stream will speed up the healing process and reduce the risk of incision problems.

You may also have physical therapy treatments once or twice each day as long as you are in the hospital. Therapy treatments will address the range of motion in the knee. Your therapist may also demonstrate exercises to improve knee mobility and engage the thigh and hip muscles. Ankle movements help pump swelling out of the leg and prevent the possibility of a blood clot.

When you are stabilized, your therapist will help you up for a short outing using your crutches or walker. After surgery, you may not be allowed to put weight on the affected leg for a period of time. This varies from surgeon to surgeon.

Most patients are able to go home after spending four to seven days in the hospital. You’ll be on your way home when you can get in and out of bed, walk up to 75 feet with your crutches or walker, go up and down stairs safely, and access the bathroom. It is also important that you regain a good muscle contraction of the quadriceps muscle and that you gain improved knee range of motion. Patients who need extra care may be sent to a different unit of the hospital until they are safe and ready to go home.

Most orthopedic surgeons recommend that you have routine checkups after your revision surgery. How often you need to be seen varies from every six months to every five years, according to your situation and what your surgeon recommends. You should always consult your orthopedic surgeon if you begin to have pain in your artificial joint or if you begin to suspect something is not working correctly.

Rehabilitation

What should I expect during my recovery?

After you are discharged from the hospital, your physical therapist may see you for one to six in-home treatments. This is to ensure you are safe in and about the home and getting in and out of a car. Your therapist will review your exercise program and make recommendations about your safety.

Your staples will be removed two weeks after surgery. Patients are usually able to drive within eight weeks and walk without a walking aid by two to three months. Upon the approval of the surgeon, patients are generally able to resume sexual activity by six to eight weeks after surgery.

You may see a physical therapist for outpatient therapy. Your therapist may use heat, ice, or electrical stimulation if you are still having swelling or pain.

During this time, you should continue to use your walker or crutches as instructed. If you had a cemented procedure, you’ll advance the weight you place on your sore leg as much as you feel comfortable. If you had a noncemented procedure, place only the toes down until you’ve had a follow-up X-ray and your surgeon or therapist directs you to put more weight through your leg (usually by the fifth or sixth week after surgery). Most patients progress to using a cane in six to eight weeks.

Your therapist may use hands-on stretches for improving range of motion. Strength exercises address key muscle groups including the buttock, hip, thigh, and calf muscles. Endurance can be improved through stationary biking, lap swimming, and using an upper body ergometer (upper cycle).

Therapists sometimes treat their patients in a pool. Exercising in a swimming pool puts less stress on the knee joint, and the buoyancy lets you move and exercise easier. Once you’ve gotten your pool exercises down and the other parts of your rehab program advance, you may be instructed in an independent program.

When you are safe in putting full weight through the leg, several types of balance exercises can be chosen to further stabilize and control the knee. Finally, a select group of exercises can be used to simulate day-to-day activities, such as going up and down steps, squatting, and walking on uneven terrain. Specific exercises may then be chosen to simulate work or hobby demands.

Your therapist will work with you to help keep your revised knee joint healthy for as long as possible. This may require that you adjust your activity choices to keep from putting too much strain on your revised knee joint. Heavy sports that require running, jumping, quick stopping and starting, and cutting are discouraged. Patients may need to consider alternate jobs to avoid work activities that require heavy lifting, crawling, and climbing.

The therapist’s goal is to help you maximize strength, walk normally, and improve your ability to do your activities. When you are well under way, regular visits to the therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Prepatellar Bursitis

A Patient’s Guide to Prepatellar Bursitis

Introduction

Prepatellar bursitis is the inflammation of a small sac of fluid located in front of the kneecap. This inflammation can cause many problems in the knee.

This guide will help you understand

how prepatellar bursitis develops
why the condition causes problems
what can be done for your pain

Anatomy

Where is the prepatellar bursa, and what does it do?

A bursa is a sac made of thin, slippery tissue. Bursae occur in the body wherever skin, muscles, or tendons need to slide over bone. Bursae are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts.

The prepatellar bursa is located between the front of the kneecap (called the patella) and the overlying skin. This bursa allows the kneecap to slide freely underneath the skin as we bend and straighten our knees.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

How does prepatellar bursitis develop?

Bursitis is the inflammation of a bursa. The prepatellar bursa can become irritated and inflamed in a number of ways.

In some cases, a direct blow or a fall onto the knee can damage the bursa. This usually causes bleeding into the bursa sac, because the blood vessels in the tissues that make up the bursa are damaged and torn. In the skin, this would simply form a bruise, but in a bursa blood may actually fill the bursa sac. This causes the bursa to swell up like a rubber balloon filled with water.

The blood in the bursa is thought to cause an inflammatory reaction. The walls of the bursa may thicken and remain thickened and tender even after the blood has been absorbed by the body. This thickening and swelling of the bursa is referred to as prepatellar bursitis.

Prepatellar bursitis can also occur over a longer period of time. People who work on their knees, such as carpet layers and plumbers, can repeatedly injure the bursa. This repeated injury can lead to irritation and thickening of the bursa over time. The chronic irritation leads to prepatellar bursitis in the end.

The prepatellar bursa can also become infected. This may occur without any warning, or it may be caused by a small injury and infection of the skin over the bursa that spreads down into the bursa. In this case, instead of blood or inflammatory fluid in the bursa, pus fills it. The area around the bursa becomes hot, red, and very tender.

Symptoms

What does prepatellar bursitis feel like?

Prepatellar bursitis causes pain and swelling in the area in front of the kneecap and just below. It may be very difficult to kneel down and put the knee on the floor due to the tenderness and swelling. If the condition has been present for some time, small lumps may be felt underneath the skin over the kneecap. Sometimes these lumps feel as though something is floating around in front of the kneecap, and they can be very tender. These lumps are usually the thickened folds of bursa tissue that have formed in response to chronic inflammation.

The bursa sac may swell and fill with fluid at times. This is usually related to your activity level, and more activity usually causes more swelling. In people who rest on their knees a lot, such as carpet layers, the bursa can grow very thick, almost like a kneepad in front of the knee.

Finally, if the bursa becomes infected, the front of the knee becomes swollen and very tender and warm to the touch around the bursa. You may run a fever and feel chills. An abscess, or area of pus, may form on the front of the knee. If the infection is not treated quickly, the abscess may even begin to drain, meaning the pus begins to seep out.

Diagnosis

How do doctors identify the condition?

The diagnosis of prepatellar bursitis is usually obvious from the physical examination. In cases where the knee swells immediately after a fall or other injury to the kneecap, X-rays may be necessary to make sure that the kneecap isn’t fractured. Chronic bursitis is usually easy to diagnose without any special tests.

If your doctor is uncertain whether or not the bursa is infected, a needle may be inserted into the bursa and the fluid removed. This fluid will be sent to a lab for tests to determine whether infection is present, and if so, what type of bacteria is causing the infection and what antibiotic will work best to cure the infection.

Treatment

What can be done for prepatellar bursitis?

Nonsurgical Treatment

Prepatellar bursitis that is caused by an injury will usually go away on its own. The body will absorb the blood in the bursa over several weeks, and the bursa should return to normal. If swelling in the bursa is causing a slow recovery, a needle may be inserted to drain the blood and speed up the process. There is a slight risk of infection in putting a needle into the bursa.

View animation of draining the prepatellar bursa

Chronic prepatellar bursitis is sometimes a real nuisance. The swelling and tenderness gets in the way of kneeling and causes pain. For people who need to kneel, this creates a hardship both in their occupation and recreational activities. Treatment usually starts by trying to control the inflammation. This may include a short period of rest or possibly a brace to immobilize the knee. Medications such as ibuprofen and aspirin may be suggested by your doctor to control the inflammation and swelling. A knee pad may be useful in making it easier to kneel on the affected knee.

If the bursa remains filled with fluid, a needle may be inserted and the fluid drained. During the drainage procedure, if there is no evidence of infection, a small amount of cortisone may be injected into the bursa to control the inflammation. Again, there is a small risk of infection if the bursa is drained with a needle.

Your doctor may also prescribe professional rehabilitation where the problems that are causing your symptoms will be evaluated and treated. Your physical therapist may suggest the use of heat, ice, and ultrasound to help calm pain and swelling. The therapist may also suggest specialized stretching and strengthening exercises used in combination with a knee brace, taping of the patella, or shoe inserts. These exercises and aids are used to improve muscle balance and joint alignment of the hip and lower limb, easing pressure and problems in the bursa.

If an infection is found to be causing the prepatellar bursitis, the bursa will need to be drained with a needle, perhaps several times over the first few days. You will be placed on antibiotics for several days. If the infection is slow to heal, the bursa may have to be drained surgically. To drain the bursa surgically, a small incision is made in the skin, and the bursa is opened. The skin and bursa are kept open by inserting a drain tube into the bursa for several days. This allows the pus to drain and helps the antibiotics clear up the infection.

Surgery

Surgery is sometimes necessary to remove a thickened bursa that has not improved with any other treatment. Surgical removal is usually done because the swollen bursa is restricting your activity.

To remove the prepatellar bursa, an incision is made over the top of the knee (either straight up and down or across the knee). Since the bursa is in front of the patella, the knee joint is never entered. The thickened bursa sac is removed, and the skin is repaired with stitches. You may need to stay off your feet for several days to allow the wound to begin to heal and to prevent bleeding into the area where the bursa was removed.

Some types of bursae will probably grow back after surgery, because the skin needs to slide over the kneecap smoothly. The body will form another bursa as a response to the movement of the patella against the skin during the healing phase. If all goes well, the bursa that returns after surgery will not be thick and painful, but more like a normal bursa.

Rehabilitation

What should I expect with treatment?

Nonsurgical Rehabilitation

Chronic prepatellar bursitis will usually improve over a period of time from weeks to months. The fluid-filled sac is not necessarily a problem, and if it does not cause pain, it is not always a cause for alarm or treatment. The sac of fluid may come and go with variation in activity. This is normal.

Patients with prepatellar bursitis may benefit from two to four weeks of physical therapy. Treatments such as ultrasound, electrical stimulation, and ice may be used to help control pain and swelling.

Therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can’t tolerate injections.

After Surgery

If surgery is required, you and your surgeon will come up with a plan for your rehabilitation. You will have a period of rest, which may involve using crutches. You will also need to start a careful and gradual exercise program. Patients often work with a physical therapist to direct the exercises for their rehabilitation program.

Popliteal Cysts

A Patient’s Guide to Popliteal Cysts

Introduction

A popliteal cyst, also called a Baker’s cyst, is a soft, often painless bump that develops on the back of the knee. A cyst is usually nothing more than a bag of fluid. These cysts occur most often when the knee is damaged due to arthritis, gout, injury, or inflammation in the lining of the knee joint. Surgical treatment may be successful when the actual cause of the cyst is addressed. Otherwise, the cyst can come back again.

This guide will help you understand

how a popliteal cyst develops
why a cyst can cause problems
what can be done for the condition

Anatomy

What is a popliteal cyst?

The knee joint is formed where the thighbone (femur) meets the shinbone (tibia). A slick cushion of articular cartilage covers the surface ends of both of these bones so that they slide against one another smoothly. The articular cartilage is kept slippery by joint fluid made by the joint lining (the synovial membrane). The fluid is contained in a soft tissue enclosure around the knee joint called the joint capsule.

A popliteal cyst is a small, bag-like structure that forms when the joint lining produces too much fluid in the knee. The extra fluid builds up and pushes through the back part of the joint capsule, forming a cyst. The cyst squeezes out toward the back part of the knee in the area called the popliteal fossa, the indentation felt in the back part of the knee between the two hamstring tendons and the top part of the calf muscle. Most people will be able to feel the cyst in the hollow area right behind the knee joint.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

Why does a popliteal cyst develop?

A popliteal cyst may form after damage to the joint capsule of the knee. The weakening of the joint capsule in the damaged area can cause the small sac of fluid to form. This can lead to a bulging of the joint capsule, much like what occurs when an inner tube bulges through a weak spot in a tire. The cyst may become larger over time.

A popliteal cyst can actually be a response to other conditions that cause swelling in the knee joint. This swelling is most often from problems of osteoarthritis or rheumatoid arthritis in the knee joint. It can also be caused by trauma, either from a direct blow to the knee or from repetitive activities that lead to overuse in the knee joint. A popliteal cyst is not from a blood clot in the leg, although sometimes it can be mistaken for a blood clot.

Symptoms

What does a popliteal cyst feel like?

The symptoms caused by a popliteal cyst are usually mild. You may have aching or tenderness with exercise or your knee may feel unsteady, as though it’s going to give out. You may feel pain from the underlying cause of the cyst, such as arthritis, an injury, or a mechanical problem with the knee, for instance a tear in the meniscus. Along with these symptoms, you may also see or feel a bulge on the back of your knee. Anything that causes the knee to swell and more fluid to fill the joint can make the cyst larger. It is common for a popliteal cyst to swell and shrink over time.

Sometimes a cyst will suddenly burst underneath the skin, causing pain and swelling in the calf. A ruptured popliteal cyst gives symptoms just like those of a blood clot in the leg, called thrombophlebitis. For this reason, it is important to determine right away the cause of the pain and swelling in the calf. Once the cyst ruptures, the fluid inside the cyst simply leaks into the calf and is absorbed by the body. In this case, you will no longer be able to see or feel the cyst. However, the cyst will probably return in a short time.

Diagnosis

How do doctors identify a popliteal cyst?

Your doctor will ask you to describe the history of your problem. Then the doctor will examine your knee and leg. A physical exam is usually all that is needed to diagnose a popliteal cyst. Unless the cyst has ruptured, further testing is typically not needed.

If the cyst has ruptured, additional tests will be required. Regular X-rays will not show the cyst since it is a soft tissue, and X-rays show mostly bones. A cyst can be seen with a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to create pictures that look like slices of the area your doctor is interested in. This test requires no needles or special dye and is painless. Your doctor may order an ultrasound test. This test uses sound waves to allow the doctor to see the outline of the cyst and determine whether it is filled with fluid or solid tissue. This is useful in determining whether the lump could actually be a tumor instead of a fluid-filled cyst.

Treatment

What can be done for the condition?

There are two types of treatment for popliteal cysts: surgical and nonsurgical. Whether or not the cyst has ruptured, how painful the cyst has become, or how much it interferes with the normal use of your knee will determine which is the best course of treatment for you. In adults the treatment is most often nonsurgical. If surgery is needed, it is usually done on an outpatient basis, meaning you can leave the hospital the same day. Unless there is a lot of discomfort from the cyst, surgery is rarely required.

Nonsurgical Treatment

Drawing the fluid out with a needle and syringe can reduce the size of the cyst. Then cortisone can be injected into the affected area to reduce inflammation. These are usually temporary solutions, however. Nonsurgical treatment also includes rest and keeping your leg propped up for several days.

In some cases doctors have their patients work with a physical therapist who uses massage treatments, compression wraps, and electrical stimulation to reduce knee swelling. Flexibility and strengthening exercises for the lower limb may be used to help improve muscle balance in the knee.

Nonsurgical treatments are usually most effective when the underlying cause of the cyst is addressed. In other words, the effects of arthritis, gout, or injury to the knee need to be controlled.

If nonsurgical methods fail, complete removal of the cyst may be needed. Once they are reassured that the cyst is not dangerous, many people simply ignore the problem unless it becomes very painful.

Surgery

The goal of surgery is to remove the cyst and repair the hole in the joint

lining where the cyst pushed through. Unfortunately, about half of the time the cyst comes back, or recurs, after being removed. Surgeons are cautious when suggesting surgery to remove a popliteal cyst because they are prone to recur. The cure is often permanent, but preventing further cysts depends a great deal on the success of treating the underlying cause. You should be aware that there is a very real chance that your cyst may return after being removed and there is no guarantee that the surgery will be successful.

Surgery can take more than an hour to complete. It is performed either under a general anesthetic, which causes you to sleep during the surgery, or using spinal anesthesia, which numbs the lower half of your body only. With spinal anesthesia, you may be awake during the surgery, but you won’t be able to watch what’s happening.

An incision will be made in the skin over the cyst. The cyst is then located and separated from the surrounding tissues. The area of the joint capsule where the cyst appears to be coming from is identified. A synthetic patch may be sewn in place to cover the hole in the joint capsule left by the removal of the cyst.

Your knee will be bandaged with a well-padded dressing and a splint for support. Your surgeon will want to check your knee within five to seven days. Stitches will be removed after 10 to 14 days. You may have some discomfort after surgery, and you will be given pain medicine to control the discomfort.

A popliteal cyst forms very near the major nerve and blood vessels of the leg. It is possible that these structures can be injured during surgery. If an injury happens, it can be a serious complication. Injury to the nerves can cause numbness or weakness in the foot and lower leg. Injury to the blood vessels may require surgery to repair them. In addition, it is uncommon but possible that another cyst can occur.

Rehabilitation

What should I expect with treatment?

Nonsurgical Rehabilitation

With nonsurgical rehabilitation, a popliteal cyst may improve in two to four weeks. Improvement, however, depends a great deal on improvement in the underlying condition (the problems that are causing the knee to swell). As long as the joint continues to swell, the size of the cyst will ebb and flow. If the knee is kept from swelling, the cyst won’t swell.

Your doctor may have you work with a physical therapist. Treatments such as ultrasound, electrical stimulation, and soft-tissue massage may be used to ease pain and swelling from the cyst.

After Surgery

If you have surgery to remove the cyst, you can resume your daily activities and work as soon as you are able. You should keep your knee propped up for several days to avoid swelling and throbbing. Take all medicines exactly as prescribed by your surgeon. Be sure to keep all follow-up appointments.

Your surgeon may want you to use crutches or a cane for awhile. Avoid vigorous exercise for six weeks after surgery. You should be able to resume driving two weeks after surgery. Your surgeon may have you attend physical therapy sessions to regain the strength in your leg.

Plica Syndrome

A Patient’s Guide to Plica Syndrome

Introduction

Plica syndrome is an interesting problem that occurs when an otherwise normal structure in the knee becomes a source of knee pain due to injury or overuse. The diagnosis can sometimes be difficult, but if this is the source of your knee pain, it can be easily treated.

This guide will help you better understand

what a plica is
how plica syndrome can cause problems
what doctors can do to treat the condition

Anatomy

What is a plica, and what does it do?

Plica is a term used to describe a fold in the lining of the knee joint. Imagine the inner lining of the knee joint as nothing more than a sleeve of tissue. This sleeve of tissue is made up of synovial tissue, a thin, slippery material that lines all joints. Just as a tailor leaves extra folds of material at the back of sleeves on a shirt to allow for unrestricted motion of the arms, the synovial sleeve of tissue has folds of material that allow movement of the bones of the joint without restriction.

Four plica synovial folds are found in the knee, but only one seems to cause trouble. This structure is called the medial plica. The medial plica attaches to the lower end of the patella (kneecap) and runs sideways to attach to the lower end of the thighbone at the side of the knee joint closest to the other knee. Most of us (50 to 70 percent) have a medial plica, and it doesn’t cause any problems.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

How does a plica cause problems in the knee?

A plica causes problems when it is irritated. This can occur over a long period of time, such as when the plica is irritated by certain exercises, repetitive motions, or kneeling. Activities that repeatedly bend and straighten the knee, such as running, biking, or use of a stair-climbing machine, can irritate the medial plica and cause plica syndrome.

Injury to the plica can also happen suddenly, such as when the knee is struck in the area around the medial plica. This can occur from a fall or even from hitting the knee on the dashboard during an automobile accident. This injury to the knee can cause the plica, and the synovial tissue around the plica, to swell and become painful. The initial injury may lead to scarring and thickening of the plica tissue later. The thickened, scarred plica fold may be more likely to cause problems later.

Symptoms

What does plica syndrome feel like?

The primary symptom caused by plica syndrome is pain. There may also be a snapping sensation along the inside of the knee as the knee is bent. This is due to the rubbing of the thickened plica over the round edge of the thighbone where it enters the joint. This usually causes the plica to be tender to the touch. In thin people, the tissue that forms the plica may be actually be felt as a tender band underneath the skin. In rare cases where the plica has become severely irritated, the knee may become swollen.

Diagnosis

How will my doctor know it’s plica syndrome?

Diagnosis begins with a history and physical exam. The examination is used to try and determine where the pain is located and whether or not the band of tissue can be felt. X-rays will not show the plica. X-rays are mainly useful to determine if other conditions are present when there is not a clear-cut diagnosis.

If there is uncertainty in the diagnosis following the history and physical examination, or if other injuries in addition to the plica syndrome are suspected, magnetic resonance imaging (MRI) may be suggested. The MRI machine uses magnetic waves to show the soft tissues of the body. Usually this test is done to look for injuries, such as tears in the meniscus or ligaments of the knee. This test does not require any needles or special dye and is painless. A computed tomography (CT) scan may also be used to see whether the plica has become thickened. Most cases of plica syndrome will not require special tests such as the MRI or CT scan.

If the history and physical examination strongly suggest that a plica syndrome is present, then arthroscopy may be suggested to confirm the diagnosis and treat the problem at the same time. Arthroscopy is an operation that involves inserting a small fiber-optic TV camera into the knee joint, allowing the surgeon to look at the structures inside the knee joint directly. The arthroscope allows your surgeon to see the condition of the whole knee and determine whether the medial plica is inflamed.

Treatment

What can be done for plica syndrome?

The majority of people with plica syndrome will get better without surgery. The primary goal when treating the plica is to reduce the inflammation. This may require limiting activities like running, biking, or using a stair-climbing machine.

Nonsurgical Treatment

Your doctor may suggest anti-inflammatory medications such as ibuprofen or aspirin to reduce the inflammation. Ice packs or ice massage can help reduce the inflammation and swelling in the area of the plica and may be suggested by your doctor or physical therapist. Ice massage is easy and effective. Simply freeze water in a paper cup. When needed, tear off the top inch, exposing the ice. Rub three to five minutes around the sore area until it feels numb.

A cortisone injection into the plica, or simply into the knee joint, may quickly help to reduce the inflammation around the plica. Cortisone is a powerful anti-inflammatory medication, but it should be used sparingly inside joints. There is always a risk of infection associated with injections into any joint.

Surgery

If all nonsurgical attempts to reduce your symptoms fail, surgery may be suggested. Usually, an arthroscope (mentioned earlier) is used to remove the plica. The small TV camera is inserted into the knee joint through one-quarter inch incisions. Once the plica is located with the arthroscope, small instruments are inserted through another one-quarter inch incision to cut away the plica tissue and remove the structure. The area where the plica is removed heals back with scar tissue. There are no known problems associated with not having a plica, so you won’t miss it.

Rehabilitation

What should I expect following treatment?

Nonsurgical Rehabilitation

If your treatment is nonsurgical, you should be able to return to normal activity within four to six weeks. You may work with a physical therapist during this time. Treatments involve stretching and strengthening exercises for the leg.

Treatments such as ultrasound, friction massage, and ice may be used to calm inflammation in the plica. Therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can’t tolerate injections.

After Surgery

Your surgeon may have you work with a physical therapist after surgery. Your first few rehabilitation sessions are designed to ease pain and swelling and help you begin gentle knee motion and thigh tightening exercises. Patients rarely need to use crutches after this kind of surgery.

As the program evolves, more challenging exercises are chosen. Patients do closed chain exercises by keeping their foot on a surface while working the knee joint. These exercises mimic familiar activities like squatting down, lunging forward, and going up or down steps. These exercises help keep pressure off the kneecap while getting a challenging workout for the leg muscles. Your therapist will work with you to make sure you are not having extra pain in your knee during the exercises. You may be shown stretches for the soft tissues along the edge of the kneecap as well as flexibility exercises for the hamstrings, quadriceps, and calf muscles.

The therapist’s goal is to help you keep your pain under control, increase the strength of your quadriceps muscles, and maximize the range of motion in your knee. When you are well under way, your regular visits to the therapist’s office will end. The therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Posterior Cruciate Ligament Injuries

A Patient’s Guide to Posterior Cruciate Ligament Injuries

Introduction

The posterior cruciate ligament (PCL) is one of the less commonly injured ligaments of the knee. Understanding this injury and developing new treatments for it have lagged behind the other cruciate ligament in the knee, the anterior cruciate ligament (ACL), probably because there are far fewer PCL injuries than ACL injuries.

This guide will help you understand

where the PCL is located
how a PCL injury causes problems
how doctors treat the condition

Anatomy

Where is the PCL, and what does it do?

Ligaments are tough bands of tissue that connect the ends of bones together. The PCL is located near the back of the knee joint. It attaches to the back of the femur (thighbone) and the back of the tibia (shinbone) behind the ACL.

The PCL is the primary stabilizer of the knee and the main controller of how far backward the tibia moves under the femur. This motion is called posterior translation of the tibia. If the tibia moves too far back, the PCL can rupture.

More recent research has shown us that the PCL also prevents medial-lateral (side-to-side) and rotatory movements. This confirms the suspicion that the PCL’s effect on knee joint function is more complex than previously thought.

The PCL is made of two thick bands of tissue bundled together. One part of the ligament tightens when the knee is bent; the other part tightens as the knee straightens. This is why the PCL is sometimes injured along with the ACL when the knee is forced to straighten too far, or hyperextend.

Both bundles of the PCL not only change length with knee flexion and extension, but they also change their orientation (direction of the fibers) from front-to-back and side-to-side. This function allows the ligament to keep the tibia from sliding too far back or slipping from side-to-side.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

How do PCL injuries occur?

PCL injuries can occur with low-energy and high-energy injuries. The most common way for the PCL alone to be injured is from a direct blow to the front of the knee while the knee is bent. Since the PCL controls how far backward the tibia moves in relation to the femur, if the tibia moves too far, the PCL can rupture.

Sometimes the PCL is injured during an automobile accident. This can happen if a person slides forward during a sudden stop or impact and the knee hits the dashboard just below the kneecap. In this situation, the tibia is forced backward under the femur, injuring the PCL. The same problem can happen if a person falls on a bent knee. Again, the tibia may be forced backward, stressing and possibly tearing the PCL.

Other parts of the knee may be injured when the knee is violently hyperextended, but other ligaments are usually injured or torn before the PCL. This type of injury can happen when the knee is struck from the front when the foot is planted on the ground.

Symptoms

What does an injured PCL feel like?

The symptoms following a tear of the PCL can vary. The PCL is not actually enclosed inside the knee joint like the ACL. So unlike an ACL tear, which swells the joint with blood, PCL injuries don’t make the knee swell as much. Most patients with a PCL injury sense a feeling of stiffness and some swelling. Some patients may also have a feeling of insecurity and giving way of the knee, especially when trying to change direction on the knee. The knee may feel like it wants to slip.

The pain and moderate swelling from the initial injury will usually be gone after two to four weeks, but the knee may still feel unstable. The symptom of instability and the inability to trust the knee for support are what requires treatment. Also important in the decision about treatment is the growing realization by orthopedic surgeons that long-term instability leads to early arthritis of the knee.

Diagnosis

How do doctors identify the problem?

The history and physical examination is probably the most important tool in diagnosing a ruptured or deficient PCL. During the physical examination, special stress tests are performed on the knee. Three of the most commonly used tests are the posterior Lachman test, the posterior sag test, and the posterior drawer test. The posterior drawer test is a very sensitive and specific test for PCL injuries. The doctor will place your knee and leg in various positions and then apply a load or force to the joint. Any excess motion or unexpected movement of the tibia relative to the femur may be a sign of ligament damage and insufficiency.

Tests are also done to see if other knee ligaments or joint cartilage have been injured. Damage to the PCL along with damage to the posterolateral corner (PLC) of the joint cartilage often leads to rotatory instability. This means the tibia slides back on the femur and twists or rotates at the same time. Rotatory instability can affect walking ability. Failure to diagnose a PCL injury can be a major cause of failure of surgery to repair a ruptured anterior cruciate ligament (ACL). The doctor may order X-rays of the knee to rule out a fracture. Ligaments and tendons do not show up on X-rays.

The magnetic resonance imaging (MRI) scan is probably the most accurate test without actually looking into the knee. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. The pictures show the anatomy, and any injuries, very clearly. This test does not require any needles or special dye and is painless.

In some cases, arthroscopy may be used to make the definitive diagnosis if

there is a question about what is causing your knee problem. Arthroscopy is a type of operation where a small fiber-optic TV camera is placed into the knee joint, allowing the surgeon to look at the structures inside the joint directly. The vast majority of PCL tears are diagnosed without resorting to this type of surgery, though arthroscopy is sometimes used to repair a torn PCL.

Treatment

What can be done for the condition?

Nonsurgical Treatment

Initial treatment for a PCL injury focuses on decreasing pain and swelling in the knee. Rest and mild pain medications, such as acetaminophen, can help decrease these symptoms. You may need to use a long-leg brace and crutches at first to limit pain. Most patients are given the okay to put a normal amount of weight down while walking.

Less severe PCL tears are usually treated with a progressive rehabilitation program. Patients intending to return to high-demand activities may require a functional knee brace before returning to these activities. These braces are designed to replace knee stability when the PCL doesn’t function properly. They help keep the knee from giving way during moderate activity, but they can give a false sense of security and won’t always protect the knee during sports that require heavy cutting, jumping, or pivoting. These braces are not the type you can buy at the drugstore. Most orthopedists will recommend wearing a brace for at least one year after a reconstruction, so even if you decide to have surgery, a brace is probably a good investment.

Most patients receive physical therapy treatments after a PCL injury. Therapists treat swelling and pain with the use of ice, electrical stimulation, and rest periods with your leg supported in elevation.

Exercises are used to help you regain normal movement of joints and muscles. Range-of-motion exercises should be started right away with the goal of helping you swiftly regain full movement in your knee. This includes the use of a stationary bike, gentle stretching, and careful pressure applied to the knee by the therapist.

Exercises are also given to improve the strength of the quadriceps muscles on the front of the thigh. As your symptoms ease and strength improves, you will be guided in specialized exercises to improve knee stability.

Surgery

If the PCL alone is injured, nonsurgical treatment may be all that is necessary. When other structures in the knee are injured, patients generally do better having surgery within a few weeks after the injury. Long-term studies show that without reconstructive surgery, over time, knee instability and joint degeneration develop.

If the symptoms of instability are not controlled by a brace and rehabilitation program, then surgery may be suggested. The main goal of surgery is to keep the tibia from moving too far backwards under the femur and to get the knee functioning normally again. New studies also suggest the need to restore medial-lateral (side-to-side) and rotational stability, too.

Even when surgery is needed, most surgeons will have their patients attend physical therapy for several visits before the surgery. This is done to reduce swelling and to make sure you can straighten your knee completely. This practice reduces the chances of scarring inside the joint and can speed your recovery after surgery.

Most surgeons now favor reconstruction of the PCL using a piece of tendon or ligament to replace the torn PCL. This surgery is most often done using the arthroscope (mentioned earlier). Incisions are usually still required around the knee, but the surgery doesn’t require the surgeon to open the joint. The arthroscope is used to perform the work needed on the inside of the knee joint. Most PCL surgeries are now done on an outpatient basis, and most patients stay either one night in the hospital, or they go home the same day as the surgery.

In a typical surgical reconstruction, the torn ends of the PCL must first be removed. Once this has been done, the type of graft that will be used is determined. One of the most common tendons used for the graft material is the patellar tendon. This tendon connects the kneecap (patella) to the tibia.

About one third of the patellar tendon is removed, with a plug of bone at either end. The bone plugs are rounded and smoothed. Holes are drilled in each bone plug to place sutures (strong stitches) that will pull the graft into place. Then holes are drilled in the tibia and the femur to place the graft. These holes are placed so that the graft will run between the tibia and femur in the same direction as the original PCL. The graft is then pulled into position using sutures placed through the drill holes. Screws are used to hold the bone plugs in the drill holes.

Another very common graft involves using two of the tendons that attach to the tibia just below the knee joint, the gracilis tendon and the semitendinosus tendon. By arranging these tendons into three or four strips, the graft has nearly the same strength as a patellar tendon graft.

The gracilis and semitendinosus tendons can be taken out without really affecting the strength of the leg because bigger and stronger hamstring muscles will take over the function of the two tendons that are removed.

Other materials are also used to replace the torn PCL. In some cases, an allograft is used. An allograft is tissue that comes from someone else. This tissue is harvested from tissue and organ donors at the time of death and sent to a tissue bank. The tissue is checked for any type of infection, sterilized, and stored in a freezer. When needed, the tissue is ordered by the surgeon and used to replace the torn PCL. The advantage of using an allograft is that the surgeon does not have to disturb or remove any of the normal tissue from your knee to use as a graft. For this reason the operation also usually takes less time.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Nonsurgical treatment of an injured PCL will typically last six to eight weeks. You will be able to return to your sport activities when your quadriceps muscles are back to near their normal strength, your knee stops swelling intermittently, and you no longer have problems with the knee giving way.

After Surgery

You may use a continuous passive motion (CPM) machine immediately after your operation to help the knee begin to move and to alleviate joint stiffness. The machine straps to the leg and continuously bends and straightens the joint. This continuous motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint.

Your surgeon may also have you wear a protective knee brace for up to six weeks after surgery. You’ll probably use crutches for two to four weeks in order to keep your knee
safe and will probably be instructed to put only a limited amount of weight down while you’re up and walking.

Patients usually take part in formal physical therapy after PCL reconstruction. The first few physical therapy treatments are designed to help control the pain and swelling from the surgery. Therapists will begin to focus on range of motion exercises within three weeks. They take care to avoid letting the tibia sag back under the femur, as this can put strain on the healing graft.

Strengthening exercises for the quadriceps muscle on the front of the thigh are safe to begin right away. Muscle stimulation and biofeedback, which both involve placing electrodes over the quadriceps muscle, may be needed at first to get the muscle going again and help retrain it. As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the knee’s strength and function.

When you get full knee movement, your knee isn’t swelling, and your strength is improving, you’ll be able to gradually get back to your work and sport activities. Some surgeons prescribe the use of a functional brace for athletes who intend to return quickly to their sport.

Ideally, you’ll be able to resume your previous lifestyle activities. However, athletes are usually advised to wait at least six months before returning to their sport. And most patients are encouraged to modify their activity choices.

You will probably be involved in a progressive rehabilitation program for four to six months after surgery to ensure the best result from your PCL reconstruction. In the first six weeks following surgery, expect to see the physical therapist two to three times a week. If your surgery and rehabilitation go as planned, you may only need to do a home program and see your therapist every few weeks over the four to six month period.

Tibial Osteotomy

A Patient’s Guide to Tibial Osteotomy

Introduction

Knee osteoarthritis often affects only one side of the knee joint. When this occurs, realigning the angle made between the bones of the leg can shift your body weight so that the healthy side of the knee joint takes more of the stress. The procedure to realign the angles of the lower leg is called a proximal tibial osteotomy.

This guide will help you understand

what your surgeon hopes to achieve with the procedure
what happens during the surgery
what to expect after your operation

Anatomy

Which parts of the knee are involved?

The knee joint is formed where the thighbone (femur) meets the shinbone (tibia). Two bony knobs on the end of the femur, called condyles, sit on the top surface of the tibia. The inside condyle (the one closest to the other knee) is called the medial femoral condyle. The lateral femoral condyle is on the outer half of the femur (farthest from the other knee). The top of the tibia bone forms a flat surface called the tibial plateau.

The knee is divided into two halves, or compartments. The medial compartment is the inside half of the knee and is formed by the connection of the medial femoral condyle and the tibial plateau. The lateral compartment is the outside half of the knee and is formed by the connection of the lateral femoral condyle and the tibial plateau.

Articular cartilage covers the ends of bones. It has a smooth, slippery surface that allows the bones of the knee joint to slide over each other without rubbing. This slick surface is designed to minimize pressure and friction as you move.

Related Document: A Patient’s Guide to Knee Anatomy

Rationale

What does the surgeon hope to achieve with surgery?

Osteoarthritis of the knee sometimes affects one side of the knee far more than the other. While either side can suffer greater damage, usually the inside half of the knee joint (the medial compartment) is more affected. When this uneven damage occurs to one side of the knee, the other side may still have good cartilage on the joint surfaces.

In some cases, surgery to realign the angles in the lower leg can result in shifting pressure to the other, healthier side of the knee. The goal is to reduce the pain and delay further degeneration in the weaker half of the knee.

This procedure is most often used for younger, active patients and for those who have osteoarthritis in only one side of their knee joint. This operation may increase the life span of the joint and prolong the time before a knee replacement surgery becomes necessary.

Preparation

How should I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. The amount of time you spend in the hospital varies and depends on how quickly you recover.

Surgical Procedure

What happens during the operation?

There are two methods to realign the knee joint. One involves taking out a wedge of bone; the other involves adding a wedge of bone. Any operation for cutting through a bone is called an osteotomy. In a closing wedge osteotomy, the surgeon cuts though the tibia on the lateral side, removes a wedge of bone, and pins the open edges together. In an opening wedge osteotomy, the surgeon cuts though the tibia on the medial side and opens a wedge, adding a bit of bone graft to hold the wedge open.

Closing Wedge Osteotomy

In the closing wedge osteotomy, an incision is made in the lateral side of the knee to allow the surgeon to see the upper end of the tibia. Care is taken to protect the nerves and blood vessels that travel across the knee joint.

Once the tibia bone is exposed, two cuts are made through the upper tibia in the shape of a wedge. The surgeon uses either X-rays or a fluoroscope, a special kind of X-ray machine that casts images on a fluorescent screen, to make sure the wedge is the right size and is placed correctly.

The surgeon takes out the wedge, and the two sides of the tibia are brought closer together and held in position with a metal plate or pins. This changes the angle of the tibia and helps straighten the alignment of the knee. After fixing the two edges of bone with a plate or pins, the surgeon stitches the skin together, and the leg is placed in a padded splint to protect the knee joint.

Opening Wedge Osteotomy

In the opening wedge osteotomy, an incision is made in the medial side of

the knee. Again, care is taken to protect the nerves and blood vessels that travel across the knee joint.

Once the tibia bone is exposed, one cut is made through the upper tibia. A fluoroscope or X-rays are used to make sure the cut is in the right place.

After the bone is cut, the two sides of the tibia are separated to form a wedge-shaped opening. This opening is then filled with bone graft. The bone graft is usually taken from pelvis bone, through an incision in the side of your hip. The bone graft is held in position with a metal plate or pins. After fixing the two edges of bone with a plate or pins, the surgeon stitches the skin together, and the leg is placed in a padded splint to protect the knee joint.

Complications

What might go wrong?

anesthesia complications
thrombophlebitis
infection
scar tissue formation
nonunion of the bones

Anesthesia Complications

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include

pressure stockings to keep the blood in the legs moving
medications that thin the blood and prevent blood clots from forming

Infection

Following surgery, it is possible that the surgical incision can become infected. This will require antibiotics and possibly another surgical procedure to drain the infection.

Scar Tissue Formation

The most common complication after a tibial osteotomy is the formation of scar tissue in the joint below the kneecap. Bleeding and swelling from the surgery can cause the body to form scar tissue. When scar tissue builds up just below the kneecap, the knee can’t straighten completely. When this happens, another operation may be required to remove the scar tissue.

Nonunion of the Bones

Sometimes the two bone edges do not heal as planned. This is called a nonunion. This condition requires another operation to add bone graft and perhaps additional metal plates or pins. The bones need to be completely immobilized to fuse, or heal together firmly, so an external fixator may be needed to help hold the bones in position as they heal. The external fixator is worn over the skin and connects to the metal pins to hold them firmly in place. Because the bone of the upper tibia is wide and has a good blood supply, nonunion is rare.

Continued Pain

In some cases the tibial osteotomy simply does not achieve the results expected. This can occur due to more advanced osteoarthritis in other areas of the joint, especially in the cartilage behind the kneecap. If you continue to have pain or do not achieve the results that you expect from the operation, the next step is usually to replace the knee joint with an artificial joint.

After Surgery

What happens after surgery?

Your surgeon may have you use a continuous passive motion (CPM) machine immediately after surgery to help the knee begin moving and to alleviate joint stiffness. The machine straps to the leg and continuously bends and straightens the joint. This motion is thought to reduce stiffness, ease pain, prevent blood clots from forming, and prevent extra scar tissue from forming inside the joint.

Along with the CPM, you may be seen by a physical therapist to maximize your range of motion. As your condition stabilizes, your therapist will also help you up for a short outing using your crutches or your walker.

Most patients are able to go home after spending one or two days in the hospital. You’ll be on your way home when you can demonstrate a safe ability to get in and out of bed, walk up to 75 feet with your crutches or walker, go up and down stairs safely, and access the bathroom. It is also important that you regain a good muscle contraction of the quadriceps muscle in the thigh and that you gain improved knee range of motion.

A tibial osteotomy in the best of circumstances is probably only temporary. It is thought that this operation buys some time before a total knee replacement becomes necessary. The benefits of the operation usually last for five to seven years if successful.

Rehabilitation

What should I expect during my rehabilitation?

You will probably wear a knee brace for up to six weeks after surgery to protect the knee joint as you recover. Your stitches will normally be removed in 10 to 14 days. Recovery after a tibial osteotomy takes two to three months.

During your recovery period, you should use your walker or crutches as instructed. If you had a closing wedge osteotomy, you probably won’t have to limit how much weight you place on your foot. But with an opening wedge procedure, you’ll need to protect the healing bone graft by only placing the toes of the operated leg on the floor when you walk. Your surgeon will take a follow-up X-ray to see when the graft is safe for you to begin putting more weight down when you walk. This is usually six to eight weeks after surgery.

A physical therapist will begin assisting you with treatment shortly after surgery. Your therapist may use heat, ice, or electrical stimulation if you have swelling or pain. Your therapist may also use hands-on stretches and show you exercises to improve knee range of motion. Strength exercises address key muscle groups including the buttock, hip, thigh, and calf muscles. Endurance can be achieved through stationary biking, lap swimming, and using an upper body ergometer (upper cycle).

When you are safe in putting full weight through the leg, several types of balance exercises can be chosen to further stabilize and control the knee.

Finally, a select group of exercises can be used to simulate day-to-day activities, such as going up and down steps, squatting, rising on your toes, and bending down. Specific exercises may then be chosen to simulate work or hobby demands.

Many patients have less pain and better mobility after a tibial osteotomy procedure. Your therapist will work with you to help keep your knee joint healthy for as long as possible. This may require that you adjust your activity choices to keep from placing too much strain on your knee.

The therapist’s goal is to help you improve knee range of motion, maximize strength, and improve your ability to do your activities. When you are well under way, regular visits to your therapist’s office will end. The therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Osteochondritis Dissecans of the Knee

A Patient’s Guide to Osteochondritis Dissecans of the Knee

Introduction

Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). A joint surface damaged by OCD doesn’t heal naturally. Even with surgery, OCD usually leads to future joint problems, including degenerative arthritis and osteoarthritis.

This guide will help you understand

where in the knee the condition develops
how doctors diagnose the problem
what treatment options are available

Anatomy

What part of the knee is affected?

OCD mostly affects the femoral condyles of the knee. The femoral condyle is the rounded end of the lower thighbone, or femur. Each knee has two femoral condyles, referred to as the medial femoral condyle (on the inside of the knee) and the lateral femoral condyle (on the outside). Like most joint surfaces, the femoral condyles are covered in articular cartilage. Articular cartilage is a smooth, rubbery covering that allows the bones of a joint to slide smoothly against one another.

The problem occurs where the cartilage of the knee attaches to the bone underneath. The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

The lesions usually occur in the part of the joint that holds most of the body’s weight. This means that the problem area is under constant stress and doesn’t get time to heal. It also means that the lesions cause pain and problems when walking and putting weight on the knee. It is more common for the lesions to occur on the medial femoral condyle, because the inside of the knee bears more weight.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

How does the condition develop?

Juvenile Osteochondritis Dissecans

Children as young as nine or ten can develop this condition. But the disease behaves much differently in children and for this reason is given a separate name, juvenile osteochondritis dissecans (JOCD), meaning osteochondritis dissecans of children.

OCD and JOCD cause the same kind of damage to the knee, but they are separate diseases. In the child who is still growing, the problem is much more likely to heal itself. In the adult, the bones are not growing. For this reason, the treatment and prognosis of OCD and JOCD can be very different.

Many doctors think that JOCD is caused by repeated stress to the bone. Most young people with JOCD have been involved in competitive sports since they were very young. A heavy schedule of training and competing can stress the femur in a way that leads to JOCD. In some cases, other muscle or bone problems can cause extra stress and contribute to JOCD.

Osteochondritis Dissecans

Sometimes JOCD is not treated or does not heal completely. When this happens, JOCD develops into OCD. OCD can occur any time from early adulthood on, but most patients are adults under age 50. The cases of OCD that are first diagnosed in early adulthood probably began as JOCD. When a person gets OCD later in life, it is probably a brand new problem.

Doctors aren’t sure what causes OCD. There is less of a link between strenuous, repetitive use and OCD. Many people who develop OCD don’t have any particular risk factors.

Because OCD leads to damage to the surface of the joint, the condition can lead to problems with bone degeneration and osteoarthritis. The damage to the joint surface affects the way that the joint works. Like a machine that is out of balance, over time this imbalance can lead to abnormal wear and tear on the joint. This is one cause of degenerative arthritis and osteoarthritis.

Symptoms

What do OCD and JOCD feel like?

OCD and JOCD cause the same symptoms. The symptoms start out mild and grow worse with time. Both problems usually start with a mild aching pain. Moving the knee becomes painful, and it may be swollen and sore to the touch. Eventually, there is too much pain to put full weight on that knee. These symptoms are fairly common in athletes. They are similar to the symptoms of sprains, strains, and other knee problems.

As the condition becomes worse, the area of bone that is affected may collapse, causing a notch to form in the smooth joint surface. The cartilage over this dead section of bone (the lesion) may become damaged. This can cause a snapping or catching feeling as the knee joint moves across the notched area. In some cases the dead area of bone may actually become detached from the rest of the femur, forming what is called a loose body. This loose body may float around inside of the knee joint. The knee may catch or lock when it is moved if the loose body gets in the way.

Diagnosis

How do doctors identify this problem?

Your doctor will ask many questions about your medical history. You will be asked about your current symptoms and about other knee or joint problems you have had in the past. Your doctor will then examine the painful knee by feeling it and moving it. You may be asked to walk, move, or stretch your knee. This may hurt, but it is important that your doctor knows exactly where and when your knee hurts.

Your doctor will probably order an X-ray of your knee. Most OCD lesions will show up on an X-ray of the knee. If not, your doctor may suggest a bone scan.

A bone scan involves injecting a special type of dye into the blood stream and then taking pictures of the bones with a special camera. This camera is similar to a Geiger counter and can pick up very small amounts of radiation. The dye that is injected is a very weak radioactive chemical. It attaches itself to areas of bone that are undergoing rapid changes, such as a healing fracture. A bone scan is the best way to see the lesions in the very early stages.

Your doctor may want to do other imaging tests, such as magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. With this machine, doctors are able to create pictures that look like slices of the knee and see the anatomy, and any injuries, very clearly. These tests may help determine the extent of damage from OCD and JOCD, and they also help rule out other problems.

Treatment

How do doctors treat the condition?

Many cases of JOCD can be completely healed with careful treatment. OCD will probably never completely heal, but it can be treated. There are two methods of treating JOCD: nonsurgical treatment to help the lesions heal, and surgery. Surgery is usually the only effective treatment for OCD.

Nonsurgical Treatment

Nonsurgical treatments help in about half the cases of JOCD. The goal is to help the lesions heal before growth stops in the thighbone. Even if imaging tests show that growth has already stopped, it is usually worth trying nonsurgical treatments. When these treatments work, the knee seems as good as new, and the JOCD doesn’t seem to lead to arthritis.

Nonsurgical treatment of JOCD can take from 10 to 18 months. During that time, it is crucial to stop doing everything that causes pain to the knee. This means stopping exercise and sports. It may require using crutches or wearing a cast for a couple of months when symptoms are present. As knee symptoms ease, exercises can be started that don’t involve placing weight through your foot. The exercises should be done carefully and should not cause any pain. Patients often work with physical therapists to develop an exercise program.

Your doctor may want to see what is happening in the knee and may suggest additional tests if your symptoms change. This may include new X-rays, MRI scan or a bone scan if your symptoms warrant additional testing. Even in JOCD, surgery may eventually be required. When the lesion has become so bad that it detaches totally or partially from the bone, nonsurgical treatment will not work. Even with the treatment, some patients continue to have symptoms or their bone scans show signs that the damage is getting worse.

Some patients who are too near the end of bone growth may not benefit with nonsurgical treatment. When these problems develop, your surgeon may suggest surgery.

Surgery

If the lesion becomes totally or partially detached, surgery is needed to remove the loose body or to fix it in place. Your surgeon will need to gather lots of information about your knee and your problem before surgery.

This may require additional bone scans, X-rays, or MRIs. Your surgeon may also use an arthroscope, a tiny camera inserted into the knee to look at your knee before doing surgery to fix the problem. These tests are important because your surgeon needs to know the exact location and the size of the lesion to determine what kind of surgery will work best.

Arthroscopic Method

In some cases, your surgeon will be able to use the arthroscope to do the surgery. If the arthroscope can be used, the procedure requires smaller incisions than for an open surgery. This may reduce the time needed before the knee can be moved and exercised.

Open Method

Open surgery is needed when your surgeon can’t get a picture of the entire lesion, when it is unclear how the fragment would best fit into the bone, or when it would be too difficult to replace the fragment using the arthroscope. Open surgery usually requires larger incisions than arthroscopic surgery to allow the surgeon to see into the knee and perform the operation.

Fragment Repair

If the loose bone fragment is in a weight-bearing area of your bone, your surgeon will try to reattach it if at all possible. Your surgeon may use tiny metal pins or screws to hold the fragment in place. This sometimes proves difficult. The damaged fragment often doesn’t fit perfectly into the bone anymore. And the bone around the fragment has often changed in ways that mean your surgeon will need to rebuild it.

Despite the difficulties, reattaching the fragment generally results in much better knee function than removing it. Your knee will not be as good as new, but a careful plan of exercise and follow-up care can help you use your knee again without pain.

Allograft Transplant

In rare cases, the lesion must be removed from a weight-bearing area. Your surgeon may try to fill in the hole using an allograft. An allograft is an actual transplant of bone and cartilage from a donor into your knee. The bone is usually obtained from a bone and tissue bank.

In this case, bone material is transplanted into the hole left in the bone. Allografts have risks, including graft rejection and infection. But they can be very successful in returning function to the knee.

Osteochondral Autograft

An autograft is a procedure for grafting tissue from the patient’s own body. The place where the graft is taken is called the donor site. In this case, surgeons graft a small amount of bone (osteo) and cartilage (chondral) from the donor site to put into the lesion. Usually, the donor site for this procedure is on the joint surface of the injured knee. Surgeons are careful to take the graft from a spot that won’t cause a lot of problems, usually on the top and outside border of the knee cartilage. Even then, people sometimes end up with problems around the donor site. Surgeons have gotten good results with this surgery, but it is challenging to contour the graft to be just the same shape as the covering of the joint.

Autologous Chondrocyte Implantation

A new technology called autologous chondrocyte implantation is currently being developed. It involves using cartilage cells (chondrocytes) to help regenerate articular cartilage. This technology looks promising for treating JOCD and OCD but is still very much experimental.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

The goal of nonsurgical rehabilitation is to help you learn ways to protect the injured area of cartilage while improving knee motion and strength. You may be advised to avoid heavy sport or work activities for up to eight weeks. Doing exercises in a pool can help you stay limber and fit while protecting the knee during this period.

Your doctor may have you work with a physical therapist for four to six weeks. Range-of-motion and stretching exercises are used to improve knee motion. Your therapist may issue shock-absorbing shoe insoles to reduce impact and protect your knee joint. You will also be shown strengthening exercises for the hip and knee to help steady the knee and give it additional protection from shock and stress.

After Surgery

If you have surgery, your surgeon may have you use a continuous passive motion (CPM) machine after surgery to help the knee begin to move and to alleviate joint stiffness.

With the exception of arthroscopic removal of a loose body, patients are instructed to avoid putting too much weight on their foot when standing or walking for up to six weeks. This gives the area time to heal. Weight bearing is usually restricted for up to four months after transplant procedures.

Patients are strongly advised to follow the recommendations about how much weight is safe. They may require a walker or pair of crutches for up to six weeks to avoid putting too much pressure on the joint when they are up and about.

Many surgeons will have their patients take part in formal physical therapy after knee surgery for osteochondritis lesions. The first few physical therapy treatments are designed to help control the pain and swelling from the surgery. Physical therapists will also work with patients to make sure they are only putting a safe amount of weight on the affected leg.

Exercises are chosen to help improve knee motion and to get the muscles toned and active again. At first, emphasis is placed on exercising the knee in positions and movements that don’t strain the healing part of the cartilage. As the program evolves, more challenging exercises are chosen to safely advance the knee’s strength and function.

Ideally, patients will be able to resume their previous lifestyle activities. Some patients may be encouraged to modify their activity choices, especially if an allograft was used.

The therapist’s goal is to help you keep your pain under control, ensure safe weight bearing, and improve your strength and range of motion. When you are well under way, regular visits to your therapist’s office will end. The therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Knee Osteoarthritis

A Patient’s Guide to Osteoarthritis of the Knee

Introduction

Knee Osteoarthritis (OA) is a common problem for many people after middle age. OA is sometimes referred to as degenerative, or wear and tear, arthritis. OA commonly affects the knee joint. In fact, knee OA is the most common cause of disability in the United States. In the past, people were led to believe that nothing could be done for their problem. Now doctors have many ways to treat knee OA so patients have less pain, better movement, and enhanced quality of life.

This guide will help you understand

how OA develops
how OA of the knee causes problems
how doctors treat the condition

Anatomy

Which parts of the knee are affected?

The main problem in OA is degeneration of the articular cartilage. Articular cartilage is the smooth lining that covers the ends of the leg bones where they meet to form the knee joint. The cartilage gives the joint freedom of movement by decreasing friction. The layer of bone just below the articular cartilage is called subchondral bone.

When the articular cartilage degenerates, or wears away, the bone underneath is uncovered and rubs against bone. Small outgrowths called bone spurs or osteophytes may form in the joint.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

How does knee OA develop?

OA of the knee can be caused by a knee injury earlier in life. It can also come from years of repeated strain on the knee. Fractures of the joint surfaces, ligament tears, and meniscal injuries can all cause abnormal movement and alignment, leading to wear and tear on the joint surfaces. Not all cases of knee OA are related to a prior injury, however. Scientists believe genetics makes some people prone to developing degenerative arthritis. Obesity is linked to knee OA. Losing only 10 pounds can reduce the risk of future knee OA by 50 percent.

Scientists believe that problems in the subchondral bone may trigger changes in the articular cartilage. Normally, the articular cartilage protects the subchondral bone. But some medical conditions can make the subchondral bone too hard or too soft, changing how the cartilage normally cushions and absorbs shock in the joint.

Symptoms

What does knee OA feel like?

Knee OA develops slowly over several years. The symptoms are mainly pain, swelling, and stiffening of the knee. Pain is usually worse after activity, such as walking. Early in the course of the disease, you may notice that your knee does fairly well while walking, then after sitting for several minutes your knee becomes stiff and painful. As the condition progresses, pain can interfere with simple daily activities. In the late stages, the pain can be continuous and even affect sleep patterns.

Diagnosis

How do doctors identify OA?

The diagnosis of OA can usually be made on the basis of the initial history and examination.

X-rays can help in the diagnosis and may be the only special test required in the majority of cases. X-rays can also help doctors rule out other problems, since knee pain from OA may be confused with other common causes of knee pain, such as a torn meniscus or kneecap problems. In some cases of early OA, X-rays may not show the expected changes.

Magnetic resonance imaging (MRI) may be ordered to look at the knee more closely. An MRI scan is a special radiological test that uses magnetic waves to create pictures that look like slices of the knee. The MRI scan shows the bones, ligaments, articular cartilage, and menisci. The MRI scan is painless and requires no needles or dye.

If the diagnosis is still unclear, arthroscopy may be necessary to actually look inside the knee and see if the joint surfaces are beginning to show wear and tear. Arthroscopy is a surgical procedure in which a small fiber-optic TV camera is inserted into the knee joint through a very small incision, about one-quarter of an inch long. The surgeon can move the camera around inside the joint while watching the pictures on a TV screen. The structures inside the joint can be poked and pulled with small surgical instruments to see if there is any damage.

Treatment

What can be done for the condition?

Nonsurgical Treatment

OA can’t be cured, but therapies are available to ease symptoms and to slow down the degeneration. Recent information shows that mild cases of knee OA may be maintained and in some cases improved without surgery.

Medication

Your physician may prescribe medicine to help control your pain. Acetaminophen (Tylenol®) is a mild pain reliever with few side effects. Some people may also get relief of pain with anti-inflammatory medication, such as ibuprofen and aspirin. Newer anti-inflammatory medicines called COX-2 inhibitors show promising results and don’t cause as much stomach upset and other intestinal problems.

Medical studies have shown that glucosamine and chondroitin sulfate can also help people with knee OA. These supplements seem to have nearly the same benefits as anti-inflammatory medicine with fewer side affects. Many doctors feel the research supports these supplements and are encouraging their patients to use them.

If you aren’t able to get your symptoms under control, a cortisone injection may be prescribed. Cortisone is a powerful anti-inflammatory medication, but it has secondary effects that limit its usefulness in the treatment of OA. Multiple injections of cortisone may actually speed up the process of degeneration.

Repeated injections also increase the risk of developing a knee joint infection, called septic arthritis. Any time a joint is entered with a needle, there is the possibility of an infection. Most physicians use cortisone sparingly, and avoid multiple injections unless the joint is already in the end stages of degeneration, and the next step is an artificial knee replacement.

A new type of injectable medication has become available in the United States. Hyaluronic acid has been used in Europe and Canada for several years. Doctors inject three to five doses into the joint over a one-month period. The medicine helps lubricate the joint, ease pain, and improve people’s ability to get back to some of the activities they enjoy. Some people have had good results for up to eight months after getting these treatments.

Physical Therapy

Physical therapy plays a critical role in the nonoperative treatment of knee OA. A primary goal is to help you learn how to control symptoms and maximize the health of your knee. You will learn ways to calm pain and symptoms, which might include the use of rest, heat, or topical rubs.

Physical therapists teach their patients how to protect the arthritic knee joint. This starts with tips on choosing activities that minimize impact and twisting forces on the knee. People who modify their activities can actually slow down the effects of knee OA. For instance, people who normally jog might decide to walk, bike, or swim to reduce impact on their knee joint. Sports that require jumping and quick starts and stops may need to be altered or discontinued to protect the knee joint.

Shock-absorbing insoles placed in your shoes can also reduce impact and protect the joint. In advanced cases of knee OA or when the knee is especially painful, a cane or walker may be recommended to ease joint pressure when walking. People who walk regularly are encouraged to choose a soft walking surface, such as a cinder or grass track.

A new type of knee brace, called a knee unloading brace, can help when OA is affecting one side of the knee joint. For example, a bowlegged posture changes the way the knee joint lines up. The inside (medial) part of the knee joint gets pressed together. The cartilage suffers more damage, and greater pain and problems occur. The unloading brace pushes against the outer (lateral) surface of the knee, causing the medial side of the joint to open up. In this way, the brace shares the pressure and unloads the arthritic medial side of the joint. A knee unloading brace can help relieve pain and allow people to do more of their usual activities.

For mild cases of knee OA, you may be given a heel wedge to wear in your shoe. By tilting the heel, the wedge alters the way the knee lines up, which works like the unloading brace mentioned above to take pressure off the arthritic part of the knee.

Range-of-motion and stretching exercises will be used to improve knee motion. You will be shown strengthening exercises for the hip and knee to help steady the knee and give additional joint protection from shock and stress. People with knee OA who have strong leg muscles have fewer symptoms and prolong the life of their knee joint. Your therapist will also suggest tips for getting your tasks done with less strain on the joint.

Surgery

In some cases, surgical treatment of OA may be appropriate.

In cases of advanced OA where surgery is called for, patients may also see a physical therapist before surgery to discuss exercises that will be used just after surgery and to begin practicing using crutches or a walker.

Arthroscopy

Surgeons can use an arthroscope (mentioned earlier) to check the

condition of the articular cartilage. They can also clean the joint by removing loose fragments of cartilage. People have reported relief when doctors simply flush the joint with saline solution. A burring tool may be used to roughen spots on the cartilage that are badly worn. This promotes growth of new cartilage called fibrocartilage, which is like scar tissue. This procedure is often helpful for temporary relief of symptoms for up to two years.

Related Document: A Patient’s Guide to Arthroscopy

Proximal Tibial Osteotomy

OA usually affects the side of the knee closest to the other knee (called the medial compartment) more often than the outside part (the lateral compartment). OA in the medial compartment can lead to bowing of the knee. As mentioned earlier, a bowlegged posture places more pressure than normal on the medial compartment. The added pressure leads to more pain and faster degeneration where the cartilage is being squeezed together.

Surgery to realign the angles in the lower leg can help shift pressure to the other, healthier side of the knee. The goal is to reduce the pain and delay further degeneration of the medial compartment.

One procedure to realign the angles of the lower leg is called a proximal tibial osteotomy. In this procedure, the upper (proximal) part of the shinbone (tibia) is cut, and the angle of the joint is changed. This converts the extremity from being bowlegged to straight or slightly knock-kneed. By correcting the joint deformity, pressure is taken off the cartilage. A proper joint angle actually allows the cartilage to regrow, a process called regeneration.

This surgical procedure is not always successful. Generally, it will reduce your pain but not eliminate it altogether. The advantage to this approach is that very active people still have their own knee joint, and once the bone heals there are no restrictions on activities.

A proximal tibial osteotomy in the best of circumstances is probably only temporary. It is thought that this operation buys some time before a total knee replacement becomes necessary. The benefits of the operation usually last for five to seven years if successful.

Related Document: A Patient’s Guide to Tibial Osteotomy

Artificial Knee Replacement

An artificial knee replacement is the ultimate solution for advanced knee OA.

Surgeons prefer not to put a new knee joint in patients younger than 60. This is because younger patients are generally more active and might put too much stress on the joint, causing it to loosen or even crack. A revision surgery to replace a damaged prosthesis is harder to do, has more possible complications, and is usually less successful than a first-time joint replacement surgery.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Nonsurgical treatments are used to maximize the health of your knee and to prolong the time before surgery is needed. Physical therapy may be needed to ease pain and improve mobility, strength, and function. The focus of these visits is to help you learn to control symptoms as well as learn strategies to protect your knee over the years. You will probably progress to a home program within two to four weeks.

After Surgery

Physical therapy treatments after surgery depend on the type of surgery performed. Rehabilitation is generally slower and more cautious after knee replacement procedures and certain types of tibial osteotomies. After simple procedures such as arthroscopy, you may begin fairly aggressive exercise therapy immediately.

Therapy treatments usually begin the next day after surgery. Your first few rehabilitation sessions are used to ease pain and swelling, help you begin gentle knee motion and thigh tightening exercises, and get you up and walking safely. You may need to use either a walker or crutches after surgery. Some patients may be instructed to limit how much weight they place on the knee for four to six weeks.

After going home from the hospital, some patients may be seen for a short period of home therapy before beginning outpatient physical therapy. Outpatient treatments are designed to improve knee range of motion and strength and to safely progress your ability to walk and do daily activities.

The therapist’s goal is to help you keep your pain under control, maximize knee mobility, and improve muscle strength and control. When you are well under way, regular visits to your therapist’s office will end. The therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Viscosupplementation for Osteoarthritis of the Knee

A Patient’s Guide to Viscosupplementation for Osteoarthritis of the Knee

Introduction

The squeaky hinge gets the grease. In the same way, the joint that aches from osteoarthritis (OA) gets the attention. Since the knee works like a hinge joint, it makes sense that lubricating the joint might help people with knee osteoarthritis. Accordingly, a treatment called viscosupplementation has been used by doctors to restore lubrication in osteoarthritic knee joints.

Viscosupplementation has been around for 20 years. It is becoming a common form of treatment for patients with knee OA. While the injections are thought to have a number of benefits, some are still not well understood, and the injections themselves can be costly. The treatment for a single knee costs more than $500.

This guide will help you understand

what doctors believe the supplements can do
how the treatments are administered
what to expect after treatment

Anatomy

What part of the knee does OA affect?

The main problem in knee OA is degeneration of the articular cartilage. Articular cartilage is the smooth lining that covers the ends of the leg bones where they meet to form the knee joint. The cartilage gives the joint freedom of movement by decreasing friction.

The articular cartilage is kept slippery by joint fluid made by the joint lining (the synovial membrane). The fluid, called synovial fluid, is contained in a soft-tissue enclosure around the knee joint called the joint capsule.

An important substance present in articular cartilage and synovial fluid is called hyaluronic acid. Hyaluronic acid helps joints collect and hold water, improving lubrication and reducing friction. It also acts by allowing cells to move and work within the joint.

Osteoarthritis results in less hyaluronic acid in the synovial fluid. As a result, the joint surfaces of the knee don’t get lubricated and are more likely to get injured from daily stresses and strain on the joint.

When the articular cartilage degenerates, or wears away, the bone underneath is uncovered and rubs against bone. Small outgrowths called bone spurs, or osteophytes, may form in the joint.

Related Document: A Patient’s Guide to Knee Anatomy

Rationale

What do doctors hope to achieve with this treatment?

A healthy knee contains about 2 milliliters of synovial fluid and a hyaluronic acid concentration of 2.5 to 4.0 milligrams per milliliter. Patients with knee OA have one-half to one-third less hyaluronic acid than normal.

The missing hyaluronic acid changes the viscosity (the stickiness) and the elasticity of the synovial fluid. That’s a problem because the viscosity of the synovial fluid is thought to help maintain normal joint lubrication and to protect the joint from shock and strain. When there are reduced levels of hyaluronic acid, the joint may be more susceptible to injury. So viscosupplementation (injecting hyaluronic acid into the joint)is used in an effort to make the osteoarthritic synovial fluid more like healthy synovial fluid.

The idea behind hyaluronic acid injections is fairly simple. Since the synovial fluid in osteoarthritic patients is low in hyaluronic acid, the injections are intended to boost the level.

It isn’t clear how this works. The injected hyaluronic acid seems to leave the knee relatively quickly, so it’s possible doctors aren’t simply replacing missing hyaluronic acid. Research suggests that viscosupplementation may stimulate the body to create additional hyaluronic acid.

Injections of hyaluronic acid reduce the chemicals that cause inflammation within the synovial fluid of patients with arthritis. These anti-inflammatory properties may explain why some patients report pain relief. The injections are also thought to potentially protect or repair the chondrocytes, the cartilage cells. However, tests have only involved animals so far and are inconclusive.

Doctors suggest viscosupplementation for patients who can’t tolerate or shouldn’t take nonsteroidal anti-inflammatory drugs (NSAIDs). Patients who haven’t had success with other nonsurgical treatments, such as NSAIDs or corticosteroid injections, may also be candidates. The treatments are helpful for patients with mild knee osteoarthritis who need better knee function and for patients with advanced knee arthritis who hope to prolong the time before needing a total joint replacement.

Although this treatment is only prescribed for OA of the knee, someday it may be used to treat OA in other joints, such as the shoulder, hip, ankle, and wrist.

Preparation

How will I prepare for treatment?

The decision to proceed with this treatment must be made jointly by you and your orthopedic surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, you should talk to your doctor.

Once you decide to have the treatment, your orthopedic surgeon will have you schedule your appointments, usually one visit per week for three to five weeks.

Procedure

How are these treatments administered?

In the United States, two viscosupplements are available for patients with knee OA. They are Synvisc® and Hyalgan®.

To begin, you’ll lie on your back with your knee straight. The knee is then scrubbed with a germ-killing solution. You’ll be asked to relax your leg muscles while the orthopedist places the needle into the knee joint just to the left or right of the kneecap.

After the viscosupplement has been injected into the knee, the needle is removed. The area is cleaned and bandaged. Patients are asked to bend and straigthen the leg a few times to get the substance to all parts of the joint.

Patients usually get one shot into the knee joint each week for up to five weeks.

Complications

What might go wrong?

Studies have shown that viscosupplementation is safe. Pain, warmth, and swelling at the site of the injection are the most common complaints. These normally clear up in one to two days.

Severe inflammation is an unlikely complication, but it can occur. The joint may swell with fluid. The symptoms may mimic septic arthritis, an infection in the knee joint.

Any injection into the knee joint does carry a risk of infection. Because more than one injection is usually given, the risk of infection goes up.

After Care

What happens after treatment?

Patients are able to go about their usual activity after the procedure. Within a few days, patients may be instructed by their doctor to attend physical therapy.

When the shots work, they can provide relief for several months. Unfortunately, people generally don’t get equal relief when they go back for a second or third series of shots.

Rehabilitation

Alhough viscosupplementation appears to have a useful place in treating knee OA, it is best used along with a variety of proven strategies. Patients do best when they also

Get aerobic exercise.
Do strengthening and range-of-motion exercises. These are most often taught and monitored by physical therapists.
Lose weight.
Use heat and cold packs.
Wear wedged insoles in their shoes when indicated.
Receive massage.
Use equipment to help take pressure off their joints, such as a cane.
Participate in education programs or support groups.

By decreasing pain and increasing joint movement in the knee, viscosupplementation may help patients maximize their ability to take care of their knee OA.