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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.

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.

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.

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.

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.