Shoulder

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.

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.

Related Document: A Patient’s Guide to Joint Injections for Arthritis

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.

Related Document: A Patient’s Guide to Shoulder Dislocations

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.

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.

Related Document: A Patient’s Guide to Joint Injections for Arthritis

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.

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 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.

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 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.

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.