I have been diagnosed with adhesive capsulitis, I have read that sometimes you can also have a rotator cuff injury and with this diagnosis. How will I know if this is also the case?

There has recently been some discussion of rotator cuff injuries being associated with adhesive capsulitis, or frozen shoulder, with no known cause and this is something to consider. A recent study by Ueda et al has attempted to clarify some of the information that is in the research these days. This study has better defined the range of motion restrictions in frozen shoulder as they relate to possible rotator cuff injuries. They have shown that if there is severe restriction in all motions, for example less than 100 degrees of forward flexion, external rotation of 10 degrees or less and internal rotation reach to the 5th lumbar level or less it is not likely that there is a rotator cuff injury. However, if you have loss of motion in only one direction, or less severe loss in all directions there can be up to a fifty percent chance of having a rotator cuff injury. In this case, according to Ueda et al, it would be appropriate to have imaging, such as an MRI, to look further into this possibility.

My mom has pain in her shoulder and limited range of motion, but only for reaching overhead. She did not have any known injury. The doctor has told her she has adhesive capsulitis, does she need an MRI to confirm this diagnosis?

Adhesive capsulitis, also known as frozen shoulder is often associated loss of range of motion in the shoulder with no known cause. In general an MRI is not needed to confirm this diagnosis, however there has been some recent indications that in some cases of frozen shoulder the rotator cuff may be involved. In this case an MRI would be appropriate to confirm or deny the presence of injury to the rotator cuff. In a recent study by Ueda et al research was conducted to determine the prevalence of rotator cuff injuries in patients with stiff shoulders. This study found that patients who had global loss of range of motion, in all directions, for example less than 100 degrees of forward flexion, external rotation of 10 degrees or less and internal rotation reach to the 5th lumbar level or less it is not likely that there is a rotator cuff injury. However, if you have loss of motion in only one direction, or less severe loss in all directions there can be up to a fifty percent chance of having a rotator cuff injury. In this case, according to Ueda et al, it would be appropriate to have imaging, such as an MRI, to look further into this possibility.

I am a 23 year old beach volleyball player and have undergone a surgical SLAP repair. I still have pain and am unable to perform my usual serve. I have a big tournament coming up in 3 months, what should I do?

A thorough workup including physical examination needs to be performed hopefully identifying the cause of pain. A bout of nonoperative treatment including physical therapy focusing on your overhead serving mechanics as well as strengthening and ROM will likely occur first. Injections into the subacromial or glenohumeral region may also prove beneficial.

I have calcific tendonitis and have been going to physical therapy for 2 months. How long should I be going to therapy before I seek other options? This seems to be taking awhile.

A recent review of the literature suggests you should give conservative treatment, like physical therapy, up to six months prior to seeking more invasive options like surgery. It is important to remember that the most pain and inflammation associated with calcific tendonitis occurs right before the calcium deposit is reabsorbed into the body and the tendon repairs itself.

I am in my 20’s and recently broke my upper arm bone during a skiing accident.  They call it a “mal-union” break.  What is this?

A mal-union fracture is one that heals in a less than ideal setting or one that disrupts the joint motion.  Sometimes these are addressed by going back in and re-breaking the fracture or by shaving off the bone that is interfering with function.  In your case, depending specifically where the break is, shoulder joint osteotomies (bone shaving) are not recommended.

I have noticed that my shoulder blade sticks out on one side. It is the same side that I get shoulder pain when rock climbing, what is happening?

Scapular dyskinesia is a term used to describe poor movement patterns of the shoulder blade. The shoulder blade, or scapula, moves in multiple planes and must be coordinated with the glenohumeral joint in order to allow full range of motion of the shoulder. When the length, strength or timing for firing the scapular stabilizing musculature is not optimal, scapular dyskinesia occurs. One type of scapular dyskinesia is winging of the scapulae.

Scapular winging can result from either weakness or stiffness of multiple muscle groups, including serratus anterior, trapezius, rhomboid major and minor, and/or levator scapulae. Of these muscles, serratus anterior is the most common muscle contributing to winging. It is a flat muscle that originates on the upper eight or nine ribs and inserts on the medial border of the scapula. Its primary action is to stabilize the scapula against the rib cage, then laterally rotate the inferior angle of the scapula during overhead activity. The trapezius muscle may also be involved with scapular winging. This muscle helps retract, elevate and rotate the scapula and is most often injured with surgeries in the cervical area. A third muscle group that may be involved is the rhomboid major and minor, which together retract, elevate and medially retract the inferior angle of the scapula. Injury to these muscles can be a result of entrapment of the C5 nerve under a hypertrophied scalene muscle.

The cause of scapular dyskinesia is a muscle imbalance of the scapular stabilizers that can either be neurogenic in nature or inherently muscular. With scapular winging in particular, traction or stretch injuries to the long thoracic nerve can be a primary cause. The long thoracic nerve passes between the anterior and middle scalenes then travels along the chest wall to the serratus anterior. Positions in overhead sports can easily stretch the long thoracic nerve resulting in repetitive or traumatic stretch injuries to the nerve and resulting in neuropraxia that inhibits the serratus anterior. Neuropraxia can occur with increases in nerve length of only ten per cent. Aside from long thoracic nerve injuries, spinal accessory nerve injury can also lead to scapular winging as it inhibits trapezius muscle activity.

I know that weakness in several different muscles that can cause scapular winging. How can I tell what weakness is causing my scapular winging?

The clinical presentation of an individual with scapular winging typically includes report of posterior shoulder pain that may radiate down the arm or up the neck. The pain can either be associated with an event or insidious in nature. The individual may experience loss of range of motion into forward flexion or abduction, weakness and a sensation or clicking or catching of the shoulder joint with movement. A skilled clinician will look at scapular position at rest and identify any scapular dyskinesia present with active range of motion of the shoulder or weight bearing on hands in a push up type position. A patient with serratus anterior palsy with exhibit winging at rest and may have pain at rest in periscapular muscles that are attempting to compensate for the weak serratus. Winging is typically accentuated in a wall push up position. If trapezius palsy is involved, wasting or atrophy of the muscle will be visible at the neckline and shoulder drooping will be present. Weakness will be present in overhead positions and winging will become apparent with resisted abduction or external rotation. Winging associated with rhomboid dysfunction is the most difficult to identify. Patients may report medial scapular pain and demonstrate mild winging at rest that increases as they lower their arms from forward flexion.

What is a massive, contracted, immobile rotator cuff tear?

These tears are less common and sometimes referred to as “irreparable”. They require advanced arthroscopic skill to achieve the best outcome. The supraspinatus, infraspinatus are torn and pulled away from their attachment sites. They measure greater than 2cm in length from anterior to posterior and medial to lateral.

How will I know what rotator cuff repair is best for me?

You will need to discuss this with your surgeon. It will have many factors and will vary depending on the individual. Your personal factors can be: age, activity level to return to, health, etc. Surgical factors: degree/type of rotator cuff tear, surgical technique and surgeon.

Is using the tendon of the sternocleidomastoid (SCM) muscle to anchor the collar bone to the sternum this surgery better than using a tendon from another part of the body?

It is hard to say if one technique is indeed “better” than another, as they have not been directly compared in the research. However it is useful to look at the results of studies using each technique and consider outcomes and complications. In this study, with a fairly high number of participants (thirty-two) there were very few complications and high success rate. This paper mentions another study (Guan and Wolf) that reported on six patients who had a similar reconstruction but with the use of a tendon from a second surgical site (gracilis, semitendinosus, or palmaris longus). At a follow up time of fourth-four months five of these six patients had no pain and had returned to normal activities. Another study (Bae et al.) reported on nine patients with tendon graft from another body part, with ninety percent of patients reporting full recovery after fifty-five months. According to these other results it appears that all these techniques are successful for the outcome, however it is difficult to directly compare the results. The main difference to consider is with a tendon graft from another body part there will be a second incision site, which can create it’s own complications.

What is the recovery like following reconstruction of the SC joint using a SCM tendon graft?

The recovery protocol reported in this study indicates the arm was in a sling with a body belt for the first six weeks. During this time passive forward flexion to the shoulder level and passive external rotation to neutral were allowed. After the first six weeks active-assisted range of motion was begun in midrange as well stretching into full range. Scapular postural isometrics were also initiated after six weeks with the exclusion of pectorals major activity. After twelve weeks strengthening in the full range was introduced with progression guided by discomfort. Noncontact sports were allowed following six months as long as the joint was pain free and full motion was available. Participation in full contact sports was allowed following six months if a full push up was possibly without pain or scapular dysfunction for repeated repetitions.