FAQ Category: Shoulder

Pain that lingers after a shoulder surgical procedure is not all that uncommon. But you are right to wonder what’s causing it and what can be done about it. A follow-up visit to both your surgeon and your therapist would be a good idea. They will each look for different potential causes of the problem. Together, you will be able to figure out what to do to resolve the issue.

From your description, it sounds like you could be experiencing a problem called coracoid impingement. Coracoid impingement refers to a pinching of the soft tissue structures by the coracoid process.

The coracoid process is a small hook-like structure at the top front part of the scapula (shoulder blade). The coracoid process works together with the acromion to stabilize the shoulder joint.

The patient’s first inkling that something is wrong is a dull, aching pain along the front of the shoulder. As the arm moves forward and up, across the chest, or internally rotates, the coracoid pinches against the subscapularis tendon, subcoracoid bursa, and/or the biceps tendon.

Coracoid impingement is an uncommon problem and rarely occurs alone without some other change in the nearby anatomic structures contributing to the problem. For example, rotator cuff tears or degeneration or an unusual shape or length of the coracoid bone can lead to coracoid impingement. Calcium build up in the subscapularis bone or the formation of a ganglion cyst can also cause impingement in this area.

Coracoid impingement just doesn’t occur by itself. There is usually another reason why this additional problem has developed. It should be considered as a possible cause of anterior (front) shoulder pain after shoulder surgery to repair a torn rotator cuff or relieve pressure under the subacromion.

The patient’s history can offer helpful clues. There is often a previous history of fractures of the humerus, coracoid, or glenoid (shoulder socket). Prior shoulder surgery is another contributing factor.

The surgeon will search carefully for factors such as rotator cuff damage or degeneration, shoulder joint instability, or arthritis. A re-examination of the shoulder is next. The physician looks for tenderness over the coracoid process, pain when the arm is moved across the chest, and weakness of the subscapularis muscle.

Other signs and symptoms may include shoulder instability, pain on testing the biceps tendon, and generalized weakness of the rotator cuff. An arthroscopic examination (using a special scope to look inside the joint) is the best way to find out what’s causing the problem. You may have had this done before (or as part of) the last surgery. It is a very helpful tool in diagnosing the cause of your pain.

The problem of coracoid impingement is rare and and occurs most often along with some other shoulder pathology. It may go unrecognized until the main problem is treated. It does require separate treatment before the painful symptoms resolve. Don’t hesitate to make another appointment with your surgeon. Earlier follow-up is often better to avoid compensation patterns of movement and other problems developing.

The rotator cuff is a group of four muscles and their tendons that surrounds the shoulder. They function in two ways. First, they help hold the head of the humerus (upper arm bone) in the acetabulum (shoulder socket). Second, they contract and pull the arm into different positions (e.g., arm up overhead, arm out to the side, arm behind you).

The result of these two functions is stability and mobility. Exercise programs for the shoulder help strengthen the rotator cuff as it performs both functions hundreds of times each day.

Studies show that over time, many people develop degeneration of the tissues of the rotator cuff. In fact, as many as 54 per cent of adults age 70 or older have significant degenerative changes of the rotator cuff.

Taking a look at the tissues under a microscope has shown that the injured or degenerating rotator cuff tendon has disorganized tendon fibers, fewer normal cells, and quite a bit of fill-in by fat and scar tissue.

Exercises won’t impact that kind of tissue. Instead, other healthier muscles take over or compensate for the weakened tendons. Over time those compensation patterns seem to catch up with us. Then even what seems like a minor movement, fall, or other injury is enough to tear the tendon completely.

Long-term studies of adults and the natural history (what happens over time) of rotator cuff tendons is needed. The information gained may help direct treatment by identifying the true underlying problem. And perhaps help prevent those injuries in the first place!

When it comes to injuries of the rotator cuff, there are actually three possibilities. There can be a strain, muscle tear (partial or full-thickness), and degenerative defects.

A rotator cuff strain has been defined as an intact rotator cuff (no tear) but with edema (swelling) and bone bruises where the rotator cuff attaches to the bone. These are tissue changes that have been observed with MRIs.

Traumatic injury resulting in an acute tear of one or more tendons of the rotator cuff can also be seen on MRIs. Left unrepaired (surgically), the tear or “defect” fills in with fat and scar tissue. This process is called fatty infiltration and granulation.

The third condition, degeneration, is seen more often in older adults. There isn’t an inflammatory process like we would normally see with an acute injury. The cells that make up the collagen matrix (basic structure) of the rotator cuff are altered.

As a result, the body’s effort to repair and remodel degenerating or defective tissue is unbalanced. The natural break down of tissue occurs without an equal amount of repair and remodeling.

This ongoing process of unbalanced degeneration, repair, and remodeling results in a rotator cuff defect that is referred to as a tendinopathy. The literal translation of tendinopathy is “pathology (disease) of the tendon”. The result can be a tearing of the rotator cuff tendon with no trauma or only minor trauma in the older adult.

Studies show that defects in the rotator cuff occur more often than we thought. Up to half of all adults over the age of 70 may have unknown rotator cuff defects. Because many people are asymptomatic (no symptoms and especially no pain), the presence of rotator cuff disease goes unnoticed. Why some people have symptoms while others do not (with equal rotator cuff disease) remains a mystery.

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.

The rotator cuff helps raise and rotate the arm. 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.

The largest muscle in the rotator cuff is the subscapularis. This muscle helps rotate the shoulder and arm inward (internal rotation). The subscapularis helps stabilize the shoulder in the socket and prevent forceful anterior (forward) dislocations.

The subscapularis also helps balance the force applied on the shoulder from the posterior (back side of the) rotator cuff. The rotator cuff surrounds the entire shoulder joint like an envelope (front, back, side, and under the arm). Any weakness on one side from a tear or damage to the rotator cuff will affect how the rest of the cuff functions.

It is unusual to have an isolated subscapularis tendon tear. If the trauma or force is strong enough to rupture this portion of the rotator cuff then it’s likely other areas have been damaged. This could include other rotator cuff tendons, ligaments, and/or the joint surface. Other muscle/tendon units around the shoulder that are not part of the rotator cuff can also be injured (e.g., biceps tendon).

The largest muscle in the rotator cuff is the subscapularis. This muscle helps rotate the shoulder and arm inward (internal rotation). The subscapularis helps stabilize the shoulder in the socket and prevent forceful anterior (forward) dislocations.

The subscapularis also helps balance the force applied on the shoulder from the posterior (back side of the) rotator cuff. The rotator cuff surrounds the entire shoulder joint like an envelope (front, back, side, and under the arm). Any weakness on one side from a tear or damage to the rotator cuff will affect how the rest of the cuff functions.

Surgery to repair the rotator cuff can be done with a traditional open incision procedure or with a more minimally invasive approach using arthroscopy. Arthroscopic surgery involves the use of a surgical scope that is inserted into the joint. It gives the surgeon a view inside the joint in order to identify the torn parts and fix them.

Surgical techniques used differ depending on the location and severity of tendon tear/rupture. Type of sport the athlete is involved in is also considered when planning the specific surgical approach. Attention is paid both to functional demand and cosmetic appearance.

Your post-operative recovery and return-to-sports will depend somewhat on how invasive the surgery is, how severe the damage is, and your overall health and condition before the injury. Patients with good strength, good health, and a good attitude often have the best results.

You may be placed in a shoulder splint for 10 days up to three weeks. Again, this depends on the extent of the surgery, surgical technique used, and surgeon preference. Most surgeons performing a rotator cuff tendon repair will tell the patient there’s to be no lifting and no vigorous activity. These restrictions often last six weeks up to 12 weeks.

A rehab program under the direction of a physical therapist is often advised. The therapist will guide you through the prescribed exercises and gradually progress you through activities. Sports specific training for athletes helps them return to their chosen sports fit and ready for the challenges they face. You may expect the process from surgery through rehab to last about six months (longer if there are complications).

Joint injection and specifically the accuracy of needle placement is the focus of a recently published systematic review. In a review of this type, many studies with small numbers of patients are combined together to create a larger pool of data to analyze. The results are statistically more significant when conclusions can be drawn that affect hundreds rather than dozens of patients.

According to the results of this systematic review, studies show that accuracy of joint injections can be improved. In the shoulder, coming in from behind (posterior approach) is more accurate than from the front (anterior approach). In fact, the reported accuracy rate increased from 45 per cent injecting from the front to 85 per cent accuracy from the back.

Additionally, the surgeon who uses ultrasound, fluoroscopy, or magnetic resonance imaging to guide the needle to the right spot will also be more accurate. And that was true for all joints (elbow, knee, or shoulder).

As with all procedures of this type, surgeon experience and technical expertise can make a difference as well. It may be helpful to know how many of these injections each surgeon has performed and the success rate using these two different approaches. A third opinion never hurts either.

Injury to the glenohumeral ligament of the shoulder can produce instability that leads to dislocation. When you say you have a chronically dislocating shoulder, it’s unlikely that conservative (nonoperative) care will work.

The soft tissue structures that hold the shoulder in the socket have been damaged repeatedly. Scar tissue forms to help heal the injury naturally but the next injury stretches the soft tissues out even more. If the labrum (a fibrous rim around the socket) is torn and/or there are other injuries along with the glenohumeral ligament, shoulder stability cannot be restored without surgery.

However, there’s no reason not to try a rehab program. Work with your orthopedic surgeon and a physical therapist who specializes in these kinds of problems. Give the program a good two to three months’ effort and see what results might be possible.

If you are an athlete and plan to return to your sport or if you are a manual laborer who needs full motion and strength for your work, surgery may really be your best option.

If the pain and instability don’t improve with a consistent exercise program, then talk with your surgeon about other options. Even with surgery, it may be possible to have the procedure done arthroscopically. This type of approach is less invasive with fewer muscles and tendons disrupted getting to the shoulder to make the necessary repairs.

A quick review of HAGL injuries might help other readers researching this question. The word humeral tell us the shoulder is involved because the humerus is your upper arm bone. At the top of the humerus is the round ball that fits into your shoulder socket and makes all those circular arm movements possible. Avulsion of tendons or ligaments means there has been a tearing of the soft tissues — enough to pull away from the bone where it was attached.

The glenohumeral ligament is a band of tissue around the shoulder that provides the stability needed to keep the head of the humerus in the socket. Age-related degeneration and trauma (injuries) that damage this ligament can result in a chronically dislocating shoulder.

Recognizing that a patient has a humeral avulsion of glenohumeral ligaments (HAGL) is a key to successful treatment of shoulder instability. In many cases, a patient with a shoulder that frequently pops out of the joint has more than one type of damage to the soft tissue structures. If the HAGL lesion goes undetected, surgery to treat other problems may not be successful. This is not uncommon and sounds like what happened to you.

How does the surgeon diagnose the problem? There are several steps in the diagnostic process. First, the surgeon asks the patient all about how this happened, what the symptoms are, and what makes it better or worse. A very important piece of patient history is a prior failed shoulder surgery.

HAGL tears occur most often when the person has the arm in a position of abduction (away from the body) and external rotation (outward rotation). Think of a pitcher’s arm after the wind-up and just before releasing the ball or how you would hold your hand under your head when lying on the ground looking up at the stars. Force or trauma with the arm and hand in this position cause avulsion injuries of the soft tissues leading to dislocation.

Clinical tests are carried out to give the surgeon an idea of the joint motion and muscle strength (or weakness). The surgeon will challenge the shoulder in different positions and directions. These tests are called provocative maneuvers.

This step helps identify which muscles, tendons, and ligaments might be affected. The direction of instability is determined through these tests. The shoulder can have multidirectional instability meaning it is unstable (dislocates) in more than one direction — forward, backward, upward, and/or downward.

X-rays and other imaging studies such as MRI may be done. These tests give the surgeon a look inside to see what is going on. But for humeral avulsion injuries of the glenohumeral ligaments, magnetic resonance arthrography or MRA (dye injected into the joint before the MRI) is really essential.

An even better diagnostic test is the arthroscopic exam where the surgeon inserts a long, thin needle into the joint. There’s a tiny TV camera at the end of the scope that gives an inside view of the joint. The surgeon can see where the ligament attaches and look for any places along the rim of the socket or front and back of the joint capsule where the soft tissue has pulled away from the bone.

Humeral avulsion of glenohumeral ligaments (HAGL) can go undetected when the torn edge of the ligament scars down to the joint capsule. The area of damage isn’t easily seen because it is hidden underneath the subscapularis muscle. If this lesion isn’t discovered and repaired, the shoulder will remain unstable. Repeated dislocations even after surgery to correct some other problem (e.g., torn labrum, avulsion of tendon, rotator cuff tears) is an indication of an HAGL lesion.

It does seem like everybody knows someone who has had a rotator cuff problem. With over half a million news rotator cuff injuries or tears each year, it’s highly likely you may find yourself in this same group. Older adults (65 years old and older) have the highest incidence of rotator cuff tears. Research shows that more than half of the adults in this age group have a rotator cuff tear — many without even knowing it!

With the aging of the many Baby Boomers (folks born between 1946 and 1964), it’s likely that the number of patients with rotator cuff disease showing up in the surgeon’s office will continue to increase. Surgeons are anticipating this problem by asking how to optimize treatment?

The answer isn’t straightforward (do this or do that) because there are so many issues that affect the decision-making process. For example, when should patients receive conservative (nonoperative) care and when should they have the tear repaired surgically? Should treatment vary depending on when the tear occurred (i.e., is the tear acute meaning it happened recently or is it chronic — it’s been there a long time).

Should everyone who is recommended to have surgery really go through with it? What if they have known risk factors that predict a poor result (like people who smoke or who have diabetes or other serious health concerns)? And what about surgery? Is there one procedure that works best for each type, size, shape, and location of tears?

According to a panel appointed by the American Academy of Orthopaedic Surgeons (AAOS), the evidence to help guide surgeons is fairly limited, weak, or inconclusive. As for negative predictive risk factors (e.g., smoking, diabetes, infection) the panel could not tell surgeons they should or shouldn’t advise against surgery unless the MRI showed a significant tear, the patient was elderly, or the patient had a Worker’s Compensation claim. And these risk factors did not predict a poor outcome 100 per cent of the time.

The panel concluded there is a definite lack of strong evidence to help guide surgeons. The path in choosing the best treatment for optimal outcomes in patients with rotator cuff tears isn’t clear. Every patient deserves an individual evaluation with all factors and variables taken into consideration.

It’s best if you sit down with your surgeon and discuss your goals, health concerns, preferences, and expectations. Only then can you work out a plan of care that is optimized for you and your situation. Don’t let all the “naysayers” dictate your choices. It’s entirely possible that you could have a very successful outcome. The decision is really up to you and your surgeon working together.

The American Academy of Orthopaedic Surgeons has published Clinical Practice Guidelines (CPGs) for the care and management of rotator cuff tears. The guidelines consist of 14 recommendations based on all available current (high-quality) evidence in the literature. The full guidelines are available on line at the American Academy of Orthopaedic Surgeons website (www.aaor.org/guidelines).

But if you take a look at them, don’t be surprised by what you see. The evidence just isn’t there yet to support one type of treatment over another in most cases. There is agreement among all the physicians who came up with these guidelines that “if it’s not broke, don’t fix it.”

In this case that means, if a person has a rotator cuff tear but it doesn’t hurt and doesn’t bother them, then don’t do surgery to repair it. Anyone who does have painful symptoms, loss of motion, decreased strength, and altered function should consider having surgery.

The evidence was inconclusive more often than not. Answers to many questions are lacking. Does exercise help? If so, what kind of exercise? Should you have the joint injected with a steroid and numbing agent? Does ice work better than heat? When would electrical stimulation be effective? When should you take a nonsteroidal antiinflammatory medication? These are questions that must be investigated further before any recommendations can be made.

And that’s just on the side of conservative care. When it comes to recommendations about surgery, the waters get even murkier. Should the surgeon use suture anchors to reattach the torn tendon to the bone or is it better to drill a tunnel through the bone and thread the tendon through to anchor it down? Should the surgeon perform the surgery using an open incision, arthroscopic repair, or the more recently develop mini-open approach? Once again, the evidence is inconclusive on these points.

What did the evidence support? There was weak support for doing surgery to repair chronic, full-thickness rotator cuff tears that cause pain and other disabling symptoms. Early surgery following the acute tear may have better outcomes than waiting until the problem becomes chronic. If the tear is only a partial one and doesn’t go all the way through the tendon, then conservative care with inflammatory meds and physical therapy may really be acceptable choices.

The panel concluded there is a definite lack of strong evidence to help guide surgeons. The path in choosing the best treatment for optimal outcomes in patients with rotator cuff tears isn’t clear. Every patient deserves an individual evaluation with all factors and variables taken into consideration. No doubt that is how your surgeon developed the plan of care you followed.

The first thing to do is get an orthopedic evaluation and find out exactly what’s wrong so an appropriate plan of care can be established. Many times, a concerted effort at rehab can restore motion and strength needed for balance and favorite activities. It can take quite a while, so you have to go into it knowing that daily exercise is going to be needed.

If a conservative approach has already been tried (or you try it and it doesn’t achieve the results you want), then surgery may be helpful. The surgeon will do an arthroscopic diagnostic exam to locate the damage and investigate the full extent of your injury.

Shoulder stabilization can be achieved using special suture anchors and stitches. The surgeon will clear the area of any pieces of soft tissue or frayed edges around the shoulder joint. If the joint capsule is torn, it can be stitched back together. If the labrum (rim of cartilage around the shoulder socket) is damaged, a labral repair can be done.

Following shoulder stabilization surgery, patients are put in a sling to immobilize the joint while the soft tissues are healing. After that, you’ll find yourself back in rehab for three to six weeks whle you work on regaining motion, strength, joint proprioception (sense of position), and normal movement patterns. The therapist can also tweak your program to help prepare you for sports and recreational activities of your choosing.

So don’t throw the towel in just yet. There are almost always options and treatments for problems like this!

When the shoulder dislocates repeatedly, it’s time to get some serious help. That’s when the surgeon steps in and provides the kind of stabilization procedure you had. Special suture anchors are used to repair damage to the soft tissue. The surgeon can use either an open incision approach or an arthroscopic method to accomplish the task.

Sometimes the stabilization doesn’t hold and the shoulder re-dislocates. Once again, the surgeon can go back in and use surgical means to restabilize the joint. This is the decision point at which you find yourself right now. Invariably, the question comes up whether the second surgery will do the trick (or not). No one likes to face a revision operation for something they hoped would be taken care of the first time around.

Various studies have been published on the rates of success/failure for arthroscopic versus open stabilization. The rates of failure requiring a revision operation are fairly even between the two different approaches. So the next question is: how do the results compare between the initial stabilization surgery and the revision (second) surgery?

In a recent study from Germany, this comparison was made just for patients who were treated using the arthroscopic approach. The same technique using suture anchors was used for both sets of patients for a clear comparison. And patients were “matched” between the groups so that their ages, sex (male versus female), and hand dominance (right-handed versus left-handed) were the same between the two groups.

Everyone was followed for at least two years so the data collected reflect mid-range results. Patients will be followed further in order to gather long-term results as well. But for now, here’s what they found. First of all, the patients who had a longer period of time with more recurrent dislocations before the initial stabilization surgery were the most likely to require further surgical procedures.

Four other differences were seen from the revision group when compared to the group who only had the initial stabilization procedure. Shoulder function was reduced in the revision group. Return to sport or work at the same level as before the first surgery was a bigger problem for the revision group. Many had to reduce their work/play, change sport, or even quit sports involvement.

Shoulder fatigue with everyday activities like writing or raising the arms overhead was reported more often in the revision group. A sudden, unguarded movement (e.g., losing balance) requiring the arms to respond quickly created problems for the revision group. The revision group was afraid of falling, especially if it meant a fall onto the involved shoulder. And finally, the revision group was unable to maintain their preferred level of fitness.

You probably get the picture the surgeons saw: outcomes after revision (salvage) surgery for recurrent shoulder instability just aren’t as good as results for patients who only need one stabilization procedure. But some of those patients did have a good result.

So perhaps there are individual patient factors that contribute to a successful outcome. Your surgeon will be the best one to advise you on this one — your age, activity level, and type and severity of soft tissue damage are likely important factors that could tip the scales in your favor for a good result.

Bone growth is usually completed in girls by age 16 and in boys around age 18 to 20. But there are always people who complete the growth process later than expected. Males especially can continue gaining heighth into their early 20s.

One area of the body where bone growth and ossification (hardening) isn’t complete until age 18 to 20 is the end of the clavicle (collarbone). The growth plate here (called the physis) does not close with fusion of all layers of the clavicle until around age 23 to 25.

Dislocations of the sternoclavicular (SC) joint (where the collarbone attaches to the breastbone or sternum) are rare. The soft tissue structures in this area are very strong. It takes a great force to overcome resistance and stability provided by the shape, size, and strength of the ligaments.

Car accidents and sports injuries account for most of the reasons why the SC joint might dislocate. And even athletic events have to be pretty extreme to dislodge this joint. For example, dislocation can occur to a player lying on the field who is then subjected to the force of another player falling or jumping on his or her clavicle. Or taking a direct hit or kick to the clavicle can also dislodge the SC joint.

We don’t know your situation exactly but it sounds like you may be in that in-between age group for this particular injury. Your surgeon will be able to advise you regarding the best plan of care given your injury, chronological age, and bone age.

The place where your collarbone meets the breast bone is called the sternoclavicular (SC) joint. Another name for the breast bone is the sternum. The anatomical term for the collarbone is clavicle, hence the name for the joint between these two bones: sternoclavicular or SC joint.

Injuries to the SC joint are rare but when they do occur, the results can be very serious. The close proximity of structures such as the trachea, esophagus, lungs, blood vessels, and nerves to the arms makes this injury the cause of problems that can be life-threatening.

Injuries of the SC joint can be classified as mild-to-severe. A mild injury means there’s pain and even swelling but the ligaments aren’t torn or damaged so the joint is still stable. If the ligaments stretch because of severe swelling, the joint can get partially separated, a condition called subluxation. Subluxation is considered a moderate injury. The most serious injury is a dislocation.

The swelling can prevent the surgeon from being able to tell the direction of the dislocation (anterior or posterior). The patient’s symptoms are somewhat diagnostic. For example, difficulty breathing may point to a posterior dislocation affecting the trachea (windpipe) or lungs. Difficulty swallowing suggests injury to the esophagus.

Imaging studies such as X-rays, MRIs, and CT scans are usually needed to make the final diagnosis and help the surgeon plan the best course of treatment. Mild injuries may respond well to conservative (nonoperative) care. Ice and pain relievers relieve symptoms (pain and swelling) and positioning with a sling helps protect the area while it is healing.

There are two ways to reduce (realign) a SC joint that is dislocated: closed or open reduction. Anterior dislocations are treated most often with closed reduction. Closed means the surgeon does not make an incision to gain access to the joint. Instead with the patient asleep (under anesthesia), pressure is applied to the collarbone to push it back in place. The joint will probably still be unstable until healing is completed, so the joint is supported and protected for a few weeks.

Posterior dislocations of the SC joint can also be treated with closed reduction. Again, the patient must be sedated. The surgeon uses positioning and traction of the arm while an assistant applies pressure to the clavicle to shift it back in place. X-rays are taken to confirm successful closed reduction of anterior or posterior dislocations treated in this fashion.

When the surgical team is unable to use closed reduction, an open procedure is done. The clavicle is manually reduced and stability of the joint assessed. Reconstructive surgery using a tendon graft to replace the ruptured ligaments may be needed to restore joint stability. The surgeon may not know what will be needed until during the surgery — whether reduction can be done with positioning and traction or with a surgical procedure. Expect her to be immobilized for a few weeks and make a nice recovery.

You didn’t mention how old your son is but age, weight, and severity of the fracture can make a difference. Fractures may be treated differently in a young child who is still growing. Teens who have passed the fast growing stage but who aren’t fully (skeletally) mature should not be treated the same as either children or adults.

In the case of the collar bone (referred to as the clavicle in medical terms), this is one of the last bones to finish ossifying (hardening into bone). That’s one reason why young children and teens who break their clavicle are often put in a sling or figure-eight collar — the bone repairs, remodels, and is restored fairly easily.

But if growth is complete (or nearly done) — and this is seen on X-rays — then the ability of the clavicle to remodel and repair is much more limited. In such cases, if the fracture is displaced (separated) then surgery may be required.

Studies have shown that completely displaced clavicular fractures should be reduced (ends of the bones put back together) and held together with pins or metal plates and screws until healing takes place. With open reduction and internal fixation (ORIF), healing takes place much faster compared with nonoperative care. This is a boon for patients who participate in sports because they can return to play much sooner (three months after surgery rather than four months later).

This is a question under close scrutiny in the research world that deals with orthopedic problems. A recent article from surgeons at the Center for Shoulder, Elbow, and Sports Medicine at Columbia University Medical Center in New York City may shed some light on what’s happening in this area. The authors review alternate treatment approaches for glenohumeral arthrosis (damage to the shoulder joint). The term “alternate” refers to some other way to solve the problem without a shoulder replacement.

There are restorative procedures that can be done to help the joint cartilage heal and recover. Smaller lesions can be treated with abrasion, microfracture, and drilling techniques. Larger holes and defects may respond better to grafting procedures. Grafting uses cartilage and subchondral bone (first layer of bone under the cartilage) from the patient or from a donor to fill in the hole and stimulate bone and chondral growth around the defect.

The decision about which restorative approach to use is very complex. All of the treatments just mentioned for restorative care of the shoulder cartilage are being used and studied primarily in the knee. Their use for the shoulder is just beginning.

There is a different management approach already in use for a case of shoulder arthrosis that is not quite ready for replacement. This is called joint resurfacing. The damaged head of the humerus (upper arm bone) is shaved down and covered with a metal cap. This is similar to putting a cap on a tooth. Results of resurfacing in young, active patients have been very favorable so far. Loosening of the metal cap is the number one problem to develop.

For patients with large defects, another new idea is the focal humeral resurfacing implant. The device looks like a large screw with a smooth head. It is screwed into the head of the humerus and provides a smooth surface to slide and glide in the joint.

Resurfacing of the shoulder joint can be done without a metal cap or implant. Surgeons are experimenting with various soft tissues to use as a covering. This technique is referred to as biologic interposition. The Achilles tendon from behind the heel is the most popular graft tissue for this treatment but others are being tried.

The use of knee cartilage (called the meniscus) to cover chondral defects in the shoulder has moved from cadaver studies to live humans. The meniscus has the right shape (round) and is flexible enough to conform to the joint surface. Concerns about complications and lack of durability have delayed routine use of this procedure.

And finally, there is a movement in the scientific world to find a way to engineer chondral (cartilage) tissue. This technique is called regenerative tissue or biologic resurfacing. Some experts really see this as the future of medicine for worn out parts and places anywhere in the body, including the joint cartilage.

As you can see from this report, there are many treatment options for shoulder chondral lesions that are being developed and studied. Not all are currently available or available routinely. In time, researchers will sort out which patients are good candidates for each procedure. If and when restoration of the joint surface just isn’t possible, then a partial or complete joint replacement can be considered.

Young, active adults like yourself with shoulder problems may not want a shoulder replacement as the solution to their pain and loss of motion. And, at the same time, they may not be a good candidate for such a procedure. The surgeon’s challenge is to find other ways to treat this problem called glenohumeral arthrosis.

The glenohumeral joint is what the lay person would call the shoulder joint. Arthrosis means damage has occurred to the joint surface. The first step in managing glenohumeral arthrosis requires a careful examination of the chondral (cartilage) surface and first layer of bone (the subchondral area).

The surgeon often uses X-rays and other more advanced imaging studies along with arthroscopic examination to find out what’s going on inside the joint. There could be a rotator cuff tear, hole in the cartilage, or some abnormality of the surrounding soft tissue structures.

Conservative care is usually tried first for a good three to six months. The goal is to decrease pain and increase motion. Work and activity levels must be adjusted to protect the joint from further microtrauma. A physical therapist will guide patients through necessary lifestyle changes to accomplish this. At the same time, the therapist will prescribe an exercise program to improve strength, motion, and function.

Medications such as Tylenol, ibuprofen, and other nonsteroidal antiinflammatory drugs may be added to assist these nonoperative measures. Early reports support the use of hyaluronic acid injected into the joint. This treatment is used successfully for knee osteoarthritis and is being tried for patients with shoulder osteoarthritis.

When an adequate trial of conservative care fails to help, then surgery may be considered. There isn’t one “best” treatment that works for everyone. The surgeon re-evaluates the patient in order to identify the best treatment approach. If you have not been evaluated by an orthopedic surgeon yet, an appointment for a consultation might be the next step.

The surgeon will take into consideration your individual factors such as age, activity level, goals, and job requirements. Disease-based factors are also reviewed and “weighed in” on the final decision. The surgeon takes into account the cause of the problem, the size of the chondral (cartilage) defects, and how deep the lesion goes.

For any size chondral lesion, the first line of surgical treatment is an arthroscopic examination and debridement. Debridement refers to surgically cleaning out the area of any debris and pieces of cartilage or other fragments in the joint space. The surgeon smoothes any rough sports and removes bone spurs.

If conservative care and/or debridement has been tried unsuccessfully with you, then surgery may be needed. There are other surgical procedures (e.g., joint resurfacing) available besides joint replacement. Your surgeon will advise you as to which one might serve you best.

The reverse shoulder arthroplasty is a new enough procedure that surgeons are still studying who would benefit from this implant. The procedure is called a reverse shoulder arthroplasty.

The round ball-shaped bone that normally fits into the shoulder socket is removed and replaced with an artificial cup. The anatomic socket is replaced with a titanium round head. The two parts of the shoulder (round head and socket) are reversed in location.

Although it was designed for patients with massive rotator cuff tears that cannot be repaired, it has also been used for patients with severe bone loss, failed shoulder replacement, and humeral fractures that did not heal. Given that criteria, with your failed shoulder replacement, you might qualify for a revision surgery using the reverse implant.

The main indications for this surgery are pain, loss of shoulder motion, and failed conservative (nonoperative) care. A rotator cuff tear that is too large to repair is another criterion for the use of the reverse shoulder arthroplasty.

It may not be the best choice for patients with pain but preserved motion (more than 90-degrees of shoulder elevation). Experts in this area suggest trying other options first for this type of situation. For example, rotator cuff repair or debridement should be considered. This doesn’t seem to describe your particular situation.

Continued improvements in the design of the reverse shoulder implant and in surgical techniques will likely yield improved outcomes and greater implant survival in years to come.

Along with hip and knee joint replacements, shoulder replacement has become increasingly popular for people with pain and loss of motion from arthritis. But the shoulder is a bit different from the hip and knee. A tear in the muscles around the shoulder (called the rotator cuff) can complicate things.

Replacing the joint without an intact, functioning rotator cuff may not improve the situation. Without the muscles to hold the joint in place and move the arm, the surgery may not be successful. Surgeons who recognized this problem designed a special replacement joint (implant) just for large rotator cuff tears that cannot be repaired.

The procedure is called a reverse shoulder arthroplasty. The round ball-shaped bone that normally fits into the shoulder socket is removed and replaced with an artificial cup. The anatomic socket is replaced with a titanium round head. The two parts of the shoulder (round head and socket) are reversed in location.

The indications for this surgery are pain, loss of shoulder motion, and failed conservative (nonoperative) care. A rotator cuff tear that is too large to repair is another criterion for the use of the reverse shoulder arthroplasty.

In a recent study, the surgeon who designed the reverse shoulder implant investigated the results of treatment with this implant. The focus was on patients who had a massive rotator cuff tear but no sign of shoulder joint arthritis. The study was done at the Foundation for Orthopaedic Research and Education in Tampa, Florida. It was funded by the company that manufactures the implants (Don Joy Orthopaedic Surgical company).

Results were measured using patient report about pain, X-rays to look at the joint, and several tests of shoulder strength, motion, and function. There were two groups: those who had a previous shoulder surgery (usually a failed rotator cuff repair) and those who had never had shoulder surgery before. Results were compared between the two groups.

They found significant improvements in all areas measured for both groups. There were a few failed implants and 18 of the 60 patients said they wouldn’t have the surgery if they had it to do over again (unknown reasons why they felt that way). Two-thirds of the group had an excellent result and were very pleased.

The patients most likely to be disappointed with the results were those who had severe shoulder pain but fairly good motion (greater than 90-degrees). Sometimes after the reverse shoulder implant, their motion was less than before surgery.

When problems occurred with the reverse shoulder arthroplasty, it was usually because the implant came loose or broke. Other complications included fracture of a bone in the shoulder complex affecting the humerus (upper arm bone), clavicle (collar bone), or scapula (shoulder blade). Shoulder dislocation, deep infection, and hematoma (pocket of blood) were also reported in individual patients.

Your orthopedic surgeon is the best one to advise you on this. The MRI will show the size (length and width) and depth of the tear. It will show which tendon(s) is affected. From there, the surgeon can evaluate your shoulder motion, strength, and function and get an idea of whether or not the tear has affected any of these factors.

Although the tear size is small and asymptomatic (without symptoms or pain free), there is a concern that the tear could get worse. Tear progression is also possible as a result of the fall if the force of the trauma disrupted the rotator cuff but the MRI didn’t show it yet.

Surgeons are studying rotator cuff tears like yours — those that are present but unknown because they don’t cause any pain. There are questions that remain unanswered. For example, why are some rotator cuff tears (RCTs) painful while others are not?

And what makes them convert from a pain free (asymptomatic — without symptoms) to a symptomatic tear? If we knew the answers to these questions, we might be able to prevent rotator cuff tears from getting worse and becoming painful.

What we know so far is that the larger the tear at first, the greater the chances of pain developing. And rotator cuff tears on the dominant hand side are more likely to develop painful symptoms.

You may be in a wait-and-see situation. If your physician finds muscle weakness or loss of normal shoulder motion, you may be a good candidate for a short-course of rehabilitation.

A physical therapist will evaluate what you need and set you up on a strengthening and motion program designed to restore full, normal shoulder motion. This may help keep that tear from getting worse or rupturing completely.