FAQ Category: Shoulder

The rotator cuff is a group of four muscles and their tendinous attachments that surround the shoulder in the socket. They provide both stability (to hold the head of the humerus in the socket) and strength for smooth and controlled movement.

Unfortunately, tears of tendons and especially of the rotator cuff don’t “go away”. The body does initiate a healing response. Although the tendon can’t repair itself with normal tendon tissue, scar tissue does form around the tear and tries to patch things up.

Tears that are too large to fill in with scar tissue often fill in with fat cells. This process is referred to as fatty infiltration. Fat doesn’t have even the strength of fibrosis (scar tissue), so it doesn’t lend any strength or stability to the rotator cuff.

A recent study at Washington University School of Medicine in St. Louis followed a large group of older adults (60 years old or older) with painfree rotator cuff tears. They wanted to see if it is possible to predict who will get worse and who won’t. They thought perhaps this type of information would help them direct treatment in order to prevent worsening of painful symptoms and decline in function.

They discovered that the larger the tear when first diagnosed, the more likely the patient would end up with pain and loss of motion and function. Patients who had a rotator cuff tear of the dominant hand were also more likely to develop worsening symptoms over time.

They also noticed that fatty infiltration was not a sign that shoulder pain would begin. Changes in the way the shoulder moves (called arthrokinematics were noticed more often in patients with advanced stages of rotator cuff tears. Arthrokinematics were more likely to be disrupted when the infraspinatus muscle (one of the four rotator cuff muscle/tendons) was torn.

Your best bet is to see an orthopedic surgeon for an evaluation and recommendations about what might be best for you and your particular situation. If nothing must be done right now, close follow-up over time is advised to recognize early signs of change that might indicate the need for more direct intervention.

Many adults (mostly women) between the ages of 40 and 60 years of age develop a strange case of shoulder pain and stiffness called adhesive capsulitis. You may be more familiar with the term frozen shoulder to describe this condition.

There isn’t a one-best-treatment known for adhesive capsulitis. A review study was published on the topic. The authors are two orthopedic surgeons from the Hospital for Special Surgery in New York City. They report that studies done so far just haven’t been able to come to a single evidence-based set of treatment guidelines for this problem.

They offered their “preferred” method with the caution that although this set of steps seems to work for them, no studies have been done to prove the validity of their approach.

Having said that, they recommend using a cortisone injection into the joint only during stage one. The steroid helps stop the inflammatory process that often gets out of hand if left untreated. They don’t recommend the use of oral (pills taken by mouth) steroids but oral nonsteroidal antiinflammatories (NSAIDs) are given throughout all stages.

Physical therapy is the mainstay of nonoperative treatment during all stages. The therapist decides what approach to take based on the stage of disease. Early on, the goal is to reduce pain and interrupt the inflammatory cycle. This can be done with modalities such as electrical stimulation, joint mobilization, the use of cold, and iontophoresis. Iontophoresis is a way to push medications through the skin directly into the inflamed tissue.

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

Physical therapy for the later (more chronic) stages continues in a similar fashion with added strengthening exercises. If conservative care fails to relieve pain and stiffness, then arthroscopic surgery is considered as the next step. The surgeon cuts the capsule, releases adhesions, and manipulates the shoulder (moves the arm through its full motion) under anesthesia. Physical therapy resumes immediately (the next day) after surgery.

Hopefully, your condition caught so early can be treated and turned around without the need for surgery. Your orthopedic surgeon is the best one to advise you based on your age, general health, condition of the shoulder, and any other factors that could affect your rehab and recovery.

Your sister is correct: frozen shoulder and adhesive capsulitis are actually two separate conditions.

What separates these two diagnoses? Both show up looking like a painful, stiff shoulder. But adhesive capsulitis (as its name implies) affects the fibrous ligaments that surround the shoulder and form what’s called the capsule. The condition referred to as a frozen shoulder usually doesn’t involve the capsule.

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

Secondary adhesive capsulitis (or true frozen shoulder) might have some joint capsule changes but the shoulder stiffness is really coming from something outside the joint. Some of the conditions associated with secondary adhesive capsulitis include rotator cuff tears, biceps tendinitis, and arthritis.

How does the orthopedic surgeon diagnose one from the other? An accurate diagnosis is made when an arthroscopic exam is done. Tissue samples taken from inside and around the joint are examined under a microscope.

But there are some clinical signs that help without doing an arthroscopic exam. For example, in the early stages of adhesive capsulitis, pain is accompanied by stiffness and loss of full passive shoulder motion. External rotation is affected first. The rotator cuff remains strong. These two symptoms differ from secondary adhesive capsulitis (what might otherwise be called a frozen shoulder). The condition referred to as a frozen shoulder is more often characterized by damage to the rotator cuff and loss of internal rotation first.

Manipulation under anesthesia has the advantage of restoring shoulder motion without using an open incision. But it does have the disadvantage that it is tearing or rupturing the tight, scarred down joint capsule.

If you haven’t tried the conservative route of physical therapy, you might want to consider that course of treatment before looking into surgical options. Physical therapy can help you regain lost shoulder motion while paying attention to your posture and alignment.

You will be given a home program to follow. Cooperation with the exercises and activities recommended by the therapist will ensure a successful outcome. Stretching exercises to increase flexibility will be followed by strengthening exercises to restore strength.

The therapist will show you ways to move that will avoid impingement (pinching of the muscles and tendons around the joint). Helping you change movement patterns and poor postural habits can also go a long way in preventing a relapse.

If you have completed a course of therapy and exercise without improvement, then arthroscopic surgery might be the next step. Although the surgeon inserts the scope into the joint, an open incision is not required.

Instead of the uncontrolled tearing of the capsule with manipulation under anesthesia, the surgeon can use the arthroscope to release the capsule slowly and gently. If there are any bone spurs or inflamed synovial tissue, the surgeon can also remove these at the same time.

Talk with your orthopedic surgeon about your treatment options. Let him or her know you are interested in a less traumatic approach. Many patients get good results without the trauma of manipulation or open incision surgery.

The first step is to get a proper diagnosis to find out what’s causing the pain. If she is from out-of-town, you might want to suggest she see her own doctor when she gets home. If she is open to receiving care in your community, then a referral to her primary care physician or orthopedic surgeon is advised.

The most common causes of chronic shoulder pain in an older adult include rotator cuff tear or degeneration, arthritis, a frozen shoulder, or a labral tear. The labrum is a rim of fibrous cartilage around the shoulder socket. It provides increased depth and stability for the shoulder joint.

The physician will rule out more serious problems such as fracture, infection, or tumor. For any of the soft tissue problems mentioned, the first step is usually to get the pain under control. That can often be done with a simple pain reliever such as acetaminophen (Tylenol). If a stronger medication such as an antiinflammatory is needed, the physician will prescribe one that is best for her age, condition, and general health.

Other conservative measures such as physical therapy or a steroid injection into the joint are additional options should the pain medication fail to do the job. Physical therapy can help a person regain lost shoulder motion while paying attention to posture and alignment.

Helping change movement patterns and poor postural habits can also go a long way in preventing a relapse. Stretching exercises to increase flexibility will be followed by strengthening exercises to restore strength. If needed, the therapist will show your mother-in-law ways to move that will avoid impingement (pinching of the muscles and tendons around the joint).

There are other treatment options, but this is usually the starting point. Your mother-in-law may just need a little direction in getting started to find the help she needs. Don’t hesitate to at least make the offer. If she doesn’t pursue treatment in your area, she may feel more encouraged to do so once she returns home.

Many people injure the rotator cuff and don’t realize it. Or they may have had a shoulder injury at one time but didn’t go see the doctor. Over time, the tissues either knit back together or filled in with scar tissue or fat. Pain, if present, went away.

But it’s also possible you just didn’t have any painful symptoms to alert you to the problem. This is more common in adults who experience degeneration of the rotator cuff as they get older. And it is also the case that some people simply have more pain, symptoms, and disability with a rotator cuff tear than others.

No one knows for sure why these differences exist. Experts suggest that age may play a role — and perhaps the strength of the other muscles around the shoulder. If the biceps and deltoid muscles are intact, they can accomodate for the loss of strength from the torn rotator cuff.

And then there is the size and shape of the tear itself. Large or massive tears that can’t be repaired (or repaired easily) present with more chronic symptoms. Left untreated, the body does what it can to heal itself. The affected individual does what he or she can do to adapt and the rest is history.

A nerve plexus refers to the entire group of nerves as they first start out with several main branches that divide to form a much larger number of nerve groups. The brachial plexus starts at the neck but travels under the clavicle (collar bone) and down the arm.

These nerves provide both sensation (pain, temperature, touch, vibration) and motor function (muscle contraction) for the entire upper extremity including the shoulder, arm, wrist, and hand.

Traumatic injuries of the brachial plexus refer to stretching, avulsion, or rupture of a group of nerves that come from the spinal cord in the neck. Avulsion tells us the nerve root is torn from the spinal cord where it attaches. Rupture refers to a complete tear across the nerve dividing it into two or more parts. The upper part is still attached to the spinal cord.

Brachial plexus injuries are usually caused by some type of trauma such as a car accident, fall onto an outstretched arm (especially if the head and face are turned away from that side), and stretching or pulling on the hand, wrist, or forearm. Gunshot wounds, knife lacerations, and other blunt open injuries are also likely causes of nerve avulsion or rupture.

Surgery is often needed to reconstruct the nerve. The surgeon must choose among several different approaches, each with their own specific surgical techniques. When there is a clean cut through the nerve, it is possible to stitch the two ends of the nerves back together in what is referred to as a direct repair.

But most of the time, there are multiple nerves that involve both sensory and motor function. In these cases, it may be necessary to perform nerve grafting, nerve transfers, or even muscle transfers. The nerves used depend on the location of the primary (main) nerve injury and the muscles (motion) affected.

Brachial plexus injuries can be complex, difficult to treat, and devastating for the patient. Every effort must be made to establish a correct diagnosis (which nerve is affected, location of the lesion, severity of the lesion) in order to plan treatment specific to that problem. Recent advances in the surgical repair and reconstruction of traumatic brachial plexus injuries has opened up treatment options and improved results.

There was a study done in Italy that might help answer your questions. One surgeon performed arthroscopic surgery on 43 patients with recurrent shoulder dislocations. Here are a few details to give you an idea of just who those patients were.

Most were men (only four women in the study). All but two were competitive athletes in contact or overhead sports. Everyone had at least one dislocation after the first injury. Some patients had as many as 10 more dislocations.

One of the questions the surgeons who conducted this study asked was, Will patients treated arthroscopically have arthritis later? They also wanted to know if shoulder function improved with the surgery and if the patients would be satisfied with the results. The final question was whether or not they could predict who might have a good (or poor) response to the arthroscopic Bankart repair using suture-anchors. Suture-anchors are stitches that reattach the labrum back onto the bone.

The Bankart procedure is done to reattach the labrum (a rim of fibrous cartilage) when it is torn away from the shoulder socket. When the force of injury is enough to tear the labrum, a piece of bone attached to the labrum comes with it. The layers of soft tissue around the labrum (ligaments, joint capsule, tendons) are also damaged and must be stitched back together layer by layer.

How did this group do with the arthroscopic Bankart repair? Well, the problem of recurrent shoulder dislocation wasn’t eliminated. A fair number of patients (16 per cent) had redislocation spontaneously (meaning without trauma). Adding in those who dislocated again due to trauma, there was an overall recurrent rate of 22.5 per cent (that’s almost one-fourth of the entire group).

The surgeons tried to tell if there was some specific reason why these athletes were still dislocating after surgical repair. It didn’t appear to be related to their age or the number of times they dislocated before surgery. Certainly, overhead throwing athletes had the greatest number of problems. Not having enough shoulder external (outward) rotation seemed to be a factor for some of the patients.

What about arthritis? Did these patients develop degenerative changes in the joint despite the surgery? Some did but the majority (two-thirds) did not have any signs of arthritic changes on X-ray. Those who did have changes were mild to moderate. There were no cases of severe degenerative arthritis — at least not at the end of the first 10 years.

And were the patients happy with the results? Eighty-four per cent (84%) said, Yes, they would have the same surgery over again. Most of them based this response on the fact that they could return to their previous level of sports participation. Those who were not satisfied with the results had recurrent dislocation(s) and/or experienced what is referred to as apprehension — feeling like the shoulder is going to dislocate with certain movements (external rotation, overhead throwing).

The authors noted that arthroscopic stabilization does have acceptable long-term results when used to do a Bankart repair on unstable shoulders. Shoulder osteoarthritis isn’t really a big concern in the first 10 years after surgery. This group of patients will continue to be followed to see what happens over the next 10 years. Your risk of recurrent dislocation is something your surgeon may be able to address based on your particular injury and activity level.

In theory, yes, you could have surgery to repair (probably reconstruct) that bum shoulder. But in reality, you’ll need to have an orthopedic surgeon evaluate your arm in order to answer that question for you. The standard treatment for recurrent shoulder dislocation is to reattach torn muscles and smooth or repair the labrum if it has frayed or pulled away from the bone.

The labrum is a fibrous rim of cartilage around the shoulder socket. It helps give the socket greater depth in order to stabilize the round head of the humerus (upper arm bone) in the shallow acetabulum (socket). With repeated shoulder dislocations, there’s a pretty good chance you have some involvement of the labrum that will need attention.

Most surgeries of this type are done with an open incision but a recent study from Italy showed good long-term results when done arthrocopically. By inserting a scope through several small openings, the surgeon can avoid cutting into the muscles around the shoulder. Even in patients who had a 10 to 20 year history of recurrent shoulder dislocations, there were successful results.

The big concern with long-term shoulder instability such as you describe is really arthritis. A loose, unstable joint doesn’t have normal biomechanics and smooth movement. Those two factors are enough to cause uneven wear and tear on the joint resulting in degenerative arthritis over time. Surgery to repair the instability can (and often does) reduce the risk of progressive arthritis. If for no other reason, you would be advised to seek the counsel of an orthopedic surgeon…and good luck!

The rotator cuff is a group of four muscles with their tendons that surround the shoulder joint giving it both strength and stability. Without an intact rotator cuff, the shoulder can dislocate or may be so weak the person can no longer lift the arm up overhead or reach out to the side.

Rotator cuff tears are a common cause of shoulder pain, stiffness, weakness, and loss of motion and function. Treatment starts with conservative (nonoperative) care in physical therapy and/or with steroid injections. But in some cases, conservative care fails to reduce the painful symptoms or restore normal motion. That’s when surgery may be needed.

Surgery to repair the damage is usually successful. But if you tend to worry, then your next question may be: what happens if conservative care fails AND surgery fails? Then what are your options?

Just as before, conservative care is the first line of treatment. It is still possible that a program of strengthening exercises combined with postural changes can bring about the changes you are looking for. But if a three-month trial of physical therapy and home program doesn’t solve the problem, then you are probably looking at a second surgery.

The surgeon evaluates each patient in order to determine the most appropriate next step. It could be something as simple as a re-repair. The surgeon goes back in and resutures the torn tendon, stitiching the tear closed. This option isn’t usually possible if there is poor tendon integrity, too many torn tendons, or too much fat replacing collagen (tendon) tissue.

Sometimes it’s just a matter of going in and cleaning up frayed edges of tendon. This procedure is called debridement. At the same time, the surgeon may address lesions of the long head of the biceps tendon. Damage to the biceps (muscle that bends the elbow) is often associated with massive rotator cuff tears and may be responsible for chronic shoulder pain and dysfunction. The surgical procedure for biceps repair is called a biceps tenotomy or tenodesis.

The real key to determining what to do next depends on what is causing the persistent shoulder pain and symptoms. For example, without a normal healthy rotator cuff doing its job, the head of the humerus starts to move up putting pressure on the suprascapular nerve. Relieving tension on the nerve may reduce painful symptoms.

Some patients have massive tears that just can’t be repaired. In such cases, the age of the patient may dictate the treatment. In younger patients, the surgeon can take another tendon nearby and transfer it to do the work of the torn rotator cuff. In older adults, a hemiarthroplasty or reverse shoulder arthroplasty are better choices.

Both of these procedures are a type of shoulder replacement. The hemiarthroplasty just replaces one side of the shoulder (usually the round head and attached neck of the humerus, the upper arm bone).

A reverse shoulder arthroplasty is a total shoulder joint replacement with a twist. Instead of the round head at the top of the humerus, the surgeon inserts a socket-shaped implant. The round portion fits where the natural socket used to be. This type of replacement surgery works well when the rotator cuff is so severely damaged it no longer functions to stabilize the joint.

But all that’s way down the road from where you are at right now. It’s good to be prepared for any possibility but the balance point is to take things as they come and do the best you can with what you have.

When performing arthroscopic surgery on the joint, it is necessary for the surgeon to put something inside the knee to distend or expand it. Over the years, different substances have been used — first nitrous oxide (laughing gas), then carbon dioxide. But studies showed that the use of any gas could result in a deadly embolism. Now surgeons use water or saline (salt solution).

Embolism is another word for an object (e.g., air, blood, fat) that travels through the bloodstream, lodges in a blood vessel, and blocks it. Even a small bubble of air introduced into the joint can travel to the heart or brain and cause sudden death. That air bubble is referred to as a venous air embolism.

Cases of sudden death from air embolism during joint arthroscopy are rare but serious enough to send some surgeons back to the lab to experiment and find out what’s causing this to happen. A new study is now available that might shed some light on what’s happening. It looks like the bags of saline-solution used to distend the joint might be the problem.

There can be small amounts of air trapped in the bags, which then get pumped into the joint. It is a standard practice to prime the tube between the bag and the arthroscopic pump but not necessarily to bleed the bag of any air before connecting it to the pump. This simple step in the preoperative procedure may eliminate the problem. More study of the problem is needed before we will know for sure but it sounds like the researchers are on the right track on this problem.

When performing arthroscopic surgery on the joint, it is necessary for the surgeon to put something inside the joint to distend or expand it. Over the years, different substances have been used. Nitrous oxide (laughing gas) was first used way back in the 1920s. The practice was continued throughout much of the 20th century (1900s).

But it was discovered that air embolism from this technique could cause sudden death. Embolism is another word for an object (e.g., air, blood, fat) that travels through the bloodstream, lodges in a blood vessel, and blocks it.

Surgeons abandoned the use of nitrous oxide and used carbon dioxide instead. But studies showed that the use of any gas could result in a deadly embolism. Now surgeons use water or saline (salt solution).

But guess what? Cases of sudden death have occurred even when using an all-liquid arthroscopic system. It’s rare but it’s still fatal and therefore unacceptable. Surgeons won’t have to abandon the use of saline. But a recent experiment showed that careful pre-op and intraoperative handling of the bags of saline-solution is needed to bleed the bags of any air and prime the tubing that connects the bags to the pump.

It is suspected that venous air embolism during shoulder arthroscopy happens more often than is realized or reported. This simple change in procedure can be done with a sterile technique. And best of all, it’s 100 per cent effective.

Loss of circulation to the hands can occur with arms raised overhead from one of several different problems.
The onset of angina and a subsequent heart attack is known to be precipitated when working with the arms extended over the head.

Oxygen requirements of the heart are greater during arm work compared to leg work at the same workload level. If a person becomes weak or short of breath while in this position, ischemia (loss of blood supply) may be the cause.

Pain and numbness can also be the result of a condition known as thoracic outlet syndrome (TOS).
The main cause of TOS is that the nerves and blood vessels going from the neck down to the arm and hand get squeezed near the thoracic outlet. The thoracic outlet is this opening between the scalene muscles and the rib cage. The nerves and blood vessels go through the outlet opening, then under the collarbone (also known as the clavicle), through the armpit (the axilla), and down the arm to the hand.

There’s a wide variety of reasons why you might develop TOS as a potential cause of your current symptoms. For example, pressure on nerves and vessels can happen in people who have fractured their clavicle. It can also happen in people who have an extra first rib, although this doesn’t always result in TOS.

Extra muscle or scar tissues in the scalene muscles can put extra pressure on the nerves and arteries. Heavy lifting and carrying can bulk up the scalenus muscles to the point where the nerve and arteries get squeezed
Traumatic injury from a car accident can also cause problems that lead to TOS. In an accident, the shoulder harness of the seat belt can strain or tear the muscles. As they heal, scar tissue can build up, putting pressure on the nerves and blood vessels at the thoracic outlet.

Neck and arm positions used at work and home may contribute to TOS. People who have to hold their neck and shoulders in awkward alignment sometimes develop TOS symptoms. TOS symptoms are also reported by people who have to hold their arms up or out for long periods of time.

People with TOS often slouch their shoulders, giving them a drooped appearance. The poor body alignment of slouching can compress the nerves and arteries near the thoracic outlet. Being overweight can cause problems with posture, and women who have very large breasts may also have a droopy posture. For some reason, TOS affects three times as many women as men.

Regardless of the cause of your symptoms, this is something that should be evaluated by a medical doctor. An accurate diagnosis will guide treatment. Early discovery of the problem and early intervention usually results in improved outcomes. If it is something as serious as heart ischemia, you don’t want to delay.

There are some clinical tests examiners can use to help identify which structures in the shoulder might be causing painful symptoms. For example, there are several different tests that require putting the arm in a particular position and/or giving some slight resistance to movement in that position.

These are called provocation tests. By observing the patient’s symptoms, it is possible to identify a rotator cuff tear versus a bursitis versus an impingement problem this way. When soft tissue structures such as a bursa get pinched and inflamed, it is also possible to inject a numbing agent into the area and see if the painful symptoms go away. If they do, the injection is a confirmation that the problem was as suspected.

In the shoulder, there are quite a few different bursaes present. X-rays help show when the spaces normally cushioned by a bursa are thinned or narrowed. Ultrasound studies are much better at showing the affected tissue. And dynamic ultrasound (images taken with the arm moving) help identify the exact sequence of events that occur causing pain.

It’s likely that your physician has conducted all of the clinical tests possible but needs some additional imaging studies to confirm the final diagnosis. In order to get treatment specific to the problem, it’s likely that these studies are very important and will save you time and money in the long run.

A snapping or catching sensation felt along the front of the shoulder can be caused by many different problems. There could be a torn rotator cuff or a torn labrum. The labrum is a fibrous rim of extra cartilage around the otherwise shallow shoulder socket. It helps give the shoulder socket more depth and keeps the round ball at the top of the humerus (upper arm bone) in the socket.

Other possible causes of shoulder snapping include bursitis, tendon tears, bone spurs, or loose pieces of cartilage or bone inside the shoulder joint. There’s also a chance that it could be a shoulder bursitis.

In a recent case report, symptoms of shoulder snapping like yours were reported in a 23-year-old weight lifter. When the weight lifter first went to the Mayo Clinic Sports Medicine Center in Rochester, Minnesota, he had an eight-week history of painful shoulder snapping. The snapping occurred whenever he lifted his arm straight forward with the elbow straight or when he used his left arm in a rowing motion.

After a series of tests, they found a pocket of fluid over the tendon of the subscapularis muscle. The subscapularis muscle is part of the rotator cuff, so although the rotator cuff wasn’t torn or ruptured, there was evidence of a tendinopathy. Tendinopathy refers to chronic changes in the tendon without active inflammation.

Inflamed tissue was observed around the subcoracoid bursa. The subcoracoid bursa is sandwiched between the subscapularis muscle and the coracoid process. The coracoid process is a hook-shaped piece of bone that comes from the shoulder blade to help stabilize the shoulder.

It’s impossible to say what is causing your snapping shoulder without some specific tests to identify what’s going on. Make an appointment with your primary care physician or an orthopedic physician and get a proper diagnosis. Early treatment can sometimes help prevent minor problems from growing into major problems. It may be something simple that can be treated easily if diagnosed early.

Physicians in the military are often spread thin so they do rely on an assistant to carry out the triage, a method of screening and preliminary examination. Those recruits or soldiers who have an obvious problem that doesn’t require the expertise of a medical doctor are sent for treatment right away.

In the case of a ruptured pectoralis major (chest) muscle, the clinical signs are very obvious. There is usually some visible swelling and bruising when it is a recent (acute) injury.

With a chronic injury, there may be atrophy (wasting) of the muscle. In either case, with a complete rupture, the tendon and the attached muscle pull back (retracts) and bunch up. All of these clinical signs are very apparent, especially when looking at one arm compared to the other.

In some cases, an X-ray or other imaging study may be needed. The physician’s assistant (PA) can order those as well. The PA is highly trained to know when a patient should see the orthopedic surgeon. You can trust his or her judgment. X-rays are often negative unless there has been a bone fracture at the same time or a piece of bone (avulsion) has pulled away with the tendon rupture.

Ultrasound imaging can show damage to the muscle and the presence of any hematomas (pockets of pooled blood). MRIs help the surgeon see exactly where the damage has occurred and if the tendon is partially or fully ruptured. The MRI also shows the current location of the tendon and how far back it has retracted from the bone.

Since the insertion of the pectoralis major tendon is so close to the biceps tendon, the MRI clears up any confusion about what is included in the damage. All of this information can help when deciding what type of treatment is best.

The pectoralis muscle is the large muscle across the chest that is most active when doing push-ups or lifting weights.

It is a two-part muscle that attaches above to the clavicle (collar bone) and down the length of the sternum (breast bone). It also attaches by a fairly narrow tendon (thin compared to the muscle size) to the upper arm next to the tendon insertion of the biceps muscle.

Injuries severe enough to rupture the tendon attachment occur most often when the muscle is fully contracted and then slowly lengthens against a weight. This mechanism of injury describes the bench press — lifting overhead with arms out to the sides, elbows straight, and shoulders externally rotated.

Pectoralis major ruptures have also been reported as a result of work injuries. And this type of injury has been associated with a wide range of activities such as wrestling, sailing, water skiing, snow skiing, rugby and soccer, football, boxing, and even parachuting.

In younger adults, the injuries almost always occur in males between the ages of 20 and 40. Older adults might have this type of injury just as you described — when they have been helped by others to transfer from bed to chair and vice versa. Pressure under the arms against stiff, weak muscles while being lifted is enough to cause crush injuries, tendon ruptures, and hematomas (pools of blood around or inside the muscle).

Most of the time, surgery is required to repair the damage. It’s during the operation that the surgeon gets a close up view and 100 per cent accuracy in the diagnosis. Only older adults are treated conservatively (nonoperative). With rest, support (arm in a sling), and the use of cold and later heat, these injuries can heal enough to allow the less active person to perform normal daily activities without pain.

The Bankart procedure is done to reattach the labrum (a rim of fibrous cartilage) when it is torn away from the shoulder socket. When the force of injury is enough to tear the labrum, a piece of bone attached to the labrum comes with it. The layers of soft tissue around the labrum (ligaments, joint capsule, tendons) are also damaged and must be stitched back together layer by layer.

Clicking in the shoulder could be from several different causes. There may be a frayed edge of the labrum that is getting caught between the head of the humerus (upper arm bone) and the socket. There could be a bone spure or a bit of swelling from arthritis causing this symptom.

A recent study done on patients with recurrent (repeated) anterior (forward) shoulder dislocations showed that one-fourth of the patients had early (mild) arthritic changes that were present in the shoulder before surgery.

Only seven per cent of those cases actually showed up on X-rays. That’s because the most frequent sign of early arthritis was bone spurs developing where the labrum attaches to the shoulder socket. This type of change doesn’t appear on X-rays until the spur formation is much more advanced. The surgeons confirmed these changes when looking at the joint during the Bankart procedure.

It could be something else altogether. An accurate diagnosis will require an orthopedic examination and possibly some imaging studies.

Many studies have been done in gaining understanding of shoulder dislocations. For example, surgeons have asked the question: if surgery is done, will arthritis set in sooner than if there never had been an injury? Another area of investigation has been the role of surgery as the cause of arthritis after repeated anterior (forward) shoulder dislocation.

A group of Japanese orthopedic surgeons recently reported on a long-term study of arthritis that was present after surgery for recurrent shoulder dislocations. They discovered that one-forth of the patients actually had arthritic changes before surgery was ever done.

An analysis of all the factors present preoperatively (e.g. patient age, total number of dislocations, and side affected) was done. It showed that the severity of the damage present as a result of the repeated dislocations was the real deciding factor.

On a more positive note, after following these patients for five to 20 years, they saw that the arthritis progressed slowly over time. Many of the patients were asymptomatic — in other words, if the X-ray or CT scan hadn’t shown the arthritic changes, they would never have even known that had a problem.

Apparently, the arthritis progresses very slowly and may not be a problem for some patients. CT scans may be helpful in the diagnosis of osteoarthritis in recurrent anterior shoulder dislocations.

The more often the shoulder dislocates, the more likely postoperative arthritic changes will develop. These preoperative dislocations cause repeated trauma to the shoulder and worsening instability. Instability of this type should be treated operatively to avoid the worsening of arthritic changes.

Acromioplasty is one of the most common orthopedic procedures performed in the United States. What’s an acromioplasty? It’s the removal of a small piece of bone called the acromion. The acromion comes from the scapula (shoulder blade at the back of the shoulder) across the top of the shoulder to connect with the clavicle collar bone in the front of the shoulder.

Why is it removed? Generally, removal of the acromion is done to take pressure off the rotator cuff tendons as they pass under the acromion to attach to the upper arm. Until recently, it was believed that the reason these tendons got frayed or damaged was from rubbing against the bottom of the acromion. Shaving the underside of the acromion or removing the end of the bone altogether is one way to deal with the problem.

Rotator cuff degeneration seems to be common in midlife, often occurring between the ages 30 to 40 years old. Mechanical impingement (pinching) from the acromion is considered a major cause of this problem. Removing the acromion is a logical way to solve the problem.

Besides impingement syndrome, acromioplasty is also used for sprains and strains of the rotator cuff, shoulder bursitis, labral tears, and rotator cuff ruptures. It’s likely that your neighbor had one of these problems. She might be willing to tell you all about it if you ask!