FAQ Category: Shoulder

Shoulder dislocations, particularly anterior dislocations have a high rate of redislocation among certain groups of people, particularly young, active adults. However, surgery for first or primary dislocations is still generally reserved for people who participate in heavy physical activity or sports activities. There is no general reason why it’s done this way other than it is the accepted way. Surgery always has risks, regardless of the type of procedure and doctors usually try to err on the side of caution, using conservative (non-surgical) methods before surgery, if conservative methods are an option.

Many of our lifestyle choices and health issues affect how our body works, whether it is how we breathe, walk, or even use our arms. Someone who is obese may have other health issues and is, frequently, not very physically active. As we don’t use our joints the way they should be used, they may become stiffer and more difficult to use, and they may cause pain.

Dislocated shoulders are not like a condition that can repeat itself, such as a migraine or an asthma attack. However, once you have dislocated a shoulder, it is more delicate if the ligaments were damaged. The shoulder may not be as stable any longer, so any fall or blow to it could cause it to dislocate easier than if it had never been injured before.

The rotator cuff is a group of four muscles and their tendons that surround the shoulder joint. The four muscles/tendons are the infraspinatus, supraspinatus, subscapularis, and teres minor. Together, these muscles/tendons support, stabilize, and move the shoulder.

The infraspinatus and supraspinatus tendons are the two tendons most often involved in rotator cuff tears. When two or more tendons are involved at the same time, the tear is termed massive. Or if one tendon is torn so badly it is fully ruptured or the tear is more than an inch in diameter, the injury is also called massive. Severe and massive can both be used to describe the same injury.

Usually if the subscapularis muscle and especially the teres minor are torn, the other tendons have already been damaged. The more tendons involved in the injury, the more difficult repair can be. The surgeon is faced with many decisions about how and when to do surgery, what type of suture would hold best, and whether healing is even possible.

With massive tears, retears are common. The tissues just don’t heal as strong as normal, healthy, tissues. Fibrosis (a type of scar tissue) forms instead of real tendon tissue. The tissue is stiffer and loss of good blood supply at the cellular level. In older adults with degenerative (aging) tissue, tears often fill in with fatty tissue that isn’t strong at all.

Some tears can’t be repaired. Others require extensive surgery to debride (clean up) any frayed edges and remove tissue damaged beyond repair. A tendon transfer may be needed. No matter what decision is made, there are various techniques to choose from when performing the procedure. The bottom line is to restore the shoulder to as near normal as possible and have the repair hold up over time.

It might be helpful for the two of you to go to the surgeon together and find out what the surgeon said about the problem and potential solutions. It’s likely the physician outlined some of these things for your brother. Many people leave the doctor’s office without remembering much of what was said.

Sometimes it’s true that patients are considered medically unfit for surgery. In your brother’s case, you mentioned several risk factors (diabetes, smoking, overweight) that could put him at too great a risk for surgery. That’s when conservative (nonoperative) care may be recommended.

For patients who are medically unable to have surgery and for those who don’t want surgery, physical therapy has been shown effective as a nonoperative approach to treatment. The therapist shows the patient ways to move that will reduce the stress and pressure on shoulder structures. At the same time, a strengthening program is used to strengthen the muscles that still work normally in order to restore as much normal shoulder function as possible. Steroid injections may be used to help with pain control and improve motion during therapy.

Smoking cessation, increasing physical activity, and weight loss are not out of reach even for the most out-of-shape people. By working on improving overall health, your brother may find it possible to have surgery later if conservative care fails to provide him with the pain relief and improved function needed for daily activities. Your support could be an important part of his future success with such a program.

Acromioplasty is the removal of the end of the acromion, the round end of a curved piece of bone that comes from the back of the scapula (shoulder blade) over the top of the shoulder. Some of the shoulder muscles of the rotator cuff pass under the acromion as they travel from the scapula to the humerus (upper arm bone). And for various reasons, the rotator cuff can get pinched there causing a painful problem called subacromial impingement syndrome. Subacromial just means under the acromion.

There are two different ways to perform this operation. One is with an open incision. The other is with arthroscopy, which eliminates opening up the skin and cutting through the muscles to get to the bone. Some surgeons think arthroscopic acromioplasty is a better way to go for several reasons.

First, they are able to avoid cutting through the deltoid muscle. Deltoid sparing techniques make it possible for the patient to start moving the arm right away after surgery. They can get into rehab without delay — and for competitive athletes, that is a very important feature. For those who care, the incisions for arthroscopic surgery are much smaller and far less noticeable than the scar that results from the open incision.

So your return to practice and competitive participation may depend on how the acromioplasty is performed. You can ask your surgeon how he or she plans to do this procedure and the expected time to return-to-sports. Let your concerns and goals be known so that you can get a match between your desired outcomes and the surgeon’s technique.

Ever since arthroscopic surgery became a possibility for shoulder surgery, surgeons have been debating and comparing the open incision technique against arthroscopy for shoulder impingement syndrome. Which one is better? Does it even matter in the end? The results of a recent meta-analysis may be able to answer the question once and for all for acromioplasty.

Acromioplasty is the removal of the end of the acromion, the round end of a curved piece of bone that comes from the back of the scapula (shoulder blade) over the top of the shoulder. Some of the shoulder muscles of the rotator cuff pass under the acromion as they travel from the scapula to the humerus (upper arm bone). And for various reasons, the rotator cuff can get pinched there causing the painful problem you have called subacromial impingement syndrome. Subacromial just means under the acromion.

A meta-analysis has the power to end debates because it provides enough subjects to reach some final conclusions. After searching all the medical literature published from 2000 to 2007 plus all the presentations made on the topic at four major orthopedic meetings held during that time, the authors were able to come to shed some light by comparing results between the two procedures. They found nine studies that directly compared arthroscopic versus open acromioplasty surgeries.

It turns out that by the end of 12 months (one full year), patients had equal results in terms of complications after surgery and final outcomes such as range-of-motion, pain, and function. And patients reported equal levels of satisfaction with either procedure. It’s what happens during those 12 months that’s of significance.

For example, patients undergoing the arthroscopic procedure were able to leave the hospital faster and go back to work sooner. On average, patients having the arthroscopic procedure were back at work two weeks before patients in the open acromioplasty group. And the open acromioplasty took longer, so combined with lost wages from a delay in return-to-work, there was more expense for operative time with the open technique.

The authors of the meta-analysis concluded that although arthroscopic acromioplasty isn’t superior to open incision surgery in every way, it does have some important socioeconomic advantages to consider.

The rotator cuff in your shoulder is really four tendons that are at the shoulder, helping it move as it should. If one of those tendons is injured, it is called a tear or injury to the rotator cuff. However, there is a difference as to which tendon you injure and how severely you injure it.

Professional ball players may tear a rotator cuff because of the velocity at which they throw the ball. In their case, the velocity is so strong, they could end up developing a deep or extensive tear in more than one tendon. Your injury is caused by a different mechanism, but it is still a rotator cuff injury. Without seeing your records, it would be impossible to tell you if you injured the same tendons that a ball player might or if your injury is as severe.

The way a torn rotator cuff is treated is based on what caused the injury, exactly where the injury is, and how severe it is. Your rotator cuff is not one body part, but is really made up of four tendons that help your shoulder move. When one of the tendons becomes injured, this is a rotator cuff injury or a rotator cuff tear.

Small tears or injuries often heal on their own, with treatment such as suggested by your doctor. By not using the shoulder or by not doing the motions that caused the injury, you are resting it, allowing it to heal. By applying ice and taking the medication, you are reducing swelling and pain, which should also help the healing process.

If you feel that your shoulder isn’t healing, you should speak with your doctor to see if it is, but you don’t see it/feel it, or if you need a different treatment approach.

Any time someone faces surgery for any reason, it is necessary to disclose any and all potential problems that could occur. The list can be very long and seem impersonal. You might even think, Oh, that will never happen to me!. It can include minor problems like fever to major problems like infection.

Any surgery puts a person at risk of problems and complications — even death. Post-operative problems are more likely to develop if there are other health problems (e.g., heart disease, diabetes) that can increase the risk of serious complications with any surgery. Thankfully, serious risks and the risk of death are fairly low for a shoulder joint replacement surgery.

Patient dissatisfaction is counted as a measure of success. The surgeon could do a beautiful job installing the implant, but if you aren’t happy with the results, then the surgery wasn’t really a success, now was it? Patients report being dissatisfied when their pre- and postoperative pain levels are no different. In fact, pain could be higher after surgery. Motion and function are usually adversely affected by pain, so there are even more reasons to be unhappy.

But it’s also a fact that sometimes patients go into surgery with unreasonable expectations. They may think the new implant will allow them to do things they haven’t done in 50 years! That can create some dynamic tension and dissatisfaction. A high activity level can increase the risk of problems like implant loosening or debris collecting inside the implant just from wear and tear. That doesn’t usually happen at first but it can contribute later to patient dissatisfaction with the long-term results.

So you can see, there are a multitude of reasons why patient satisfaction may come up short after shoulder replacement surgery. But most people find that with a little patience and careful attention to their rehab program, they do just fine and are quite happy with the results.

Studies show that patients who are 50 and younger just don’t have as good of results as patients over 50 with this procedure. For a long time, we thought it was really just the age difference. Younger patients are more active and more likely to stress the implant more than a quiet, fairly inactive grandmother might. But there’s new evidence that it may not be age as much as the underlying cause of the shoulder problem.

It turns out that younger patients with shoulder pain and loss of function severe enough to warrant replacing the joint is more often due to capsulorrhaphy arthropathy than degenerative joint disease. Capsulorraphy arthropathy refers to arthritis that occurs after a previous surgery on the shoulder. That surgery might have been to repair a torn rotator cuff or relocate a dislocated shoulder. Degenerative joint disease is age-related osteoarthritis more common in older adults.

The surgeon may have been referring to age as the major difference between the two of you — more so than the differences between men and women. It is true that studies have showed that women tend to report worse outcomes than men in the months to years after shoulder replacement. Perhaps women just have a different idea of what is a successful surgery compared with men.

Younger patients seem to have more complex pathologies (e.g., loss of blood to the joint, post-traumatic arthritis) compared with older adults. The vast majority of older adults who need a shoulder replacement suffer from osteoarthritis. And the greater involvement of the surrounding soft tissues with capsulorraphy arthropathy can complicate surgery and follow-up rehab program.

Your surgeon may have some other reason(s) to suggest a difference in results between you and your grandmother. There can be complicating factors such as previous injury and/or surgery to the shoulder. And it’s entirely possible the surgeon was teasing you as a way to encourage you both to get the best results possible. You’ll never know unless you ask for a clarification of that prediction!

What is your surgeon advising? Usually the physician who has followed you through all the procedures will have a proposed plan of care or at least some options in mind. Even with a massive tear and two revision surgeries, there may be some treatment that could relieve your pain and restore some of your motion and function.

It could be that a rehab program might benefit you. A program of joint motion, muscle strengthening, and conditioning exercises might help return some of your function. A fourth revision surgery to repair the damage may or may not be in your best interests. Your surgeon is the best one to make this determination. He or she will view the imaging studies (X-rays, MRIs, CT scans) and compare them to what was found at the time of the first three procedures. That information along with the results of a current clinical examination will provide what’s needed to move forward with treatment.

It’s possible that there was other damage done to the shoulder when you first injured it that is complicating the results. Studies have shown that the more surgeries done on one shoulder, the less likely the chances are for a successful result.

You aren’t out of options yet! Depending on your age and the condition of the shoulder joint, soft tissues, and underlying bone, you might be a candidate for a total shoulder replacement. Again, your next step is to consult with your surgeon and possibly even get a second or third opinion. Gather all the information you can before making your final decision.

Each state runs its own Worker’s Compensation program. The rules and guidelines vary because of that. Your case manager should be able to help you answer this question. You must be able to show that you have the motion, strength, and function needed to complete all tasks required by your job at your pre-injury level.

A functional capacity evaluation is designed to protect you as well as the company. You don’t want to reinjure your shoulder by returning to work before you have completed the rehab process — especially after two surgeries. The company doesn’t want to bear the cost of a worker being out because he or she came back too soon or before being ready physically.

It’s really a win-win kind of situation. Worker’s comp pays for the test so you aren’t out any money. It will require some of your time (anywhere from 1/2 day to a full day). The physical or occupational therapist who conducts the test will gear it to your job requirements, so you shouldn’t be asked to do more than you would have to at work. But, again, you will have to contact your local representative to find out if an exception can be made because of your particular situation. If not, it will be an experience that will confirm your ability to return to work safely.

There’s an old saying in the medical world, When you hear hoofbeats, think horses, not zebras. The idea is to look for the obvious, not the unusual. In the case of young athletes, a rotator cuff tear would be unusual — most athletes experience this type of injury only after prolonged, repetitive overuse. But with the type of injury you describe, the history alone should tip off the examiner that there may be more going on than a simple burner or stinger.

Injuries to the neck and upper arm can stun the nerve plexus in that area causing what you referred to as burners or stingers. Numbness and even what looks like sudden paralysis develops but goes away fairly quickly (often by the end of the game). The idea to look deeper would be supported by the lack of improvement in symptoms. An athlete who is still in pain and can’t lift the arm or move it in all directions should be re-evaluated quickly.

An early diagnosis and treatment can save the athlete’s arm and career. A delayed diagnosis and waiting too long to repair the damage could result in further damage to the soft tissues. Worst case scenario is that too long of a delay in treatment could mean the soft tissues can’t be repaired. A loss of motion, strength, and function could leave the athlete out of the game.

The excellent tendon quality in young (adolescent) athletes is what makes a complete recovery possible. Before inflammation and excessive swelling fill the area, the surgeon can clean up the damage, repair the tear(s), and send the athlete along to rehab.

Your point is well taken. Although rupture of the rotator cuff in young athletes is rare, it can happen. The case of your player demonstrates the need for careful examination in any athlete who suffers a direct blow to the shoulder. Imaging studies can be followed by arthroscopic exam whenever athletes present with shoulder pain, weakness, and loss of motion that doesn’t go away quickly after the injury. With early intervention, young athletes have an excellent chance of recovery and return to sports.

Thanks for taking the time to write in and share your experience with others who might see something similar and help athletes get the prompt evaluation, diagnosis, and treatment they need.

Being in good health with strong muscles, tendons, and bones will come in handy when recovering from an acute traumatic injury of this kind. Excellent tendon quality and mobility makes it possible to get a strong repair with fewer sutures and stitches. That can limit the amount of scar tissue that develops and help you avoid other problems later.

Rehab after surgery for a rotator cuff tear begins with passive shoulder motion. You probably won’t feel like you are doing much at first. It will be important to follow your surgeon and your therapist’s advice, counsel, and guidance carefully for the best results. You don’t want to compromise the surgical repair by loading the tissues too much before they are ready to handle it.

You’ll see slow but steady improvement in motion, strength, and function. When you have full (or close to full motion), the strengthening portion of the rehab program will begin. Strengthening will help improve shoulder function and stability. The final phase of rehab is directed toward return-to-sports. A specific program will be prescribed by the therapist to prepare you for the kinds of physical actions required to play your position in football.

Although this type of acute high-energy injury is rare, reports published in the orthopedic literature suggest a four-to-six month rehabilitation program with multiple phases as described here. Young athletes are able to return to contact sports with full participation and at a level equal to their pre-injury status!

Studies suggest that up to one-quarter of all patients with a surgically repaired rotator cuff tear will retear it early after the first surgery. The reasons for this aren’t entirely clear. It doesn’t seem to be linked with how the surgery was done (e.g., mini-open repair versus all-arthroscopically repaired).

It may have something to do with the patient disregarding doctor’s orders and doing too much too soon. Young athletes eager to get back in the game and return to competitive sports may fall into this group.

The availability of improved ultrasound images makes it easier than ever to reassess the status of a rotator cuff repair and monitor healing responses. Ultrasound is a quick and inexpensive way to see if a tear has occurred. And it can be used to see how the tear is changing — either healing itself or getting larger (and by how much)..

One study from the Sports Medicine and Shoulder Service associated with a hospital for special surgery in New York City followed patients with a retorn rotator cuff repair. None of the patients had the tear repaired. The idea was to see what happened over time without intervention.

They found that in a group of 15 patients, the tears got worse with each year. And the larger the tear, the more loss of muscle strength there was. This loss of strength didn’t seem to bother the patients. They weren’t having pain and they were older (less active with fewer demands on the shoulder).

The bottom line from that study was that retears without repair still provided patients with significant benefit. There was satisfactory pain relief. And despite ultrasound images showing an increase in the size of the tear over time (which was accompanied by a loss of muscle strength), the patients didn’t seem to be adversely affected.

Your surgeon will be able to advise you as to the next step. Depending on your symptoms (pain, weakness, loss of function) or lack of symptoms, you may be told to get rechecked periodically to keep an eye on the situation. There is the option of another surgery but without evidence that this is required or necessary for satisfactory long-term results, it’s not routinely recommended.

The joint’s sense of its own position as it moves through space is called joint proprioception. We all rely on proprioception to stabilize the shoulder joint and provide equal movement from one side to the other. Physical therapists actually test patients’ proprioception by blindfolding the patient (or having the patient close the eyes), moving one arm or body part to a certain spot, and then asking the patient to move the other arm to the exact same spot.

The ability to come within millimeters of the same position from side to side is a visible sign of good proprioception. Several patterns of movement are tested to get an idea of overall joint proprioception for each body part (e.g., finger, wrist, elbow, shoulder). Fatigue from overuse and injury from repetitive motion are common causes of altered (decreased) proprioception.

A follow-up visit with your therapist may be needed but first, you might just give your therapist a phone call and relay your concerns to him or her. This may be something that was addressed during therapy without you being aware of it directly. Or it could be something that you are now ready to incorporate additional rehab to restore full proprioception. It may depend on the type of injury you had and expectations for full recovery.

Overhead throwing athletes are subjected to many different external forces that can affect the shoulder complex. With every pitch, there is a tremendous force placed on the soft tissue and bony structures. This is especially true at the end of your shoulder range of motion — both as you cock your arm back all the way and as you let the ball go during forward motion.

Add the speed and angle of each throw into the mix and you’ve got a recipe for potential problems. Injuries are often the result of many factors such as muscle imbalances and/or muscle weakness. There can be issues with too much or not enough flexibility. Flexibility of soft tissue structures such as the tendons is called tissue extensibility. Looseness of ligaments and the joint structures is referred to as joint laxity. Either of these conditions (and especially when combined together at the same time) can contribute to sudden shoulder injuries.

In point of fact, most of the time, the injuries aren’t sudden at all. They are quite gradual but the player isn’t aware of changes that will eventually result in a problem. It’s probably time for a review of your situation — including a look at your throwing patterns, joint motion, and muscle strength. Talk to your coach about the best way to handle this. Many teams have their own athletic trainers, exercise physiologists, or physical therapists who can evaluate new problems and advise the athlete accordingly.

There isn’t a lot of data about recovery from retears of previously repaired rotator cuff tears. The studies that have been done report conflicting results. Some showed that spontaneous healing is possible. Others showed not one patient had any signs of recovery.

The question has been raised whether revision (second) surgery is even needed when a repaired cuff tear retears. Many patients are perfectly happy with the results even with a retear. They don’t have pain and they don’t notice much difference in how the arm works. Of course, the average age of patients in these studies was 62, so we’re talking about an older group. The same may not be true for younger, more active adults.

Surgeons have also started taking a look to see if by not repairing a second tear, patients are left at a disadvantage much later. It’s possible the tendon might deteriorate over time to the point that surgery would no longer even be possible. Then it’s too late and the damage is done.

The questions you ask are very valid and deserve a complete answer. Unfortunately, there isn’t enough information from studies to supply you with a definite answer one way or another. It might be helpful to ask your surgeon for his or her opinion. With imaging studies like MRIs and ultrasound and possibly arthroscopic examination, the size, location, and extent of the tear can be evaluated. Any change in your condition might warrant surgical repair but this is decided on a case-by-case basis.

Shoulder dislocations as a result of a fall and/or sports injury are fairly common. Car accidents are also a major cause of shoulder dislocations. Emergency medical technicians (EMTs) have very specific training for situations like this. They do it more often than others so they tend to have more highly developed skills needed to reduce or relocate the joint.

Some techniques seem to work better than others. But there are also patient factors that can get in the way. If the patient’s pain level is high, there is likely going to be muscle guarding and splinting. In other words, the muscles contract and hold the arm in place to protect it. Trying to manipulate it back into place against the force of those muscles can make the problem worse.

Even in the best of situations, it’s possible that no technique will be successful (for whatever reasons). In those cases, the patients must be anesthetized (sedated or temporarily put to sleep with medications). Under the influence of the anesthetic, the arm moves smoothly through its motion and the surgeon can gently put the head of the humerus back in the socket.

Surgery to open the joint and repair or reconstruct it is rare but can happen. The exact reasons why one person might have a successful nonoperative reduction while another needs major surgery remain unclear. Scientists are studying this problem and looking for the best way to treat it quickly, easily, and with as little pain as possible. The goal is to avoid surgery while still regaining full shoulder motion and function.