FAQ Category: Shoulder

Orthopedic surgeons from Greece think they may have found a new way to quickly reduce an anterior shoulder dislocation with far less pain than two other methods commonly used. For those who don’t know what that means, reducing the shoulder joint simply means to put the head of the humerus (upper arm bone) back in the shoulder socket.

The new technique is called the FARES method, which stands for fast, reliable, and safe. It is done with the patient lying on his or her back. The doctor faces the patient and holds the patient’s hand while the patient’s arm is down at his side. The elbow is straight and the thumb is pointing up. This position puts the forearm is in a neutral or midline position. A gentle traction force is placed on the hand to pull the arm down away from the patient’s head.

Then the arm is slowly moved away from the body, a movement called abduction. The clinician continues to pull the arm gently downward toward the feet while applying a vertical (up and down) oscillating movement. When the arm is abducted to about 90 degrees, the examiner gently rotates the patient’s arm into a position of external (outward) rotation. Now the palm is facing the ceiling.

The arm is gently pulled up toward the patient’s head with continued traction and oscillating motions. When the arm is abducted about 120 degrees away from the side of the body, the humeral head slips back into the socket and the shoulder is reduced.

In this study, they compared how well the FARES technique for anterior shoulder reduction compared with two other methods commonly used (the Hippocratic method and the Kocher method). Each of these other methods are similar to the FARES method but with slight differences. Since you already know how to do these other techniques, we will keep our focus on the results rather than describe each method in detail. The Milch technique you mentioned wasn’t tested in this study.

The authors concluded that the FARES method of anterior shoulder dislocation reduction is safe and reliable while being faster and less painful than two other methods tested. The Kocher method was faster than the Hippocratic method but more painful for the patient. The FARES method can be done by medical students and residents who don’t have a lot of practice yet. It is a simple technique that can be done by one person. And it can be used without the expense of medications (pain relievers or muscle relaxers) or an operation.

More studies are needed to confirm these findings and to compare the FARES method of shoulder reduction with other techniques that were not considered in this study. As common as anterior shoulder dislocations are, finding the best method to reduce it that can be used in the emergency department or outpatient clinics is an important goal.

Steroid injections into joints are usually intended to reduce pain and inflammation. Because the solution injected contains a numbing agent as well as the steroid antiinflammatory, results are fairly rapid. If all goes well, you should expect to experience benefits in the first few days to weeks.

Results may depend on accuracy of the injection. Studies show that physicians who rely on their palpatory skills (vision and touch) have much lower accuracy (and poorer results). Using ultrasound or X-ray imaging to guide the needle improve accuracy from 33 to 93 per cent.

Along with improved accuracy comes rapid improvement of symptoms. Patients with serious limitations in shoulder movement and function appreciate those kind of rapid results when it comes to quality of life issues such as getting dressed, getting back to work, and even being able to wipe the bottom after toileting.

You may be given a series of exercises to perform each day at home. Bending forward and dangling the arm (Codman exercises), stretches, and wall climbing exercises (using the fingers to walk up the wall) can help restore full joint motion and function.

You may be referring to the injection of a lubricating substance called sodium hyaluronate. Repeated injections of the hyaluronate have been shown to reduce pain, improve joint motion, and restore knee function. Studies have also shown this treatment given in weekly injections over a period of five weeks works well for the shoulder, too.

Patients with adhesive capsulitis, otherwise known as frozen shoulder seem to respond well to this treatment. Patients with chronic frozen shoulder that have not improved with antiinflammatory medications or physical therapy may be the best candidates for this treatment.

Ultrasound-guided injection is advised. This approach improves accuracy in the delivery of the injection. By the time the condition has become chronic, the joint capsule has shrunk and gaining access to the joint capsule is limited. The ultrasound images make it possible for the physician to make sure the hyaluronate reaches its intended destination.

An alternate approach is with fluoroscopy, a 3-D real-time form of X-ray. Fluoroscopy also improves accuracy but exposes the patient to radiation. With improved technology, ultrasound devices (which have no harmful radiation) will probably replace fluoroscopy for these types of procedures.

You’ll need to see an orthopedic surgeon for an evaluation of your shoulder. Establishing the diagnosis is the first-step in determining the proper treatment. Whether or not you can benefit from hyaluronate injections into your shoulder will depend on the findings of the orthopedic examination.

Deciding what type of treatment is best requires an accurate diagnosis of the problem. It sounds like you are on the right track with that. Chronic pressure, traction, or kinking of the affected nerve can lead to denervation (destruction) of the nerve — and that means permanent loss of muscle strength and function supplied by the nerve. In cases like that, surgery is needed to remove whatever is putting pressure on the nerve, a procedure called decompression.

The most likely nerve involved is the suprascapular nerve along the back of the shoulder. When the nerve gets stretched or compressed enough to cause serious damage, the condition is called suprascapular neuropathy. The result can be shoulder pain and loss of function. For athletes who depend on the muscles supplied by that nerve, such a problem can be very disabling. Overhead lifting with rotator cuff tears seem to contribute to this problem most often in weight-lifters.

Sometimes the surgeon must also go in and open up a notch (opening) in the scapula (shoulder blade) where the nerve passes through. This notch or opening is called the spinoglenoid notch. Everyone has one and the natural size, shape, and location in the bone can vary. If the ligament across the top of this notch is tight and pressing down on the nerve and/or if the notch is too shallow or too small, the surgeon must make corrections in order to take pressure off the nerve.

The nerve can also get stuck to the bone by fibrous tissue so that it can’t move as the arm is raised. This condition is called nerve entrapment. Other things that can cause suprascapular nerve entrapment include bone fracture, cysts, and enlarged veins. Cysts form most often when damage to the labrum (rim of fibrous cartilage around the shoulder joint) allows fluid from the joint to escape and pool inside the cyst.

Unless there is imminent danger of permanent nerve damage, a conservative approach to treatment is usually tried first. Besides taking nonsteroidal antiinflammatory drugs (NSAIDs), tyou will likely be referred to a physical therapist for a course of stretching and strengthening exercises to address any rotator cuff problems. Special neural mobilization techniques can also be done to restore full, free mobility of the nerve along its course.

Your surgeon will continue to follow your progress with therapy. If you do not improve, then surgery is considered. The risk of permanent nerve damage is greater when the symptoms have been present a long time (more than six months). Surgery is warranted if the surgeon is trying to prevent further nerve injury.

The suprascapular nerve along the back of the shoulder passes from the neck down the arm and through an opening (notch) along the top of the scapula (shoulder blade). Then it continues down the back of the scapula where it ends. It is mostly a motor nerve, which means it controls some of the actions of the shoulder. Two muscles that are supplied by this nerve are the infraspinatus andsupraspinatus. They make up two of the four muscles of the shoulder rotator cuff. Their actions are shoulder abduction (moving the arm away from the body) and external (outward) rotation of the arm.

Suprascapular neuropathy can be difficult to diagnose. X-rays may be needed to look for fractures, unusual notch formation, and position of the humeral head in the shoulder socket as an indication of the integrity of the rotator cuff muscles. MRIs show the presence of any masses (tumors, cysts) and condition of the soft tissues (labrum, rotator cuff, muscle atrophy). An MRI can even show the nerve pathway and any areas of restriction. Special tests such as nerve conduction studies, electromyography (electrical study of muscle function), and injection of the notch can help pinpoint the location of nerve entrapment.

All of these tests are important because accurate and effective treatment depends on a correct diagnosis. You don’t want to have surgery if you don’t need it. On the other hand, a delay in surgical correction can result in permanent nerve damage — and you don’t want that either! It sounds like your surgeon is being very thorough and careful.

Be patient with the process. This is an unusual problem that doesn’t always show up with classic signs and symptoms. And even when the problem is identified, the cause of the problem isn’t always clear. Suprascapular nerve entrapment can be caused by a wide range of things from overuse to trauma to cyst to tumor or fracture. Once that gets all sorted out, you’ll be well on your way to a treatment that will hopefully restore your full mobility and function.

There really isn’t such a thing as being double-jointed. Usually this term is used to describe a joint (or a person) that is very, very flexible. In fact, they are beyond just flexible — their joint(s) are hypermobile. In other words, they stretch much farther than is normal.

You’ve probably seen people who can bend their thumb back so far, it touches their wrist. Or people who can put their legs around the back of the head. Any of these contortionists have loose ligaments and joints that allow greater motion than even the most normal, flexible person.

But there is a difference between joint laxity (looseness) and joint instability. Without some special tests, it’s impossible to tell which category your son falls into. Being able to pop the shoulder out of the joint isn’t the type of parlor trick you want to encourage.

This is especially true in a young child who is still developing and could potentially grow out of it. But stretching the soft tissues around the joint each time it’s dislocated will only continue to contribute to the problem. You only mentioned that he does this on one side. Perhaps there has been some injury or damage to the soft tissue structures that you don’t know about.

It’s a very good idea to have an orthopedic specialist take a look at him and give you some idea of what might be allowing him to voluntarily dislocate his shoulder. He or she will be able to offer you some guidelines based on the final diagnosis.

The shoulder joint is a very complex joint with over 25 possible conditions affecting just the soft tissues surrounding the joint. That doesn’t count fractures of the bone or tumors of the soft tissues and/or bone. Despite many studies trying to identify ways to accurately diagnose shoulder problems, we still don’t have it nailed down as to which one test is best for each condition. That would certainly save on the poking and prodding that’s required to figure out what’s wrong.

Many times, the examiner must rely on the history (what happened and how it happened) along with a combination of many tests. Some of the more commonly used tests check for impingement (soft tissue structure gets pinched against the bone or between two surfaces), instability (unstable joint likely to partially or fully dislocate), torn rotator cuff (partial or full-thickness tear), or adhesive capsulitis (frozen shoulder).

You may have heard your doctor mention some of these names: drop-arm sign, shoulder shrug sign, Neer Impingement sign, Hawkins-Kennedy sign, Speed test, Apprehension tests (anterior and posterior), compression test, lift-off test, painful arc sign, cross-body adduction test, resisted extension test, external rotation lag sign, and Whipple Test. So, you can see it was a very thorough collection of tests used in this field.

Research is ongoing trying to find out which test (or small cluster of tests) work best for each individual problem. An accurate diagnosis is important in order to apply the best, right treatment. This is something orthopedic specialists have been working on since the early 1930s! But in the end, sometimes the diagnosis and the treatment occur at the same time through arthroscopic exam and surgery.

Surgery for a dislocated shoulder can be done with the traditional large incision or arthroscopically, using very small incisions and long surgical instruments to reach the area to be repaired. Both types of surgeries have their pros and cons.

Traditional surgery generally takes longer to recover from because of the size of the incision and the type of work the doctor does while inside the shoulder. There is a higher risk of complications and longer time in hospital, but the success rate seems to be a bit better than that of arthroscopy. On the other hand, arthroscopic surgery generally requires a shorter recovery time, meaning shorter hospital stay, and fewer complications. However, there is a higher risk of redislocating the shoulder, according to some study findings.

You should discuss this with your doctor, weighing the pros and cons of both types of surgeries.

Whether or not steroid injections help with shoulder pain has been debated and studied for quite some time. There is some evidence that certain soft tissue disorders respond well to steroid injections. There is also some proof that injecting the correct site makes a difference in results.

Some experts recommend using ultrasound guided steroid injections for shoulder pain. It is relatively easy to perform and less expensive than other imaging methods (e.g., fluoroscopy, CT scans). Placement of the needle head is accurate even when there is fluid in the tendon sheath (lining around the tendon). The patients are not exposed to radiation with ultrasound. And it gives the physician a visual idea of exactly what’s going on inside the joint.

Anyone who has had a blind injection (physician uses body landmarks without imaging to place the needle) without results might benefit from an ultrasonography-guided injection the second time around. And anytime the first steroid injection doesn’t yield a reduction in pain and improved motion and function, it should be considered that there could be other problems going on at the same time.

There may be a second (different) problem that hasn’t responded to the steroid injection. For example, tendon tears and chronic degenerative conditions don’t respond to steroid medications when there’s no inflammatory component to the problem. But biceps tendonitis or other inflammatory conditions do respond with decreased pain, which then allows the person to move more freely and function with fewer limitations.

For best results, delivery of the steroid medication must be to the proper site. To assure most effective use of steroid injections, some type of imaging such as ultrasonography is advised.

Reactions to steroid injections have been reported and can be either local or systemic. Local reactions refer to skin and muscular changes around the site of the injection. Rash, redness, tenderness, and as you described, skin peeling can occur. Muscle spasms present at the time of the injection may go away (a positive side effect of the drug).

Systemic reactions are more along the lines of facial and/or whole body flushing, elevated blood pressure, nausea, and more rarely, vomiting. These responses occur because although the steroid is injected into a local area of tendon or joint, the blood system does absorb some of the drug. The active ingredient in the drug can then circulate throughout the body resulting in more body-wide reactions.

Any of these reactions are possible but not typical. Even though they are not uncommon, the physician administering the injection should be informed of any adverse events. This information should be placed in your permanent medical record. You may still be a good candidate for future steroid injections but the history of a reaction dictates careful observation and follow-up.

Shoulders are joints that take on a heavy load from us. They have to be able to turn and pivot, and the must be able to bear a significant amount of weight. They get jarred from time to time as we unexpectedly catch something that is falling, for example, and we often stretch them more than they should be. As a result, once they’ve been hurt, it may be difficult to get them back to their original condition.

You don’t say what type of surgery your son had, whether it was the traditional open surgery with a large incision or the smaller arthroscopic surgery with smaller incisions, but both may not always work 100 percent. According to a recent study, a lot depends on your son’s age when he first dislocated his shoulder, if it is his dominant shoulder, and his sex. Many of the failed shoulder surgeries do seem to be among men.

When doctors are testing for injuries of muscles, bones or joints, there is a lot that they can’t see. However, they do know that if you can do certain movements, then certain problems may be ruled out. The reverse is true too. If you can’t do certain motions or movements, then there are certain problems that the doctor may consider. By doing a few different tests, the doctor may be able to narrow down your particular problem, avoiding a misdiagnosis.

While it’s never pleasant to undergo an examination that causes pain, the intent isn’t to cause pain itself, but to see what triggers the pain. It is important that you tell your doctor, during the exam, if something is hurting you.

Not all injuries or problems involving the shoulder (or other joints) can be seen on x-rays. X-rays show the bones and some of the body structure, but not everything. In cases such as your husband’s, the x-rays are good for ruling out other medical problems that could have been causing pain, such as a fracture or a dislocation.

You have nothing to lose by getting an exam and diagnosis. For most musculoskeletal aches and pains, rest and recovery is all that’s needed. But with a little age behind you and a pattern of overuse, there may be need for a more specific treatment approach. And usually, early diagnosis and treatment yield better results.

One of the most common shoulder injuries adults face is a rotator cuff tendinitis or tear. The rotator cuff is a group of four tendons and muscles that surround and support the shoulder. Degenerative changes that accumulate over time may not be noticeable until an extended period of activity and then, just as you say: ouchy.

Another common injury from a combination of age-related factors and overuse is the labral tear. The labrum is a fibrous rim of cartilage around the edge of the shoulder joint. Because the shoulder has such a wide range of motion, the shoulder socket can’t be too deep. But if it’s too shallow, there is an increased risk of shoulder dislocation. The labrum gives a little lip to the socket to help balance out the need for mobility with the need for stability.

Small tears or frayed edges of the labrum develop over time. Most of these pose no problems or cause any significant symptoms even in middle-age. But if the labrum is torn away as occurs with a SLAP tear (SLAP stands for superior labral anterior-posterior),then sharp,aching pain develops deep in the shoulder. It’s worse when you try to lift heavy objects, lift something overhead, or push an object forward (e.g., pushing open a heavy door).

Sometimes patients have both injuries at the same time making the diagnosis difficult. But a skilled orthopedic surgeon can evaluate your shoulder and narrow down the diagnostic possibilities. Treatment will depend on what he or she finds.

Many times, a period of rest and pain relievers or even antiinflammatories is all that’s needed. If your symptoms have not decreased by the end of six weeks and gone away completely in three months, then you may be a candidate for surgery. But cross that bridge if and when you get there. For now, see a doctor, get a diagnosis, go from there.

SLAP stands for superior labral anterior-posterior. It refers to an injury affecting the labrum, a fibrous rim of cartilage around the edge of the shoulder joint. To help you better understand this, it might be helpful to review some basic anatomy. The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone). A part of the scapula, called the glenoid forms the shoulder socket. The glenoid is very shallow and flat. The labral rim of soft tissue makes the socket more like a cup. The labrum turns the flat surface of the glenoid into a deeper socket that molds to fit the head of the humerus.

The soft labral tissue can be caught between the glenoid and the humerus. When this happens, the labrum may start to tear. If the tear gets worse, it may become a flap of tissue that can move in and out of the joint, getting caught between the head of the humerus and the glenoid. The flap can cause pain and catching when you move your shoulder. Several tendons and ligaments attach to the labrum that help maintain the stability of the shoulder. So when the labrum tears, the shoulder often becomes much less stable.

Labral tears are often caused by a direct injury to the shoulder, such as a blow to the arm or falling on an outstretched hand. The labrum can also become torn from the wear and tear of activity, a condition called overuse. Repetitive overhead activities seem to be the greatest risk factor. Other risk factors include the way you are put together, in other words, the structure and shape of your anatomy and the way the bones meet together. The amount of natural shoulder rotation that is present as well as any retroversion (twist) of the humerus can make a difference. Tightness or contractures of the ligaments or capsule can alter the way the shoulder moves, setting off a cascade of biomechanical events that leads to a SLAP injury.

Calcific tendinitis is a degenerative condition affecting the four tendons surrounding the shoulder called the rotator cuff. These include the supraspinatus, infraspinatus, teres minor, and subscapularis muscles. All four muscles can be affected, but usually it’s just one of the four. And the tendons are listed here in declining order of frequency (i.e., supraspinatus is affected most often and subscapularis least often).

Calcium crystals called calcium pyrophosphate are deposited in the tendons. No one knows where these crystals come from exactly. But once the tendons start to degenerate, the crystals are released into the soft tissues as the tendon fibrils break down. Research shows that the calcium crystals help the tendon degenerate.

The tendons harden and symptoms of impingement can develop. With impingement, there is shoulder pain when the arm is raised overhead or to the side above shoulder level. The stiff tendon doesn’t move and glide as it should and it gets pinched between the bony structures of the shoulder. Sometimes the person with this problem can move the arm through the pain all the way overhead. But other people have limited motion that leads to decreased function.

The natural history of calcific tendinitis (i.e., what happens over time) varies from person to person and doesn’t follow a set pattern. Some people get better with time and without doing anything. Resolution of this condition can take anywhere from weeks to months. Others get worse and require treatment with antiinflammatories, physical therapy, and/or steroid injections.

If no improvement occurs after several months of conservative (nonoperative) care, then surgery might be considered. The surgeon removes as much of the calcium deposits as possible without disrupting the tendons, muscles, or other soft tissues. Some patients consider a treatment step between the nonoperative and surgical approach and that is extracorporeal shockwave therapy (ESWT). ESWT is the use of sound waves to create enough energy to disintegrate the calcium deposits. It has been used with good results for other problems like gallstones and kidney stones. Once the calcium crystals have been broken up, it appears that the body absorbs them because X-rays show they disappear.

The physician who diagnosed the problem will be able to guide you through the best treatment approach for you. If the pain is not disabling, you might try a wait-and-see approach. Let nature takes its own course and see if you experience a spontaneous recovery. If not, then it might be necessary to try some conservative care and progress from there.

The use of extracorporeal shockwave therapy (ESWT) has been shown successful in the treatment of calcific tendinitis (the medical term for your condition). It is not clear if ESWT is the best treatment approach (that remains to be determined in future studies), but a recent review of studies shows very favorable results.

Researchers from the Department of Trauma and Orthopaedic Surgery in England sorting through five years of data from recently published studies. All studies showed improvement after treating calcifying tendinitis of the rotator cuff with extracorporeal shockwave therapy (ESWT). ESWT is the use of sound waves to create enough energy to disintegrate the calcium deposits. It has been used with good results for other problems like gallstones and kidney stones. Once the calcium crystals have been broken up, it appears that the body absorbs them because X-rays show they disappear.

Most of the studies included patients with Types I and II calcification. There are three types of calcifying tendinitis diagnosed by X-rays. Type I has deposits that have clear outlines. A line can be drawn around the dense deposits to show exactly where they are, their size, and their shape. Type II disease has a clear outline but tends to be spread out more through the tissue and harder to see as a distinct shape. Type III lesions look cloudy without a specific form, shape, or outline.

All studies used a scoring system called the Constant-Murley score to measure results before and after treatment. Having one test used by everyone made it possible to compare the outcomes from one study to the next — even when the studies weren’t all conducted exactly the same way.

Extracorporeal shockwave therapy was deemed safe and effective for this potentially disabling condition. Significant improvement in motion, pain, strength, and function was consistently reported in all studies included in the review. Improvements were reported using both high-energy and low-energy shockwave therapy but high-energy had the best results. Low-energy therapy was better than no treatment or sham (placebo) groups.

The procedure is not painful and has few adverse side effects. Some patients notice redness of the skin around the shoulder area after the treatment, but it doesn’t last. For a few patients, a small amount of bleeding occurs under the skin. This condition is benign (harmless) and is called petechiae (tiny dots of blood). Before undergoing the procedure, let your doctor know of your concerns and questions. Find out what to expect in terms of the actual treatment and short-term and long-term results.

The snapping scapula syndrome is characterized by a loud pop or crack when the arm is raised up overhead. The medical term for this sound is crepitus. The sound is made by some soft tissue rubbing between the scapula and the thoracic wall. The tissue caught between these two structures could be a bursa, tendon, or muscle. The person with this problem may or may not experience pain with the movement.

A little understanding of the upper quadrant anatomy might help understand what’s going on with this condition. Then we can talk about what causes it. The scapula (shoulder blade) is an amazing anatomical structure. It is suspended over the ribs between the spine and the arm by only two ligaments. There isn’t a real joint between the scapula and the trunk.

Three layers of muscle and bursae (plural for bursa) support this structure. The bursae are small fluid-filled sacs designed to reduce friction between muscle or tendon and bone. These layers (superficial, intermediate, and deep) form a smooth surface for the scapula to move, glide, and rotate over. Because there is movement but no actual joint, this connection is considered a pseudojoint.

The scapula gives the glenohumeral joint (shoulder) a stable base from which to operate (move). The scapula itself slides, glides, and rotates in a 2:1 ratio with the shoulder. This means that for every two degrees of shoulder motion (flexion or abduction), the scapula moves one degree over the thoracic wall.

Scapulothoracic movement requires proper length-tension ratios between the scapular bone and all of the muscles around it. Any change in the glenohumeral-to-scapulothoracic ratio can result in altered or compromised shoulder motion. One particular problem called the snapping scapula syndrome is an example of what can happen when any one of these layers is disrupted for any reason.

There isn’t one reason why someone develops snapping scapula syndrome. Studies show that sometimes there’s a change in the shape or curvature of the scapula. After years of movement, the repetitive motion eventually causes a wear pattern that results in the snapping scapula syndrome. When a bursa is involved, the snapping problem could start as an isolated injury or it could be the result of repetitive (abnormal) motions of the scapulothoracic joint.

A less common cause is the development of a benign tumor called an osteochondroma. Bone spurs, scapular or rib fractures, nerve injuries with muscle wasting and weakness, or other types of tumors have also been linked with the snapping syndrome. And any surgery to the upper quadrant (e.g., breast implants or other breast cosmetic procedures, removal of a rib pressing on a nerve) can result in muscular changes that contribute to the development of the scapular snapping syndrome.

Anyone who has this problem should see an orthopedic specialist for a formal diagnosis and determination of the underlying cause. If there are no tumors requiring medical treatment, then conservative care with pain relievers and exercise may be advised. Sometimes, when the bursa are inflamed, steroid injections can be helpful.

If you have a snapping scapula syndrome, then you know that almost every time you raise your arm forward (shoulder flexion) or out to the side (shoulder abduction), you feel and/or hear a pop or crack. This sound is also referred to as crepitus. The sound is made by some soft tissue rubbing between the scapula (shoulder blade) and the thoracic wall. The tissue caught between these two structures could be a bursa, tendon, or muscle. People with this problem may or may not experience pain with the movement.

With the snapping scapula syndrome, there is a disturbance in the way the scapula moves over the thoracic wall. This altered movement pattern is called scapular dyskinesis or scapular dyskinesia. Often there are postural and muscular imbalances contributing to this syndrome. That’s where a physical therapist can help you with some simple and usually easy-to-do exercises to restore normal alignment and movement.

Making sure the head, neck, and shoulders line up and work together in a coordinated way with the rest of the body is part of a rehab approach called the kinetic chain model. Kinetic chain rehab is very much like the old song that says the neck bone’s connected to the shoulder bone and the shoulder bone’s connected to the elbow and so on. Each body part moves in relation to all the other body parts from head to toe.

Creating a rehab program for scapular dyskinesia takes into account all postural components, not just around the head, neck, shoulder, or scapula. Core training as well as individual muscle strengthening progresses through a stepwise program over a period of 10 to 12 weeks. The patient is guided through the acute phase to recovery and beyond into a maintenance phase. The goal is to restore dynamic scapular control, muscle endurance, and a return to the normal 2:1 glenohumeral-to-scapulothoracic rhythm.

Plyometrics, a fairly new exercise approach that many patients find unique and fun. The exercise training involves fast, powerful movements. Athletes use it to improve the functions of the nervous system, generally for the purpose of improving performance in sports.

But anyone can use these techniques — being a sports athlete isn’t a requirement. During plyometric movements the scapular and shoulder muscles are loaded and then contracted in rapid sequence. Plyometric training involves practicing these movements to toughen tissues and train nerve cells with the goal of getting the muscles to contract in a specific pattern in the shortest amount of time.

Although studies haven’t proven that plyometrics is the most effective way to overcome scapular dyskinesia and eliminate the snapping syndrome, many patients have experienced success and enjoy the process at the same time.

Athletes who repeatedly dislocate the shoulder often have more than one problem going on. Studies show that in the majority of cases, there was more than one problem. And the additional problems weren’t recognized or repaired, leaving the shoulder at risk for failed surgery. The surgeon evaluating patients with shoulder instability wants to provide the best possible results and reduce the risk of failure. That can mean taking time up front (preoperatively) to fully evaluate all of the dynamic structures of the shoulder to identify any and all pathology present.

Bone loss is one of those problems. Without full diagnostic imaging, the surgeon may not see how severe the condition is. If it’s bad enough, open surgery and bone grafting might be necessary. One way to give the shoulder more stability is to deepen the socket. This can be done by adding a rim of bone along the front edge of the glenoid fossa. That will help keep the humeral head in the socket and prevent it from popping out anteriorly (forward direction). Another way to prevent chronic anterior dislocations is to join two tendons together that can resist forward movement of the humerus during motions that can push the head out of the socket.

With repeated dislocations, damage can occur to the head of the humerus. The smooth surface of the humerus hits against the bony edge of the glenoid (socket). The collision causes a dent in the bone of the humerus called a Hill-Sachs lesion. The presence of a Hill-Sachs lesion increases the risk of shoulder redislocation and instability. The defect will have to be filled in either with a bone graft, synthetic plug, or tendon transfer.

Rotator cuff injuries are often missed at the time of diagnosis of the original shoulder instability. One (or more) of the four tendons that make up the rotator cuff (and usually the subscapularis muscle/tendon) may be partially or completely torn. Without the proper pull, support, and coordinated control that the rotator cuff provides, the repaired shoulder can become unstable again. As with the Hill-Sachs bony lesion, this soft tissue lesion can be repaired or reconstructed. The surgeon makes the decision based on all of the factors discussed so far.

And then there’s the management of capsular injuries. The shoulder joint is surrounded by a watertight sac called the joint capsule. The joint capsule holds fluids that lubricate the joint. The walls of the joint capsule are made up of ligaments. Ligaments are connective tissues that attach bones to bones. The joint capsule has a considerable amount of slack, loose tissue, so that the shoulder is unrestricted as it moves through its large range of motion.

The shoulder joint relies on the ability of these ligamentous tissues to hold the shoulder in place. Damage to the capsule or too much laxity from repeated dislocations can contribute to shoulder instability. Surgical repair is possible by harvesting ligamentous tissue from elsewhere and transferring it to the area of capsular deficiency.

This is just a short list of the many factors involved in planning surgical treatment for athletes with chronic shoulder instability. It sounds like you are in good hands. Be patient with the process. Ask whatever questions you may have about tests and procedures. Understanding what the surgeon is looking for and what is found may help you when it comes time to decide about treatment.