FAQ Category: Shoulder

Chronic shoulder dislocations (usually in the forward or anterior direction) can be a challenge, but they are not insurmountable. The first thing the surgeon will want to do is evaluate your situation and see what went wrong. There are multiple things that could have contributed to the failure. Finding them all and treating the whole package is essential for a successful result.

The majority of failed shoulder surgeries are attributed to misdiagnosis. It’s not that the surgeon didn’t know what was wrong with the shoulder. In 84 per cent of all 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 following surgery must go back to the beginning. With a thorough history, physical exam, and review of risk factors, the full scope of problems can be identified. Then a treatment plan to address each one is developed.

Finding the source (or sources) of the failure is important before just going back in with more surgery. There are some routine questions that must be asked like what kind of surgery was done, did it have any effect, and was there another injury or athletic event that led up to a reinjury and now the current instability? The surgeon will also look for common risk factors such as the patient’s age, inappropriate activity level (too much, too soon), or inadequate rehab after surgery.

There’s always a list in the back of the surgeon’s mind of other risk factors out of the patient’s control. This could include poor quality of soft tissue or bone, damage to the joint cartilage, and technical problems from the surgery. A careful physical exam will show how much motion the athlete has, strength and function, as well as the degree of instability (mild-moderate-severe). By comparing the unstable side to the uninvolved, stable shoulder, it’s possible to get an idea of ligamentous integrity and just where the instability is coming from.

Loss of motion, too much motion, and/or loss of strength in any particular direction provides helpful information. For example, the patient who can externally rotate the arm past 90 degrees is showing some shoulder joint instability from lax or loose ligaments. If the shoulder capsule is stretched out too much, the patient will be able to move the arm away from the body (a motion called abduction) 20-degrees or more on the unstable side compared to the other (uninvolved) side.

Testing shoulder muscle strength is a good way to look for rotator cuff tears or nerve damage. Loss of normal muscle function from either of these problems can lead to biomechanical dysfunction. With as many as 30 per cent of shoulder surgery failure, it’s not uncommon to find both muscle and nerve injury or damage to more than one muscle.

Once the physical exam has been completed, the surgeon puts the whole picture together and decides what kind of imaging might be helpful. Sometimes the original misdiagnosis occurred because there was inadequate imaging. Certain X-ray view may be needed or a three-dimensional (3-D) CT scan to look for specific types of lesions. Bone loss, location of that bone loss, and extent of bone loss are all important variables to look for before attempting another operation.

Those are all a lot of what ifs. For now, getting a follow-up appointment is the next step. Sometimes when there are so many factors to consider, patients seek a second and even third opinion before going forward with the proposed treatment plan. Surgeons are often in practice with other surgeons and have access to colleagues to review cases like this. This makes it easier and less expensive for you to get that second opinion. Stepping outside of that loop is always an option as well.

The shoulder joint called the glenohumeral joint is made up of two main parts. On one side is the humerus (the upper arm bone). At the top of the humerus is a round ball-shaped bone that fits into a shallow socket of the scapula (shoulder blade). This shallow socket is called the glenoid fossa or just glenoid. Movement of the head of the humerus in the glenoid is what gives us our shoulder movements of flexion, extension, abduction (arm away from the body), and rotation (internal and external).

Most of the attention on shoulder dislocations is focused on the head of the humerus and surrounding tissues. But the glenoid (socket) side is just as important. Any damage to the already very shallow glenoid can contribute to shoulder instability. Defects in the rim around the glenoid and bone loss within the socket are two ways the glenohumeral contact can be affected, adding to the problem of chronic dislocations.

Sometimes these defects occur because the shoulder dislocates in a traumatic event. Bone is actually fractured and a fragment of the rim breaks off. In other cases, the bone just wears away from constant contact and compression. Remember, these are athletes who are practice and perform overhead throwing motions sometimes 100s of times each season.

Other athletes such as football, volleyball, or soccer players may suffer a traumatic injury with damage to the ligaments attached to the glenoid rim. Without that little rim of fibrocartilage around the joint, it’s much easier for the shoulder to pop out of the socket and dislocate again and again. Even a small instability can change the biomechanics of the shoulder complex enough that over time, the bone wears away unevenly. In either case, rim defects get larger over time. The result is a worsening of the instability.

And so the vicious cycle gets set up and continues. Changes in the joint structure cause biomechanical alterations (i.e., the way the shoulder moves in the socket). Changes in the arc of shoulder motion wear the joint surface unevenly. This, in turn, alters forces within the glenohumeral joint, wearing the glenoid bone unevenly, and the cycle continues. This is how even a small defect can ultimately lead to chronic instability.

Athletes must be taught how to throw properly and keep a log of number of pitches thrown per practice and per game. Players must be trained from early on to report symptoms of pain, shoulder clicking or popping, and dislocation. When a minor injury isn’t treated and the player continues to throw, problems are inevitable. Everyone (players, parents, coaches) can work together to ensure safe training techniques and injury prevention.

The surgeon will ask you questions and interview you about your medical history and especially the details of your current complaints. The problem has to be identified and recognized for what it is. With chronic shoulder dislocations, treatment will fail if the full extent of the injury isn’t treated. Next, a physical examination and then appropriate imaging tests are used to define the problem. X-rays can show bone loss, MRIs show how much bone loss is present, and CT scans detect rim fractures.

From this information, it is possible to calculate how much of the humeral head is actually in contact with the glenoid surface. The surgeon may use an arthroscopic exam to examine the joint more fully. If there are any bare spots on the glenoid surface. The surgeon can get measurements of the defects and compute the percent of bone loss.

Treatment is based on the percentage of bone loss. What is considered an insignificant amount (less than 15 per cent of the surface area) may respond to conservative (nonoperative) care. Bracing, strengthening exercises, and modifying activity level may work well for athletes who are not involved in overhead sports. Rehab supervised by a physical therapist helps the patients understand which movements should be avoided in order to prevent another dislocation from occurring.

If this approach fails to restore motion and function, then surgery to repair the damage and/or reconstruct the shoulder may be required. Anyone with moderate bone loss (15 to 25 per cent) or severe bone loss (25 to 30 per cent or more) will need surgery. The exact surgery planned depends on what type of damage is involved (e.g., bone factures with fragments, labral (rim) tears, amount and location of bone loss, or other defects). Sometimes the surgeon is able to piece the bone fragments back together. This is most likely when the defects are small — limited in number and size and providing that the bone fragments can be found.

Surgical treatment becomes more complex when bone loss affects one-fourth (or more) of the joint surface. In such cases, the surgeon must look at the patient’s activity level, how long it’s been since the injury, the condition of the surrounding soft tissues, number of bone fragments, and potential for healing. Research shows that whenever possible, any bone fragments should be reattached. The risk of failure goes down for patients who are treated in this way.

There are numerous ways the surgeon can approach this problem. It may be necessary to graft bone to the shoulder socket to make up for defects in the rim. This procedure is called a glenoid augmentation. The surgeon tries to match the bone graft to the contoured (curved) surface of the glenoid. Screws are used to hold the graft in place.

It’s not enough to just wire bone fragments together and reattach them. The surgeon must pay attention to the biomechanics of the shoulder as well. Restoring the normal bony arc of motion is essential for stability. Do tyou want to return to everyday activity and function as your main goal? Or are you expecting to return-to-competitive sports participation? This is a key determining factor in patient satisfaction. Surgeons are still looking for the best way to restore the joint to near normal. They can’t always guarantee 100 per cent recovery and return to sports at a preinjury level.

Sometimes surgery fails to correct the problem. The patient continues to experience symptoms of pain and repeat dislocations. A second (
revision) surgery is needed. The biggest predictor of failed surgery the first time is just how much bone loss is present because it’s this bone loss that results in a failed stabilization. The more bone loss, the greater the risk of a failed repair.

Your surgeon will go over all of the treatment possibilities, their pros and cons, and what might be best for you given your age, activity level, extent of damage in the shoulder, and so forth.

Back in the 1970s, there was only one prosthetic implant available for patient’s needing a total shoulder replacement (TSR). Today, there are more than 70 different shoulder systems on the market.

Even though there are dozens and dozens to choose from, surgeons tend to pick between one of three main types of arthroplasty (another name for shoulder replacement). There’s the hemiarthroplasty (only one side of the joint is replaced), the reverse total shoulder arthroplasty (RTSA), and the total shoulder replacement (TSR) already mentioned.

the hemiarthroplasty. This is just the replacement of the humeral head and upper neck of the humeral bone supporting the head. At first, these were designed for people with humeral neck fractures. But the use of the hemiarthroplasty has expanded over time as surgeons found other problems that were solved with this component. Now it is also used for arthritis, rotator cuff tears, and osteonecrosis (bone death caused by loss of blood supply) of the humeral head.

Studies show that the hemiarthroplasty is more likely to be successful when used in younger patients and early after the injury (in other words, without a long delay between injury and operation). Sometimes it’s just difficult to decide between the hemiarthroplasty and a full shoulder replacement. Why do a full replacement when a partial replacement would work just as well? But there’s no sense in doing a partial replacement if the patient is going to end up needing a full shoulder replacement eventually anyway.

The most reasonable use of the hemiarthroplasty is for the patient who has bone loss and soft tissue damage that makes surgical reconstruction a very complex project. Without adequate bone mass and sufficient muscle strength, the implant loosens, which can lead to implant failure. Hemiarthroplasty offers a way around those complications.

It’s most effective when the shoulder socket is perfectly fine but the head of the humerus is arthritic, damaged from osteonecrosis or rotator cuff tears, or defective. Patients who receive a hemiarthroplasty report it is certainly better than doing nothing — they get pain relief, increased motion, and improved function. The net result is an improved quality of life.

It’s also possible to resurface the joint when arthritis has damaged the joint surface but there’s no need to tear the whole thing out and replace it. This procedure is called a resurfacing hemiarthroplasty. The humeral head is smoothed but not removed. Sparing the humeral side also preserves the patient’s natural joint angles. If there’s a need for a total shoulder replacement later, then it can be done sometime down the road. Shoulder resurfacing is used most often in young (55 years old or younger), active/athletic adults.

A reverse shoulder arthroplasty is used in older adults who have a torn rotator cuff that can’t be repaired. Instead of the round ball replacing the head of the humerus (upper arm bone), the socket is attached to the bone. The round replacement ball of the joint (called the glenosphere) is inserted into the place where the natural shoulder socket used to be.

This design helps maintain shoulder stability when the muscles are deficient and unable to function as they should. In fact, many patients who suffer pseudoparesis (inability to lift the arm) benefit from a reverse shoulder arthroplasty. The change in the fulcrum allows them to lever the arm up even when the muscles are weak from irreparable injury or damage.

When both sides of the joint are involved, it makes the most sense to perform a total shoulder replacement. Loss of joint cartilage from arthritis leading to pain and disability are the main reasons to do a full joint replacement. The rotator cuff must be in good condition to support the joint and restore full function of the shoulder and arm. And there has to be enough good bone stock to support and hold the implant in place.

Many, many studies have shown the benefit of the total shoulder replacement (TSR). Compared with the other options, the TSR gives patients more motion, less pain, and improved strength. Regardless of where the erosion occurs in the joint or what causes it (osteoarthritis versus inflammatory arthritis), the complete replacement of both sides solves the problem.

Today, there are more than 70 different shoulder systems on the market. The surgeon must evaluate carefully which option might work best for different types of patients. Sometimes there’s really more than one that could work. So, the surgeon must examine each patient carefully in making that final decision as to which one to choose.

The surgery can be very complicated. Multiple factors must be considered such as the patient’s age, underlying pathology, condition of the rotator cuff (muscles around the shoulder), and current/desired level of function. Shoulder replacements are indicated when pain is disabling and loss of motion and strength leaves the person unable to complete daily tasks and activities.

Most patients who need a shoulder replacement have arthritis either from age-related degeneration (osteoarthritis) or from a previous injury (posttraumatic arthritis). Sometimes, there’s been a history of fracture, tumors, severe rotator cuff damage, and even a failed first shoulder replacement surgery.

Bone loss and soft tissue damage can contribute to making surgical reconstruction a very complex project. Without adequate bone mass and sufficient muscle strength, the implant may loosen, which can lead to implant failure. The surgeon will do everything possible to prevent complications and implant failure.

Patient satisfaction is of utmost importance. It’s nice to reduce and even eliminate pain, but it’s far better to do so while restoring motion and function. No one can argue with that! Pre-operative planning goes a long way toward ensuring the right procedure for each individual and minimizing postoperative problems.

Shoulder replacements are available now and are usually reserved for older adults with severe osteoarthritis that is painful and limiting motion and function. Some time ago, artificial shoulder joint replacements were made available to younger patients with arthritis. But enough time has passed that we now know from short- to mid-range follow-up studies that this isn’t always the perfect solution. The implant can wear out or loosen. Then it has to be replaced. That can mean a second surgery, loss of bone, further complications, and a major set back in motion and function.

If only one side of the joint is affected, there’s no need to replace the entire joint. Hemiarthroplasties are also used for some patients. The major downside of this approach is that the side that isn’t replaced eventually wears out, too. Or the side with the replacement implant develops problems with loosening or biomechanical wear and tear. That means more surgery for those patients as well. What’s the answer to this dilemma? The evidence supports delaying joint replacement by pursuing conservative (nonoperative) care for as long as possible.

This may be of particular interest to you now since you are experiencing some problems. Patients have a few choices. Physical therapy to build up strength around the shoulder and minimize stress or overload on the joint is one approach. Acupuncture, transcutaneous nerve stimulation (TNS), and nonsteroidal antiinflammatories (NSAIDs) may be helpful. Like any medication, NSAIDs have the potential to create adverse reactions. The physician and the patient must weigh the benefits against the potential side effects when choosing these drugs. They may reduce painful inflammation and improve movement, but they can cause significant gastrointestinal (GI) complications and therefore, must be taken with another drug to protect the GI tract.

Injections of a visco-supplement or steroid may provide some relief of pain compared with placebo (pretend injections of just saline, a salt solution). The visco-supplement is a fluid that helps restore pain free movement in the joint. It has been shown to be more effective and longer lasting than the steroid injections with fewer side effects. Steroid injections reduce inflammation and usually have a numbing agent included that helps reduce pain. Ask your doctor if you might be a candidate for either of these type of injections.

When surgery is needed, it’s best to start with noninvasive (or the least invasive) procedures possible. Every effort should be made to stimulate a healing response and save the joint, rather than remove and replace it. Joint sparing is the name given this approach. There are several ways to do this. The first (and most commonly used) procedure is called debridement. The joint is shaved and smoothed down. Any debris or loose fragments of cartilage are removed. This helps restore smooth, pain free motion. The benefits can last for several years or longer.

You might benefit from one or more of these management techniques. Early conservative (nonoperative) care seems to have the best results. Don’t wait any longer before seeking professional help from a sports specialist or orthopedic surgeon.

You should expect to be interviewed by the physician (or a member of his or her staff). Any good medical interview allows the patient an opportunity to tell what’s wrong and how it happened. The examiner tries to fill in with questions that give him or her a full understanding of the your daily activities. This includes hobbies, athletic participation or other physical activity, and desires/goals from treatment.

The patient interview actually continues as the examiner begins to assess pain, inspect the shoulder complex, measure range-of-motion, and test strength. You should report any unusual symptoms such as if the shoulder locks up or catches. The examiner will want to listen and feel for this during the exam. Some provocative tests may be done that reproduce the pain. That can be very useful information when sorting through a wide range of possible reasons for shoulder pain.

There is no single test that will quickly uncover the problem. Usually, several tests combined together give the examiner information that leads to a diagnosis. Researchers have not been able to package together a group of tests that can be used routinely with each shoulder pain patient for the most accurate diagnosis.

It may be necessary to go through quite a few of the available tests before discovering what’s wrong. Sometimes normal tests are more helpful than abnormal ones. At least the examiner can tell what’s working right. Abnormal test results have a way of muddying the waters because there can be several possible corresponding problems.

The physician or physician’s assistant should conduct a very thorough exam. A full range-of-motion assessment is important. Any compensatory motions, loss of motion, or changes from one side to the other should be noted. That will help determine which shoulder-specific tests to perform.

Each muscle group can be tested for strength/weakness. Specific tests can be conducted for impingement, rotator cuff tears, labral tears, biceps tear or rupture, and nerve impingement or blood vessel compromise. Pulses, sensation, grip strength, and reflexes are useful tests to look for a neurologic or vascular (circulation) problem.

When it’s all said and done, the examiner steps back and takes a look at the big picture. Are there any other health problems? Does the patient have neck or back involvement? Are there any constitutional symptoms? Constitutional symptoms are those signs and symptoms that come in a cluster with any systemic disorder no matter which system is involved. For example, fever, chills, fatigue, unexplained perspiration, and nausea or vomiting are common constitutional symptoms.

Shoulder exams take time to complete. No one test is sensitive enough or accurate enough to draw any final conclusions from it. The results of each test point to the next test to conduct or consider. Putting all the pieces together of the history and interview with the clinical findings from the tests performed can result in an accurate differential diagnosis. The examiner who uses a systematic approach with each patient will be efficient yet thorough.

The final step is conveying to the patient the interpretation of the results. In other words, what’s wrong and what can be done about it? The physician may be able to give you a provisional diagnosis (what is the most likely cause of the pain). The final diagnosis may have to wait until the results of any blood or X-ray tests have come through.

You may want to start with her primary care physician — the doctor who sees her most regularly for all health concerns. He or she will have a good idea of your mother’s history and general health that might contribute to a shoulder problem. Although most shoulder pain is really caused by an underlying soft tissue or musculoskeletal problem, there can be other systemic causes of shoulder pain (e.g., bleeding ulcer, tumor, infection).

If she doesn’t have a regular doctor, this might be a good time to establish one — perhaps someone who has experience and training in working with older adults. Evaluating pain and problems in the shoulder is different when the patient is older. The underlying causes aren’t the same as in active, younger adults. Older adults have more degenerative disease or injuries from falls. Younger adults experience more injuries from sports or athletic participation.

If you are still interested in seeing someone at a specialty clinic like the sports clinic in your local area, give them a call. They may have someone on staff who specializes in all ages. With the increased interest on the part of older adults in staying physically active, some sports physicians follow their patients from the cradle to the grave.

The shoulder is a very complex piece of machinery. Its elegant design gives the shoulder joint great range of motion, but not much stability. As long as all the parts are in good working order, the shoulder can move freely and painlessly.

Many people refer to any pain in the shoulder as bursitis. The term bursitis really only means that the part of the shoulder called the bursa is inflamed. The bursa is a round or oval sac filled with fluid. It’s located between two bones or between a bone and a tendon. It’s job is to reduce the friction between those two tissues during movement.

Tendonitis is when a tendon gets inflamed. This can be another source of pain in the shoulder. Many different problems can cause inflammation of the bursa or tendons. Impingement syndrome is one of those problems. Impingement syndrome occurs when the rotator cuff tendons rub against the roof of the shoulder, the acromion.

Usually, there is enough room between the acromion and the rotator cuff so that the tendons slide easily underneath the acromion as the arm is raised. But each time you raise your arm, there is a bit of rubbing or pinching on the tendons and the bursa. This rubbing or pinching action is what is referred to as impingement.

Impingement occurs to some degree in everyone’s shoulder. Day-to-day activities that involve using the arm above shoulder level cause some impingement. Usually it doesn’t lead to any prolonged pain. But continuously working with the arms raised overhead, repeated throwing activities, or other repetitive actions of the shoulder can cause impingement to become a problem. Impingement becomes a problem when it causes irritation or damage to the rotator cuff tendons.

Raising the arm tends to force the humerus against the edge of the acromion. With overuse, this can cause irritation and swelling of the bursa. If any other condition decreases the amount of space between the acromion and the rotator cuff tendons, the impingement may get worse.

Bone spurs can reduce the space available for the bursa and tendons to move under the acromion. Bone spurs are bony points. They are commonly caused by wear and tear of the joint between the collarbone and the scapula, called the acromioclavicular (AC) joint. The AC joint is directly above the bursa and rotator cuff tendons.

In some people, the space is too small because the acromion is oddly sized. In these people, the acromion tilts too far down, reducing the space between it and the rotator cuff. The eventual result is impingement once again. Imaging studies can be very helpful in identifying anatomical reasons for impingement. That information guides management of this condition.

Shoulder impingement is a common condition causing significant shoulder pain in adults of all ages. Most of the time, the problem is one of subacromial impingement. Impingement means something is getting pinched. Subacromial tells us that the something in question is located under the acromion. The acromion is a piece of bone that comes around from behind where it starts in the shoulder blade and curves over the top of the shoulder.

At first, there is swelling and even hemorrhage (bleeding) of the subacromial bursa and rotator cuff. The bursa is a little cushion between the acromion and the head of the humerus (upper arm bone). Repetitive motions of the shoulder are linked with subacromial impingement syndrome.

The rotator cuff is always involved in shoulder impingement syndromes. It is made up of four tendons and their attached muscles. They enclose the entire shoulder like an envelope and give it support, stability, and functional movement. With subacromial impingement, the supraspinatus tendon of the rotator cuff is involved because it slips under the acromion and attaches into the greater tubercle, a bony bump on the humerus.

The supraspinatus abducts the arm (moves it away from the body). In someone with subacromial impingement syndrome, shoulder abduction and shoulder internal rotation cause severe pain. The supraspinatus muscle contracts to pull the arm up but at the same time, the head of the humerus slips up too far and bangs into the acromion. In the process, the supraspinatus gets pinched.

If nothing is done to stop this pattern of dysfunctional movement, fibrosis (fibrous scarring) and tendinopathy (irreversible tendon damage) develop and the condition progresses. As time goes by, and the shoulder continues to wear and tear from this syndrome and the rotator cuff is partially or completely torn through.

There are many ways to approach this problem. Some are based on how much damage has been done by the time the patient is diagnosed. When impingement first starts, nonsteroidal antiinflammatories are often prescribed but studies don’t really support their use. However, inflammation may be reduced with physical therapy modalities such as ultrasound or laser therapy.

Ultrasound is a way to heat the tissues deep in the shoulder to bring blood circulation to the area for healing. High-intensity laser works by exposing the tissue to light energy. The light is absorbed and then stimulates tissue healing at the cellular level. The intended result is to decrease pain.

The effectiveness of this type of laser therapy for shoulder impingement is under investigation. In a recent study from the Virginia Commonwealth University, high-intensity laser was very beneficial in reducing pain and improving strength and function. It was much more effective than the ultrasound treatments.

Research can now move forward in this area and take a look at optimal dosages and length of time for treatment with high-intensity laser. The results of this modality should be compared with other conservative treatments and/or placebo groups.

Wine may improve with age but research shows the shoulder doesn’t. In fact, there’s a direct relationship between increasing age and the number of rotator cuff tears. At age 50, just slightly more than one in 10 adults has a rotator cuff tear seen on MRIs. By age 80, this has increased to five out of 10 (or half of all adults).

That seems high, but many of those people are asymptomatic (i.e., have no pain or other symptoms). They don’t complain of any pain and don’t report any problems. The damage is found when MRIs are done for something else, or as in the case of scientific studies, the MRIs show these types of injuries when imaging is done for research purposes.

For those adults over the age of 66, shoulder pain on one side is actually a sign of rotator cuff tears in both shoulders. And that’s not all. Studies show that where there’s a rotator cuff tear, there’s likely a tear of the biceps tendon where it attaches to the labrum (rim of cartilage around the socket).

You may have sustained these injuries during your earlier, more active years. But it’s more likely these lesions have occurred as a result of the aging process. Degenerative changes in the soft tissues may put some people at an increased risk for rotator cuff and labral tears. Research is ongoing to find risk factors that might help us identify who the more susceptible individuals might be and how to prevent these types of injuries in the first place.

Studies show you aren’t alone. More and more adults over the age of 45 are reporting shoulder injuries such as a rotator cuff tears and superior labral anterior posterior (SLAP) lesions. As you have discovered for yourself, the labrum is a dense ring of fibrous cartilage around the rim of the acetabulum (shoulder socket). It helps deepen the socket and increases shoulder stability. If the labrum is torn from front to back, it’s called a SLAP lesion.

Rotator cuff tears with SLAP lesions are usually treated surgically. Many surgeons opt to do this procedure arthroscopically. It is minimally invasive and can reduce overall surgical costs with fewer days in the hospital. The surgery involves rotator cuff repair and either debridement or repair of the SLAP lesion. With debridement, the damaged, torn or frayed edges of the labrum are shaved smooth. With the repair procedure, the torn end of the labrum are sutured back in place using special anchors to hold it in place.

Patients report pain relief and improved function with either choice. But according to a recent study, the amount of improved function and patient satisfaction is greater in those who have a rotator cuff repair and debridement.

The authors concluded that in older adults minimal intervention might be best. With combined shoulder lesions (rotator cuff and labral tears), functional outcome is better when the SLAP lesion is shaved smooth rather than anchored back in place. The reason for this might be because (as has been shown in other studies), the labrum in older adults loses blood supply and has fewer new chondrocytes (cartilage cells) to replace the damaged ones.

You might want to discuss your options with the orthopedic surgeon and see what his or her recommendations are. Remaining active is an important lifestyle goal for older adults. Restoring motion, strength, and function in your tennis arm may help move you in that direction.

Falls from skiing accidents, sports injuries, car accidents and other traumatic events account for many first-time shoulder dislocations. When the shoulder doesn’t pop back in place on its own, the patient ends up in the emergency department or doctor’s office for a reduction (put it back in the socket). There are many ways to reduce the shoulder but most require anesthesia to put the patient asleep and relax the muscles or strong narcotic medications for pain.

The fact that it was possible to reduce the shoulder on the field suggests that perhaps it was only partially dislocated and more therefore easily put back in place. Not all first-time shoulder dislocations (partial or complete) actually result in ligament rupture or torn muscles.

The soft tissues certainly have to stretch quite a ways when the shoulder is pulled out of the socket. But with rest in a sling during the acute phase and a rehab program later to strengthen the muscles and restore normal motion, many people never experience another shoulder dislocation again.

Surgery is only needed if there is chronic instability — the shoulder dislocates over and over with minimal provocation. When just reaching the arm up over head causes it to pop out of the joint, surgery is considered. Or when the person has constant, severe pain, surgery may be the only successful alternative. But again, most patients are advised to follow a rehab program for at least six months before going with surgery.

You may not have to because a group of orthopedic surgeons from the Gifu University School of Medicine in Gifu, Japan recently published an article describing a very similar technique. They included a careful and clear description of the reduction technique along with photos of the procedure.

Basically, the patient sits in a chair facing the surgeon. The surgeon takes hold of the patient’s forearm very gently and raises the arm straight forward 90 degrees. The surgeon places his other hand on the patient’s chest wall against the front of the patient’s shoulder. The surgeon’s thumb was against the head of the humerus (upper arm bone).

Just by pulling on the patient’s arm with one hand while applying pressure on the humeral head with the other hand, the humeral head slipped back into the socket. If the patient tensed up, the surgeon just lowered the arm a little, waited for the pain to go away and the muscles to relax and started the procedure again. The hand against the shoulder helped control the tilt of the shoulder socket.

The technique is done slowly and gently. If the surgeon isn’t able to successfully reduce the shoulder after several tries, the patient can be placed supine (lying on his or her back). A forward elevation maneuver can be used instead. The dislocated arm is placed overhead while the surgeon applies traction, gently rotating the arm outward until the head of the humerus slips back into the socket.

The key to this technique is to work with patients who are already seated and self-supporting their arm. Changing positions causes the shoulder to tense up and can be avoided with this method. This method can be tried first before using drugs, mechanical force, or surgery. There was an 80 per cent success rate but no clear reason why the other 20 per cent could not be reduced with this method. The success rate wasn’t quite as high as with some other methods, but the fact that no narcotics or surgery were needed is the added benefit.

The reverse shoulder total arthroplasty (rTSA) is used for older adults who have disabling shoulder pain and loss of function due to severe rotator cuff damage. In fact, for these patients, the rotator cuff (needed for a traditional total shoulder replacement) is beyond repair.

The rotator cuff is a group of four muscles, tendons, and connective tissue that envelopes the shoulder. The rotator cuff both moves and stabilizes the shoulder. Stabilizes means it holds the shoulder in the socket and prevents dislocations.

The reverse shoulder replacement has a round sphere called a glenosphere that inserts into the area where the socket used to be. The patient’s own round head of the humerus (upper arm) is cut off and replaced with a polyethylene (plastic) cup.

With this new configuration, the center of rotation changes. The angle of pull for some of the shoulder muscles also changes. Although the outcome is pain free motion, there are some limitations. For example, the patient no longer has full adduction (moving the arm across the body).

Patients do recover faster after rTSA when compared with patients who have a standard total shoulder replacement. There is some belief that protection and rehab after a rTSA is not as important as with a total shoulder replacement.

But many patients who receive a rTSA still have poor external rotation. They may have regained shoulder flexion (overhead) motion, but the shoulder complex is far from normal in terms of motion and function.

Physical therapists are studying this question looking for answers. Who will need postoperative rehab? What type of protocol would have the best results? Early case studies published suggest that the physical therapist can be instrumental in helping the patient regain motion without creating shoulder instability.

Early pain management through the use of joint mobilizations (tiny passive movements performed on the shoulder) and modalities such as cold and electrical stimulation can also help. Later, (usually from week six to 12), the focus is on restoring normal biomechanical and neuromuscular control. During this phase, the goals are to regain full motion and start working on strengthening.

After 12 weeks post-operatively, activity level is advanced. The patient resumes functional activities of daily living and progresses to leisure activities. High-impact activities, sudden lifting, and any pushing or pulling are not allowed. When maximal improvement has been made, then exercise therapy is continued through an appropriate home exercise program.

Studies are needed to compare patients who have therapy with those who do not. If treatment is warranted, finding the best rehab management protocol is the next step. This may vary from patient to patient, thus requiring research to compare the benefits and effectiveness of the program for many different patients getting a rTSA.

You may have a condition referred to as pseudoparesis of elevation. Pseudo means like or similar to and paresis means paralysis. It seems like your arm is paralyzed in that it won’t go through the motion you clearly have available. But there’s no nerve damage or real paralysis going on.

Instead, it may be a case of a deficient rotator cuff and uneven pull of the muscles. The rotator cuff is a group of four muscles, tendons, and connective tissue that envelops the shoulder. The rotator cuff both moves and stabilizes the shoulder. Stabilizes means it holds the shoulder in the socket and prevents dislocations.

Without a properly functioning rotator cuff, when the deltoid muscle contracts, the necessary counter pull from the rotator cuff is missing. The patient ends up with pseudoparesis, which looks like an inability to lift the arm up overhead despite the fact that there is the necessary range-of-motion to do so.

It would be a good idea to see an orthopedic surgeon for an evaluation. There could be a simpler explanation. In any case, it’s likely that there is a treatment that could help you and possibly prevent further problems from developing. Early intervention can sometimes prevent more invasive procedures. It may not be too late to try a conservative (nonoperative) treatment plan.

Joint resurfacing has been around for almost 30 years. Instead of removing bone and replacing the joint, the surface of the bone is smoothed over and capped with a metal component.This treatment technique has been proven safe and effective for both the hip and the shoulder.

Shoulder resurfacing is fairly new and becoming more popular. With joint resurfacing, there is less bone destroyed and fewer fractures. Best of all, the patient can still convert to a total joint if needed later.

Surgeons have several implant designs to choose from when performing a shoulder resurfacing procedure. The implants are made of cobalt-chromium or titanium-alloy. Some have a ceramic surface coating. Others provide a titanium porous (with holes) coating on the undersurface where the implant rests against the bone. The advantage of a porous surface is that the body can fill in the holes with bone to help cement the implant-joint interface together.

A recent development in shoulder resurfacing is the use of an implant that looks like a giant screw. This method allows for partial resurfacing of the humeral head (round ball at the top of the upper arm). It is used for patients who have smaller defects in the humeral head but don’t really need the entire surface smoothed and capped.

Not everyone is a good candidate for shoulder resurfacing. Patients who benefit most are those with pain from arthritis who have completed a program of physical therapy with little or no change in their painful symptoms and function. Resurfacing is particularly attractive for younger, more active adults like yourself.

Only short-term results have been published so far for shoulder resurfacing. But they show that 90 per cent of the patients report significant improvements in motion, pain, and strength. All of that leads to better function in daily activities, leisure activities, and sports participation. Patients say they can do just about anything they want from yoga to golf to mountain biking, hockey, even power lifting.

Compared with a total shoulder replacement, there are fewer complications and problems after shoulder resurfacing. Operative time is shorter and fewer days in the hospital are typical with shoulder resurfacing compared with joint replacement. There’s also less blood loss. And, of course, the main advantage is the availability of treatment for young, active patients who are limited by their pain.

Joint resurfacing has made it possible for younger, more active adults to avoid removing bone and replacing the joint. Instead, the surface of the bone is smoothed over and capped with a smooth, round metal piece called an implant.

Surgeons have several implant designs to choose from when performing a shoulder resurfacing procedure. The implants are made of cobalt-chromium or titanium-alloy. Some have a ceramic surface coating. Others provide a titanium porous (with holes) coating on the undersurface where the implant rests against the bone. The advantage of a porous surface is that the body can fill in the holes with bone to help cement the implant-joint interface together.

Early shoulder resurfacing implants had problems with loosening. Changes in the design seem to have helped reduce this problem. A recent development in shoulder resurfacing is the use of an implant that looks like a giant screw. This method allows for partial resurfacing of the humeral head (round ball at the top of the upper arm). It is used for patients who have smaller defects in the humeral head but don’t really need the entire surface smoothed and capped.

Whether the patient receives a full or partial resurfacing, it’s fairly common for patients to reduce their level of activity. They are afraid that too much activity will dislodge, break, or wear out the implant.

The truth is, we really don’t know yet how long these implants last in the long-run. Only short-term results are available for this treatment approach. Those results are very positive with 90 per cent of all patients reporting satisfaction with the results.

Your surgeon is the best one to advise you on this. Factors such as your current (and intended) level of activity, amount of damage to the nearby muscles, and presence of any arthritic changes must all be taken into consiederation. A good post-operative rehab program with sports specific exercises may be helpful.

Laxity usually refers to looseness of the soft tissues around the joint. The affected structures can include ligaments, tendons, muscles, and/or the shoulder capsule. The capsule refers to the envelope of ligamentous tissue that surrounds the shoulder like an envelope. In the shoulder, the rotator cuff functions as a protective, stabilizing force to hold the head of the humerus (upper arm bone) firmly in the socket.

Laxity can be a natural occurrence when a person is born with collagen (protein structure that makes up soft tissues) that is pliable (very flexible). There are fewer links holding the fibers together. Laxity can also occur as a result of overuse. For example, throwing athletes who cock the arm way back and externally rotate the shoulder before releasing the ball forward can overstretch the soft tissues, thus leading to laxity.

Instability refers to the fact that the shoulder is not stable within the socket. It may partially dislocate (called subluxation) or fully dislocate. Repetitive trauma and microdamage of the soft tissues can lead to laxity, which in turn results in instability. These two terms represent a phenomenon that exists on a continuum from mild (laxity) to severe (instability).

As we come to understand trauma, microtrauma, and instability of the shoulder soft tissues, the terminology is becoming more precise. For example, some experts refer to subtle instability to describe overhead throwing athletes who develop problems from overuse rather than from trauma. Repetitive shear forces during the cocking phase of the pitch and during the throw (acceleration phase) may start a series of events that eventually lead to microinstability. The athlete has pain when pitching but doesn’t feel as if the shoulder is going to come out of the socket. Apprehension is the word used to describe a common feeling for athletes with an unstable shoulder.

There may actually be a wide range of clinical presentations for both of these terms (laxity and instability). Some patients have pain; others do not. Some feel apprehensive and fearful that the shoulder is going to come out of the socket as it has in the past. Sometimes the pitcher experiences an inability to place the ball where he or she wants it to go. The speed, force, and direction of the ball are affected but the player doesn’t have specific symptoms of pain or a sensation that the joint is dislocating.

Efforts are being made to understand these two conditions more completely. It’s likely that the terms may be modified as more information becomes available. Computerized motion analysis is giving a better three-dimensional picture of normal and abnormal shoulder movement in throwing athletes. This will help considerably in sorting out the various shades of gray between laxity and instability.

A fall on the shoulder or outstretched hand can disrupt the ligaments and capsule holding the acromioclavicular (AC) joint together. The result can be a dislocation of the AC joint. This joint is located where the end of the clavicle (collar bone) meets the acromion. The acromion is a curved bone that comes from the shoulder blade across the top of the shoulder.

The AC joint is fairly complex with its many ligaments and strong capsule holding everything together. Damage to any of these soft tissues can be severe enough to require a surgical repair. But it sounds like your son may have had a mild sprain that can (and often does) recover nicely with a little TLC.

Treatment for minor AC strains involved removing mechanical stress from the joint during the acute phase (first 10 to 14 days). The patient wears a sling or shoulder immobilizer. When the pain is mild or gone, gentle exercises can be done. A physical therapist guides the patient though a rehab program to restore motion, strength, and endurance.

Not all patients recover completely from mild AC injuries. There may be some long-term symptoms such as clicking and pain or limitations with certain activities (e.g., push-ups). And some studies have reported patients later develop arthritis in that joint. More and more emphasis is being put on completing a rehab program even for mild sprains.

Keeping your follow-up appointment is a good idea. It will give you a chance to ask some questions about the strength and stability of his shoulder/arm and find out if further treatment is needed to avoid problems later on.