FAQ Category: Shoulder

It sounds like you have an injury to the acromioclavicular (AC) joint. Sometimes this is referred to as a shoulder separation. Treatment for AC joint injuries is usually based on the severity of the damage done to bone, ligaments, capsule, and nearby muscles. AC joint injuries are broken down into six categories classified as I through VI (from mild sprain to severe dislocation). The joint can be unstable in one of three directions: front and back (anterior-posterior), side-to-side, and vertical (up and down).

A type I injury means there’s no visible injury. The patient may have some swelling and tenderness right over the AC joint (front of the shoulder), but X-rays and motion are normal. A type II injury results in pain over the AC joint and positive findings on an X-ray (widening of the AC joint space). Sometimes there’s vertical instability but not often. Types I and II AC joint injuries are treated conservatively (without surgery).

Vertical (up and down) movement of the clavicle is more common with type III injuries. X-rays show the joint is dislocated. The acromion is separated from and slightly above the clavicle. Pushing up on the elbow puts the joint back together. But it may not stay there, which is a sign of instability.

It’s likely that you have a Type III AC separation. Surgeons have the most difficulty in deciding about surgery for Type III injuries. The loss of contact between the clavicle and the acromion means that motion is going to be altered. If a rehab program isn’t enough to successfully treat this injury, then surgery is done to reconstruct the joint.

Sometimes individual patient demands require surgery early on. And in the case of a chronically dislocating AC joint, surgical intervention may be the only way to restore full, normal stability and movement.

Overhead athletes and heavy manual laborers seem to fall into this group most often. And there’s some question that maybe patients with type III injuries fail because they didn’t complete their rehab program or the rehab program wasn’t quite enough. The shoulder can function normally without an intact clavicle. But it cannot do so when the shoulder muscles are weak and unable to stabilize the joint.

You can always complete a rehab program before making this decision. Then, if the shoulder is still unstable, then surgery can be done. The best evidence suggests if you are going to take the conservative (nonoperative) approach, then give it your best and make sure you complete the rehab program. The therapist will test your strength before releasing you on your own. Any painful symptoms, clicking, or other signs of instability should be reviewed by your orthopedic surgeon.

Military records suggest that the conservative approach is not as successful for soldiers as for the regular population. The physical demands on the shoulder are just too great to prevent future dislocations. Since your training and daily activities can’t be modified, nonoperative treatment is not as effective as surgical repair early on.

Some of this may depend on the type of damage and severity of soft tissue involvement. First-time dislocations with severe damage to the shoulder are more likely to be repaired surgically. This is often the case when there has been a capsulolabral avulsion. This type of injury refers to the fact that the labrum has pulled away from the bone. The labrum is a dense ring of fibrous cartilage around the shoulder socket. It gives the shoulder socket some depth and provides the shoulder with increased stability.

If the labral tear extends up far enough, it will even pull some of the biceps tendon away from where it inserts into the labrum. The surgical procedure used most often to treat this type of injury is called the Bankart repair. During the arthroscopic procedure, the surgeon repairs each of the soft tissues damaged by the dislocation. Suture anchors are used to hold the biceps in place.

A recent military study was published with the long-term results of almost 50 soldiers treated surgically for a first-time acute anterior (forward) shoulder dislocation. Studies show that early results of surgical stabilization are excellent. This study attempted to report on the long-term results. They followed their patients for at least nine years (some as long as 14 years). They used patient questionnaires to ask about shoulder/arm function, pain levels, and patient satisfaction with the results.

Because this was mostly a military group, return to athletic activity and physical conditioning (such as doing push-ups) were also monitored. The study group was able to complete the necessary physical training with an average of 282 points (out of 300) on the Army Physical Fitness Test (push-ups, sit-ups, and 2-mile run). Only one person left the military for medical reasons and that was not for a shoulder problem.

A stable joint usually refers to one that does not sublux (partially dislocate) or dislocate fully. The circumstances under which that definition holds true may vary from one expert to another. A truly stable joint stays in the socket for all activities.

Recurrent shoulder dislocations can result in more and more soft tissue damage that eventually contributes to future dislocations. Rehabilitation is often helpful in strengthening the muscles around the joint to help hold it in place.

Restoring natural movement and kinesthetic/proprioceptive awareness is also important. These functions help the shoulder and arm move through space smoothly and with purpose as planned by the brain. Even a small loss in kinesthesia or proprioception can result in a loss of function and recovery during activities that stress or strain the joint.

Any recurrent episodes of the shoulder popping out of the joint (even if you can put it back in) count as an instability. Returning to full activities that require overhead reaching, lifting, and heavy use of the shoulder and arm usually require full strength without fear of reinjury. The physical or occupational therapist helping you with your rehab program will be able to test your shoulder and let you know when you are safe to return-to-work at full capacity.

Abnormal motion of the scapula is called scapular dyskinesia. You have a good start in your knowledge because the anatomy and relationship of bones and muscles in the shoulder complex is the key to understanding scapular dyskinesia.

The scapula (your shoulder blade) moves in a rhythm with the shoulder joint. As the arm raises overhead, the scapula slides and rotates in a 2:1 ratio with the shoulder. For every two degrees of motion in the shoulder joint, the scapula moves one degree. This is called the scapulohumeral rhythm.

Scapular dyskinesia can be observed visually. As the athlete moves his or her arm out to the side and up overhead, the scapula doesn’t glide and tilt smoothly like it should. Since most of the shoulder muscles attach to the scapula and the shoulder socket is part of the scapula, that means scapular dyskinesia affects shoulder motion as well.

Athletes (especially throwing athletes) report pain, stiffness, and impingement during shoulder movement. Impingement refers to the soft tissue around the shoulder getting pinched during certain movements. Anyone can develop scapular dyskinesia (not just throwing athletes) but the reasons for this are not always clear. Usually overuse (repetitive motions) or injury of the shoulder results in muscular imbalance that contributes to the problem.

Good question. The dead arm syndrome was a term first used by a well-known orthopedic surgeon in the early 2000s to describe the disabled throwing arm in athletes. It’s a complex series of events affecting the muscles of the shoulder and arm. The term syndrome is often used because there is a cluster or group of symptoms associated with the problem.

In the case of the dead arm syndrome, uncoordinated or deficient (weak, imbalanced) muscles around the scapula (shoulder blade) disrupt the kinetic chain. Each part of the shoulder complex from the scapula to the shoulder to the fingertips must work together in a complex series of coordinated motions. This is what we mean when we use the term kinetic chain.

Anything that alters the smooth transfer of energy along the kinetic chain can increase force produced by the shoulder. That’s when pain develops. Something has to give in order to keep up the pitching speed and control of the ball. In the throwing athlete that could mean impingement (soft tissues get pinched), labral or rotator cuff tears, or the development of a drooping throwing arm.

A drooping shoulder is just as it sounds. When the athlete is standing with the arm by his or her side, the shoulder of the throwing arm is noticeably lower than the other side. This occurs when the scapula on that side slides forward and tilts down over the rib cage. The arm follows with a forward and downward posture.

The solution to the problem is usually a special exercise program to strengthen and condition the shoulder and arm. In some cases, muscle fatigue from overuse is the cause of the problem. The athlete must be careful to avoid throwing too many pitches between practice and play. Too often, pitchers only count pitches during games and don’t realize that practice pitches count just as much.

What you are probably seeing is a device called continuous passive motion (CPM) machine. CPM is a way to keep the arm moving with gentle range-of-motion. The arm is placed in the device that is set to whatever motion is desired. It is motorized and repetitively moves the arm through the preset arc of motion. The idea is to keep adhesions (scar tissue) from forming.

In some cases, CPM has been helpful in reducing pain as well. Women seem to benefit more than men. And patients over 60 years old also seem to have a better result than younger patients. And with less pain, more motion is possible. The hope is that in the end, the patient will have a better result than if he or she just moved the arm manually.

But, in fact, studies show that CPM doesn’t really have a benefit in the long-run. It may reduce pain early on but when patients are compared 12 months later — those on CPM didn’t have any better overall strength, function, or motion than those patients who didn’t use CPM.

Given those results, it’s hard to justify the cost of the machine. Your wife will probably have just as good of results if the physical therapist works with her to move her arm. You (or a friend or other family member) can also learn how to do the passive motion exercises and help your wife with those.

If you went from surgeon-to-surgeon, state-to-state, and region-to-region in the United States you would not find one single rehab program used by all for patients who have had surgery for a rotator cuff tear.

And that’s true even though everyone agrees that patients must closely follow the postoperative Dos and Don’ts they are given. One of those Dos is to complete their rehab program from start to finish.

The authors of a recent study set out to review all of the published studies on rehabilitation for rotator cuff repairs. They wanted to see if there was enough evidence in a systematic review of this type to say just what is the optimal evidence-based rehab protocol for this problem.

They set their standard for studies to be included to those that were high-quality (Levels I and II)
evidence. The studies had to involve randomized clinical trials of patients who had rehabilitation after surgery to repair the damaged rotator cuff.

Even after searching all of the most reputable databases, they only found 12 studies published over a
40-year period (1966 to 2008). And only four of those studies were appropriate because they met all the criteria set up by the review committee to qualify as a Level I or II high-quality evidence-based study.

These four studies were limited to reviewing the results of continuous passive motion (CPM) after surgery and the use of supervised physical therapy versus unsupervised home exercise. The authors made it clear that each of these four studies had some weaknesses. The strength of the evidence was called into question because of those design flaws. So although they present the results, they advise the reader to consider the conclusions carefully.

There is clearly a need for some high-quality trials to investigate the optimal rehab program for rotator cuff repairs. Just looking at one aspect of rehab (whether that is CPM, physical therapy, exercise or some other intervention), is not likely to answer the question of what rehab program is best for patients to follow after rotator cuff surgery.

We are a long way from publishing standard guidelines for this problem. But you can find some reliable and practical advice in an excellent patient guide called The Patient’s Guide to Rotator Cuff Tears available from Medical Multimedia Group also available on-line at/public/.

Yes, most definitely. Calcium deposits in the tendons of the shoulder are referred to as calcific tendinitis. This is a disorder characterized by deposits of hydroxyapatite (a crystalline calcium phosphate).

These deposits can develop in any tendon of the body. The tendons of the rotator cuff surrounding the shoulder are affected most often. The calcific deposits can be seen on X-ray as lumps or cloudy areas. That’s how the diagnosis is confirmed.

Pain and inflammation result in loss of motion and function. Sometimes patients report shoulder stiffness or weakness. There may be a snapping or catching sensation during certain shoulder movements. The condition is often self-limiting meaning it goes away or resolves on its own in time (usually six months to a year).

Treatment begins with antiinflammatories, steroid injections, and/or physical therapy. Most patients are encouraged to stick with the treatment plan for six months. If, after six months, the pain isn’t reduced enough (or at all), then shock wave therapy called extracorporeal shock wave therapy (ECSW) may be considered. ECSW may be a good next step before thinking about surgery.

If your sister has not had any of these treatment interventions, then that might be the place to begin. But if she has tried all that unsuccessfully for at least three to six months, then surgery may indeed be the next step. Seeing an orthopedic surgeon who can evaluate her shoulder and compare X-rays from a year ago to now will help guide and direct her treatment.

The type of shock therapy you are referring to is really sound waves (not electrical shock treatments) directed at the calcium deposits. The treatment is called shock wave therapy or extracorporeal shock wave therapy (ECSW).

No one knows for sure how this works but it does seem to bring pain relief and the calcific deposit disappears on X-rays. It appears that the mass is broken up enough by the vibration of the sound waves that the body can then breakdown, liquefy, and absorb or resorb the fragments.

There are several questions still left unanswered about this treatment. Who does it help? Are there some patients for whom this would work better than others? Is it safe and effective for everyone? What dose (pulses per session or number of sessions) gives the best results? Should high- or low- energy be used? Does it even matter?

A recent meta-analysis was conducted by a group of orthopedic surgeons. A meta-analysis is done by reviewing all publications reporting on controlled trials of ECSW for calcific tendinitis of the shoulder.

Some studies compared patients who had ECSW with those who received no therapy, some other type of treatment, or a sham or placebo treatment. Sham or placebo means they thought they were getting the treatment but no sound waves were actually transmitted to the calcium deposits. There were also trials comparing shock wave therapy of different energy levels.

After comparing and analyzing all the data, they found that shock wave therapy was more effective than sham treatments or other therapy such as electrical stimulation. High-energy waves (0.2 mJ/mm2 or higher) worked faster and better in terms of pain reduction and calcium resorption.

Patients experienced a decrease in pain and improved function. And it appears that using high-energy shock waves was more important than the number of sessions. X-rays showed proof that the calcium deposits were disappearing.

It’s still not clear if patient selection is an important factor in the use of ECSW for calcific tendinitis of the shoulder. Future studies are needed to look into this variable as well as define the number of sessions needed for the fastest, most effective treatment of this condition. For now, it’s clear that ECSW is a safe and effective way to treat calcium deposits in the rotator cuff tendons. And it may help patients avoid having surgery.

Some shoulder problems are so complex and so difficult, it’s not always clear what treatment approach to take or if surgery can even help. This may be the case with massive rotator cuff tears, shoulder instability, or adhesive capsulitis (frozen shoulder).

Each patient must be examined and considered on an individual basis. Imaging studies such as MRI and arthroscopic exam help with the decision-making process, but the surgeon can’t just rely on the results of those tests to find the optimal treatment for each problem. It’s also important to consider why the patient has the problem in the first place.

For example, if there is a chronic problem like adhesive capsulitis (frozen shoulder), is it because a previous surgery failed? And if so, why did it fail? Were there surgical technical errors or other undetected injuries that affected the outcome? Was there some bony deformity, soft tissue imbalance, or other anatomical reason why this patient didn’t get a positive result from the previous surgical treatment?

In the case of a frozen shoulder, the joint capsule may be scarred down or fibrosed. The joint capsule is a group of tendon fibers wrapped in connective tissue surrounding the joint. Surgery may be needed to remove the adhesions and move the shoulder through its full range-of-motion. This is done with the patient anesthetized.

Injury, immobilization, and diabetes mellitus are the three most common reasons people develop a frozen shoulder. Sometimes, cardiac patients who have had coronary artery bypass surgery or people who have been immobilized in an intensive care unit for any reason develop this shoulder problem.

Once the specialist and the surgeon have completed all of their tests and evaluations, a plan of care can be established for your father. The goal is to choose the most optimal treatment approach for each individual situation. When patients present with complex and challenging problems, a second opinion is always helpful.

Most experts agree that a good, solid effort at rehab should be attempted before considering surgery. As much as six months should be dedicated to this task. A physical therapist provides a supervised program with strengthening exercises, scapular retraining, and proprioceptive activities. Proprioception refers to the joint having a sense of its own position and being able to recognize where it is and respond to any slight changes in movement.

The therapist will also examine the position of the scapula (shoulder blade) and see how it moves. Most people don’t realize it, but the coordinated motion of shoulder and scapula are really key to normal arm movement. If the natural rhythm and movement of the shoulder-scapular complex are off, the shoulder loses some of its stability.

If there is a problem in the way the scapula and shoulder move, the therapist will evaluate what’s going on to see just what might be causing problems with scapular position or movement. Is there an imbalance between the different groups of shoulder muscles? Are the muscles balanced but weak?

Sometimes patients are even able to avoid surgery if the shoulder responds well to rehab. But if the patient fails to improve with conservative (nonoperative) care, then surgery may be the next step. The idea is to stabilize the shoulder as much as possible before disrupting the balance of soft tissues. Stronger muscles rehab faster after surgery, so it gives the patient an advantage before going in to surgery.

You didn’t mention the reason why you have a frozen shoulder (also known as adhesive capsulitis). Sometimes the underlying cause (if there is one) is a predictor of what will happen or how to best treat it. For example, patients with diabetes who develop a frozen shoulder have a longer course of recovery with variable results compared to someone who may have fallen onto an outstretched hand or on to the elbow/upper arm.

Without that information, we will proceed as if you have primary adhesive capsulitis (no precipitating cause). The first thing to be aware of is that it can take 12 to 18 months (or longer) to move through the various stages of such a frozen shoulder.

Exercises can be helpful but they should be done based on how irritable the affected tissues are (low, moderate, high). For example, someone with high irritability has pain that limits motion and function. Someone with low irritability may have slightly restricted motion with stiffness, but no pain.

For patients with primary adhesive capsulitis (remember primary means it wasn’t caused by something else like diabetes), the patient usually begins with high irritability. As the condition gets better, the level of irritability goes down to moderate, and then to low.

Early on during the painful, high irritability stage, short-duration gentle range-of-motion may be best. The result will be to decrease pain and muscle guarding with the net effect of increasing shoulder and arm motion. This is where many people get stuck. They overstretch the tissues causing a cycle of pain, tissue damage, fibrosis (scar tissue formation), and then stiffness. Further forceful stretching starts the cycle over again.

Assessment of irritability begins with a sleep history. Can you sleep through the night? Can you lie on that side for more than an hour? If yes, you are probably in the low irritability phase and can tolerate a more vigorous program of stretching exercises. A second way to determine level of irritability is to see if the primary problem is pain or stiffness. Stiffness is a sign of fibrosis (scarring). Pain is an indication that there is an inflammatory process going on.

If you have been down this path carefully and under the supervision of a physical therapist without results,then surgery may be advised. Under anesthesia, the surgeon may manipulate (move) the shoulder. With the muscles around the shoulder completely relaxed, the surgeon can put the shoulder through its full range-of-motion, breaking any adhesions present in all directions.

There are some potential problems with manipulation such as fractures or dislocations. It’s not a good procedure for anyone with bone loss or who can’t perform the necessary follow-up program of exercises. Open incision surgery isn’t really done on a frozen shoulder. The surgeon may go into the joint using an arthroscope and release the joint capsule This isn’t always the best option since bleeding into the joint from this procedure can cause the formation of more scar tissue.

It sounds like your next step is to go back to your physician for a discussion of your situation and a change in the plan of care. There may be some treatment options left to consider but an exam is needed first to find out where you are in the process and to determine what might work best for you.

Frozen shoulder is the layperson’s term for a medical condition calledadhesive capsulitis. Inflammation of the tissues in and around the shoulder joint leads to fibrosis (scarring). The result is the joint gets stuck and can’t move smoothly anymore. Painful and limited shoulder motion are the two main characteristics of this condition.

There is some evidence that the condition gradually gets better. For that reason, it is considered self-limiting. It appears to go through several stages. There’s an initial period of pain, then stiffness (the frozen part), then recovery or the thawing phase. Sometimes the stiff, frozen stage is divided into the process of freezing and then the frozen phase.

The whole process takes anywhere from 12 to 18 months. But at least half of the patients say they still have stiffness and loss of motion for years. So, what can be done about this condition? And what works best? At the very least, it’s clear that teaching the patient about the process and what to expect is important. They should be prepared for the fact that this is not a quick and easy problem to solve. A couple of Advil and a few exercises aren’t the answer. A consistent, daily program of exercises to relieve symptoms and restore motion is important.

Muscles stretch easier when they are warmed up. So, before starting a program of flexibility exercises, patients are encouraged to apply some form of moist heat before and during stretching. A couple visits to a physical therapist can help your mother get started. The therapist will assess the joint and determine how to stretch in a way that won’t overload the tissues and cause increased irritability.

For patients in the early (painful) stages of adhesive capsulitis, low-intensity, short-duration range-of-motion may be best. The goal is to decrease pain and muscle guarding while increasing shoulder and arm motion. The therapist can also perform a technique called joint mobilization to help restore normal joint sensory awareness, gliding, and sliding motions.

Joint mobilization is a way to move the joint surfaces to increase motion. The technique involves some sliding and gliding of the shoulder joint in a variety of different directions. Which way to go is determined by areas of movement restriction. All joint mobilizations are
followed up with an active home program of gentle stretching at first progressing to longer stretches with more pressure or force.

If your mother does not appear to be making any progress (or even seems to be getting worse), a steroid injection into the joint can help. The effect on reducing or eliminating joint pain makes it possible to move more. Staying home and doing nothing is an option, but not one that is highly advisable. Just a small amount of supervision and direction in setting up and encouraging a daily home program may help prevent further problems down the road.

SLAP stands for superior labrum, anterior and posterior. It refers to a torn rim of fibrous cartilage (the labrum) that
edges the shoulder socket. The tear is at the top of the socket (that’s what superior means) and goes from the front (anterior) to the back (posterior) of the socket. This is a common injury in overhead throwing athletes, but can also occur as a result of trauma from a fall.

The exact steps in the postoperative process are determined by the type of SLAP lesion, type os surgery that was done (e.g., debridement versus repair), and how much other damage was present. The postoperative rehab program usually consists of movement, activities, and exercises performed during each of several phases from immediate post-op up to 24 weeks (six months) later.

At first, you will probably be immobilized in a special sling. Certain, simple shoulder movements calledCodman’s or pendulum exercises are allowed. A physical therapist will show you how to do these. The therapist will guide you through the entire rehab process. You will shown which movements to avoid and how to regain all motions and strength over time.

After the first four weeks, you’ll be allowed to stop wearing the sling. Some shoulder motions such as external rotation are still fairly limited. This prevents strain on the repaired labrum and allows healing without disruption. During the intermediate phase of rehab and recovery (three to six or eight weeks post-op), the therapist will do some hands-on work with you to restore normal movement of the entire shoulder complex. This includes not just the arm and shoulder joint, but also the forearm, elbow, and scapula (shoulder blade). All of these structures are important in restoring smooth, rhythmic motion of the arm for all types of sports, not just overhead throwing activities.

By the end of 10 weeks, you’ll be actively engaged in endurance training and starting some flexibility exercises. It’s important to make sure the shoulder joint has balanced motion in all directions without tightness in any one movement pattern. Strengthening, flexibility, and endurance training continue to the end of the first three months. At this point, the program will start to shift more toward sports-specific activities.

Your surgeon will let you know when you are ready to resume throwing activities. A full strengthening program is needed before getting back to full sports or athletic activities. For the best results possible, it’s important to follow the surgeon’s and the physical therapist’s directions. Cooperation and compliance bring about good results in up to 90 per cent of the patients treated this way.

SLAP stands for superior labrum, anterior and posterior. It refers to a torn rim of fibrous cartilage (the labrum) that edges the shoulder socket. The tear is at the top of the socket (that’s what superior means) and goes from the front (anterior) to the back (posterior) of the socket.

There are different types of SLAP injuries labeled Type I, Type II, Types III, and Type IV. The exact type depends on whether the labrum is frayed along the edges, partially torn, or completely pulled away from the bone.

Sometimes, the biceps tendon, which attaches along the upper front area of the socket is also pulled away. Labral tears may occur with or without biceps tendon disruption, which forms a separate classification or type of SLAP lesion. Two additional types (V and VI) have been named to include combined or complex SLAP lesions that aren’t fully described using I through IV.

Although the surgeon performs an examination of the shoulder and conducts numerous clinical tests, the exact lesion can’t be determined without imaging studies and arthroscopic exam. There are numerous tests designed to identify a SLAP lesion. MRIs are still considered the gold standard in diagnostic imaging for SLAP lesions. MRI results are important before heading into the operating room. They show the full extent of the damage, which may not be as easily seen during the procedure.

Most SLAP lesions do require surgery. But for a subgroup of patients with Type I lesions, conservative (nonoperative) care may be successful. This includes change in activity (no more throwing for a while), antiinflammatory drugs, and physical therapy. The therapist guides the patient through a process of reducing pain and restoring motion, strength, and normal movement patterns.

Anyone who has not obtained the desired results with conservative care is probably a good candidate for surgery. Patients with a SLAP lesion and a major tear of the rotator cuff (tendons around the shoulder) is also likely to need surgery. Anyone with a large labral tear who has altered biomechanics (movement of the shoulder complex is no longer normal) will benefit from repair rather than the nonoperative approach.

Most first time shoulder dislocations in athletes are anterior (forward direction). The structures around the shoulder (e.g., ligaments, capsule, muscles) are designed to prevent dislocations. But with enough force and with the shoulder in just the right position, these safeguards can be overcome. Forceful movement of the head of the humerus (upper arm bone) over the lip of cartilage around the shoulder socket is called a Bankart lesion.

There is some disagreement on whether to reduce the shoulder immediately to alleviate the athlete’s pain (which is usually intense) or transport to the hospital for X-rays and a proper diagnosis. A quick and accurate diagnosis is needed before the best plan of care can be established. The goal is to minimize further damage to the shoulder joint and surrounding soft tissues.

Some experts advise having an X-ray before trying to reduce the shoulder. Reduce means to put the shoulder back in the socket. Usually, the person is in so much pain, a closed (without surgery) reduction seems like the right thing to do. But there could be other injuries that need attention and that could be made worse by a closed reduction.

X-rays confirm the direction and severity of the dislocation. Any bone fractures present will show up on an X-ray. Other clinical tests may be performed to assess nerve, blood vessel, and soft tissue structures. If more details are needed, a CT scan and/or MRI may be ordered. MRIs with a dye injected into the joint can show the location and size of a labral tear.

Once the exam is completed, the surgeon can decide on the best plan of care for that patient. Reducing the dislocation is the first step. Sometimes this can be done without surgery. In many cases, the decision to treat immediately versus transport is really a judgment call. Age of the individual, severity of pain, and expertise of those trained to perform a closed reduction on site are some of the factors to consider.

Type of sports involvement and timing of the injury (preseason, during season, end of season) are also factored into the decision. Besides treating the immediate problem, consideration must be given to preventing future (repeat) dislocations. With all these variables to consider, you can see why there isn’t a quick and easy answer to your question.

The number of first-time shoulder dislocations in young, active athletes has gone up over time. Some of this may be because more people are involved in sports. But collision sports are also more vigorous (some say extreme) than in the past.

The structures around the shoulder (e.g., ligaments, capsule, muscles) are designed to prevent dislocations. But with enough force and with the shoulder in just the right position, these safeguards can be overcome.

Younger patients are more likely to end up with a labral tear. Injury in older adults is more common because of degenerative changes of the rotator cuff associated with aging. The labrum is a tough rim of cartilage around the shoulder socket. The rotator cuff is a group of four muscles and tendons that surround the shoulder.

Both of these anatomical structures help hold the shoulder stable and in place. A torn anterior-inferior (front/lower) labrum and joint capsule is called a Bankart lesion. Bankart lesions are very common in all anterior shoulder dislocations. A Bankart lesion reduces the depth of the shoulder socket by 50 per cent. Without the passive restraint mechanisms of the soft tissues, recurrent dislocation is possible and even probable.

Even military recruits in top shape are subject to shoulder dislocations. For young athletes and soldiers, the nature of the high physical demand on the shoulder is the real key to understanding how this injury can occur.

It may not be advised without consulting with the surgeon first. Some therapists have additional specialty training that makes them a better choice for something like rotator cuff surgery. Surgeons spend time communicating with one therapist (or even a group of therapists) the type of surgery they do and what’s required in a rehabilitation program for the patient’s best outcome.

It’s best to see someone who has an understanding of the required surgery-specific rotator cuff rehabilitation program. To put this a little different way, results of surgery depend on two things — good surgical repair and a surgery-specific rotator cuff rehab program.

That means more than ever, PTs and orthopedic surgeons communicate with one another about what kind of surgery was done, what the patient needs, and the best way to approach functional rehabilitation. For example, there three types of rotator cuff repair techniques. These include 1) open rotator cuff repair, 2) mini-open rotator cuff repair, and 3) all-arthroscopic rotator cuff repair. Each one has its own advantages and disadvantages.

Therapists know that patients who have an open incision approach must be treated differently than an all-arthroscopic procedure. The difference lies in the fact that the deltoid muscle is cut in a traditional open rotator cuff repair. For example, the patient must avoid contracting the deltoid muscle for up to eight weeks. It takes a full month longer for patients with an open-incision to regain their previous level of activity compared with even the mini-open repair.

The rehab program moves along at a pace that is directly linked with the size of the tear. Larger tears with more tissue damage and greater retraction of the tendon take longer to rehab. A more conservative approach is used.

The surgeon must let the therapist know the condition of the tear at the time of the surgery. Where was it located? How large was the tear and in which direction? Was it L-shaped, U-shaped, or crescent-shaped? What fixation method did the surgeon use to repair the tear (single-row sutures, double-row sutures, suture bridge)? In a surgery-specific rehabilitation program, the rehab timeline can then be matched to small, medium, and large tears.

Your sister may want to ask her surgeon if it’s okay to switch therapists. But be aware that most surgeons want consistency in a program. Having one therapist see the patient from beginning to end is usually preferred. Having to communicate necessary information to another therapist takes extra time for everyone.

Healing after surgery to repair a rotator cuff tear can be very slow. Most likely the surgeon has reattached the torn and retracted tendon back to the bone. The patient must protect the repair site for at least 12 weeks. The special splint you are wearing is called an abduction pillow brace. The device fits under the arm. It is designed to place the shoulder in a protective position that avoids strain on the healing rotator cuff.

If more than one part of the rotator cuff is damaged, then more protection and a longer recovery period are allowed. The speed of rehab and type of movements you can do depend on whether the torn tendon is in the anterior (front of the) rotator cuff, the posterior (back of the) rotator cuff, or in both. This information is used to restrict or encourage direction and degree of shoulder range-of-motion and strengthening.

Patients with traumatic (as opposed to wear and tear or degenerative) injuries tend to develop more stiffness postoperatively if they aren’t treated more aggressively right from the start. Early repairs after the injury can be moved through therapy more rapidly. But patients with fair-to-poor quality of tissue require a slower, more cautious approach.

Other factors that must be taken into consideration include which arm was affected (dominant versus nondominant), general health, and smoking history. People in poor health with other health problems and smokers (or tobacco users) have an increased risk of complications, poor wound healing, and reinjury.

So before taking the splint off for anything more than bathing, you must consult with your surgeon. There are just too many variables to consider to make this decision on your own. After all the time and expense of the surgery, you don’t want to do anything that could compromise the integrity of that repair site.

It’s always a good idea to gather a little information that could help you when making major decisions such as having a total shoulder replacement (TSR). Knowing a bit about the different models and makes of implants can help you understand suggestions the surgeon might make.

Many times, the decision regarding implant type and design is determined during the operation. Once the surgeon can see inside the joint and assess what needs to be done, then it’s much clearer what type of prosthesis might work best. Some surgeons have implants that they prefer to use. The more they do the surgery with that implant, the better their technique and more the results improve.

Cemented implants are used most often when there is bone loss from osteopenia or brittle bones from osteoporosis. It may take longer for the bone to fill in around the implant. The cement helps hold everything in place until full healing takes place.

When cement isn’t needed, the implant is press-fitted. It’s just like it sounds: the implant is pressed into the bone and fit to tightly match the shape of the area. Tiny holes in the implant fill in with bone material to hold it in place.

Some components combine metal-backed with polyethylene (plastic) liners. The thin liner can be exchanged with a new one if and when it wears out. This can be done without removing and replacing the entire joint. All metal components are larger than all-polyethylene. The larger implant is often selected on the basis of patient size. Small patients get the smaller plastic implant. Larger patients receive the metal-backed piece.

Other than that, there isn’t a lot of evidence yet that one works better than another (or lasts longer). Studies do show that overall, total shoulder replacements provide pain relief and improve motion for patients with osteoarthritis no matter which type is used.