FAQ Category: Shoulder

If the infection was discovered soon enough, it may be possible to treat it with antibiotics. Sometimes, it depends on the type of infection, location, and length of time left untreated.

The surgeon may decide it is necessary to go into the joint and clean out the infection using a technique called débridement. At that time, the implant can be removed and spacers coated with antibiotics can be put in place. The spacer is left in place for one month up to several months and then removed. The shoulder is then restored with a new implant.

If that fails, if there’s too much bone loss, or débridement isn’t an option for some reason, there are other procedures that can be done. One of those is a reverse shoulder prosthesis. This approach may be needed when bone loss and/or a loss of muscle function results in shoulder instability.

The reverse shoulder prosthesis (artificial joint) is made up of two parts. The humeral component replaces the humeral head, or the ball of the joint. The glenoid component replaces the socket of the shoulder, which is actually part of the scapula (shoulder blade).

In the normal artificial shoulder prosthesis, the glenoid prosthesis is a shallow socket made of plastic and the humeral component is a metal stem attached to a metal ball that nearly matches the anatomy of the normal shoulder. In the reverse shoulder replacement, the ball and the socket are reversed. In the place where the socket used to be is a round ball. At the top of the humerus, instead of a round head is a plastic cup-shaped implant.

Patients rarely lose an arm after shoulder replacement even when infection is present. With early diagnosis of the problem and intervention, results can be very good.

With any surgical procedure (such as the shoulder joint replacement), there can be problems. The most common situation is shoulder replacement surgery that fails due to fracture or bone loss. Treatment options are limited. But surgeons are looking for ways to change that.

One of the ways to approach this problem is with a reverse shoulder prosthesis. A reverse shoulder implant places a glenosphere (round ball component) where the shoulder socket used to be and a cup-shaped implant at the top of the humerus (upper arm bone).

The surgeon does have to remove the first prosthesis (implant) in order to put the reverse prosthesis in place. Removing the original implant can take quite a bit of bone with it. This is especially true when the implant was cemented in place and/or the bone has grown in and around the implant as designed. But it’s a good way to save the joint and restore more normal shoulder motion and movement.

Your mother’s surgeon may have some other procedure in mind for her. You’ll have to check with him or her to find out what’s the best approach to take. The majority of patients who have to undergo revision surgery after a shoulder replacement report good-to-excellent results and satisfaction with pain relief and improved motion and function. Hopefully, your mother will have the same positive results.

Many people do heal from a broken clavicle (collarbone). They wear a sling for a while. They are told what shoulder and arm movements to avoid for a few weeks (up to a month). This type of nonoperative treatment is called conservative care. This is the traditional way to treat fractures of the clavicle.

But not everyone gets better with conservative care. Studies show that there’s a subgroup of patients for whom the results can be less than perfect. The bone doesn’t heal, a problem called nonunion. In some cases, the bones knit together but not properly. This is called a malunion. In either case, the end result can be pain, decreased motion, and loss of shoulder function.

The clicking sensation may be a signal that there is a nonunion fracture. The bump could be a deformity in the bone from a malunion or nonunion. The best way to find out for sure is to see an orthopedic surgeon. A simple X-ray may provide a quick and easy answer. In some cases, additional imaging studies with CT scans, MRIs, duplex scanning, or arteriography may be needed.

Complications can occur with any type of surgery. Implant failure due to fracture (breakage of the bone or the implant), loosening of the implant, or subsidence (sinking into the bone) are the most common problems with shoulder joint replacements.

Other problems that can occur include subluxation (partial dislocation), polyethylene wear, and periprosthetic lucency (thinning of the bone around the implant). Subluxation comes with decreased and painful motion. There are no such symptoms with bone changes (erosion or lucency).

In a recent study comparing metal-backed to nonmetal-backed and metal-backed compared to all-polyethylene (plastic) components, there were no differences in results based on gender (male versus female). Although both the men in your family have had a failed result, this does not mean it was because of their gender.

It could be related to the similarities in their anatomy (which you may share). Or it could be the type of implant they received. Sometimes bone loss is significant enough to make a difference. In some cases, it may be related to the surgery itself.

When you see your surgeon, you might want to alert him or her to your family history and the results of your siblings. The surgeon will take a personal and family history, examine you, and order appropriate tests. He or she will be able to advise you from the results of those tests.

You’ll need to make a follow-up visit with an orthopedic surgeon. Surgery is usually done on the more severe acute acromioclavicular (AC) joint injuries (also known as shoulder separations). AC joint injuries are graded from I through V based on the severity of the separation.

Grade I is a mild sprain of the ligaments holding the joint together. Grade II is a more severe sprain. Grades III through V are varying degrees of separation of the two ends of the bones as they meet to form the AC joint. The joint is located along the front of the shoulder where the clavicle (collar bone) meets the acromion (the bone that comes across the top of the shoulder from off the shoulder blade).

A series of X-rays will be taken designed specifically to look for this problem. An MRI may be ordered. But even the best MRI (with a contrast dye injected) won’t give as good of results as an arthroscopic exam. If the separation is severe enough to need surgery, the surgeon will be repairing or reconstructing the joint using an arthroscope anyway. At the same time, the rest of the joint can be assessed for any additional injuries.

Grade III separations are usually only repaired surgically when the patient is a manual laborer or active athlete. Otherwise, a rehab program is advised for all Grade III injuries. Grades I and II are more likely to heal on their own with rest and limited activity. But Grades IV and V require surgical repair or the patient will end up with a chronically dislocated AC joint and possibly injury to the soft tissues around the area.

It’s entirely possible. When the injury is severe enough, not only does the AC joint separate, but other damage can occur in and around the joint, too. AC joint refers to the acromioclavicular junction. Sometimes this is referred to as a shoulder separation or AC joint dislocation.

The AC joint is located along the front of the shoulder where the clavicle (collar bone) meets the acromion (the bone that comes across the top of the shoulder from off the shoulder blade). AC joint separation or dislocation is the result of direct trauma (usually from a fall) on the shoulder or arm when it is next to the body. Falling on an outstretched hand or elbow can also cause the same injury. The mechanism is more indirect as force through the hand or elbow transfers to the shoulder. With enough force, the head of the humerus is pushed upward — right into the acromion.

The majority of injuries occur during activities such as bike accidents, skiing or snowboarding, and other types of falls. Other activities leading to AC joint dislocation include soccer, motorcycle accidents, ice hockey, judo accidents, or horseback riding injuries.

It’s not uncommon for the associated injuries to be missed at the time of the diagnosis for AC joint separation. The patient’s shoulder is painful and range-of-motion is limited. So clinical testing is also limited. Without a full arthroscopic exam, no one knows there are other problems. But once the AC joint has been treated, the patient with continued shoulder pain may need a second look.

Anyone with a high grade AC joint injury who continues to experience pain and loss of motion after surgical treatment should be further evaluated. The surgeon will look for the presence of other intra-articular injuries, especially labral tears, rotator cuff tears, and fractures. Post-operative MRIs using an intra-articular contrast dye give the best information.

Reverse replacements put the ball of the joint just off the shoulder blade with the socket off the upper arm rather than the usual ball at the top of the bone and the socket on the shoulder blade. This design is especially helpful for patients who no longer have a stable shoulder.

The soft tissue envelope of muscles and tendons holding the shoulder joint in the socket is called the rotator cuff. The reverse shoulder replacement by its design is more stable and requires less soft tissue support to hold it in place. It seems ideal for people who have injuries of the rotator cuff resulting in degenerative changes in the joint progressing to arthritis.

The reverse shoulder joint isn’t a perfect solution. It comes with problems of its own. For example, some patients end up with pain, loss of motion, and a problem called impingement. Impingement results in an inability to put the arm all the way down at the side. The implant design, location, and angle result in the two parts of the implant bumping up against each other, preventing full motion.

Specifically, the medial (inside) edge of the socket (now located at the top of the humerus) bumps up against the lateral outside edge of the scapula (shoulder blade) where the new round ball (glenosphere) is located. This creates a problem called scapular notching. Depending on the location of the glenosphere, motion can range from zero degrees (no impingement) up to 38 degrees of impingement (in other words, the arm is 38 degrees away from the body).

When reverse shoulder replacements were first introduced, the glenosphere was placed in the middle of the glenoid (anatomic shoulder socket). But these problems developed and surgeons recognized the benefit of changing their surgical technique to avoid complications. Despite changes made, scapular notching is still a problem.

The best person to answer your question is the surgeon. After completing a patient interview with history and clinical exam, the surgeon will be able to advise you as to the best treatment plan for your particular situation. If surgery is indicated, the type of procedure, pros and cons, and advantages and disadvantages will be discussed. Don’t hesitate to ask about a reverse shoulder replacement during your visit. That will be the best way to see if it’s for you.

Shoulder replacement or arthroplasty is not unusual anymore. Regular replacements of the ball and socket joint are often done for patients with painful and limited range of motion. But the standard shoulder replacement isn’t the best choice for some people. Some patients need a reverse shoulder arthroplasty (RSA). This is mostly used for people who have injuries of the rotator cuff and shoulder arthritis that leave the shoulder unstable.

Reverse replacements put the ball of the joint just off the shoulder blade with the socket off the upper arm. This placement is different from the usual ball at the top of the humerus (upper arm bone) and the socket on the shoulder blade.

The reverse shoulder joint isn’t a perfect solution. It comes with problems of its own. For example, some patients end up with pain, loss of motion, and a problem called impingement. Impingement results in an inability to put the arm all the way down at the side. The implant design, location, and angle result in the two parts of the implant bumping up against each other, preventing full motion.

When reverse shoulder replacements were first introduced, the glenosphere was placed in the middle of the glenoid (anatomic shoulder socket). But problems developed and surgeons recognized the benefit of changing their surgical technique to avoid those complications. Despite changes made, impingement was still a problem.

So, new implant designs and surgical techniques are the subject of ongoing studies. Some surgeons may wish to wait until the procedure is applicable to more patients. When a surgeon only does a handful of any procedure, the results may not be as good as for the surgeon who performs dozens or even hundreds. Referring to a surgeon who specializes in reverse shoulder replacements makes good sense.

The AC joint is part of the shoulder complex. The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone). The connection between the scapula and the clavicle is the AC joint.

To be a little more specific, the part of the scapula that makes up the top of the shoulder is called the acromion. The AC joint is where the acromion and the clavicle meet. Ligaments hold these two bones together.

AC joint separations are graded from mild to severe, depending on which ligaments are sprained or torn. The mildest type of injury is a simple sprain of the AC ligaments. Doctors call this a grade I injury. A grade II AC separation involves a tear of the AC ligaments and a sprain of the coracoclavicular ligaments. A complete tear of the AC ligaments and the coracoclavicular ligaments is a grade III AC separation. This injury results in the obvious bump on the shoulder.

Conservative care usually includes resting the arm in a sling, using ice, taking oral antiinflammatory drugs, and exercising. A specific rehab program under the direction of a physical therapist is often prescribed.

A recently published study looked at the long-term (10 year) results of conservative care for Type I and II AC joint separations. The authors report that what seem like minor shoulder injuries may not be as innocent as they first appear. The incidence of residual symptoms is fairly high. More than one-third of the patients with a Type I injury had ongoing symptoms years later. And patients with type II AC separation were twice as likely to have long-term symptoms as those with type I injuries.

Should patients with mild shoulder separations continue to skip the surgery and stick with conservative care? Why do half the patients end up with residual symptoms and the other half don’t? Researchers will be able to answer your question and these additional questions in the coming years.

It may be possible to find subgroups of patients who respond better than others to conservative care. Likewise, there may be patients with milder types of AC joint separation who would have a better result with surgery than with nonoperative care.

Differences from one side of the body to the other side are common. In fact, photos taken of the face comparing one side to the other show that we aren’t really symmetrical (the same from side to side) at all. Minor differences aren’t usually very obvious. So, if you can see a big difference from one side to the other, there may be other factors involved.

For example, hand dominance can play a part in asymmetries (not symmetrical; uneven). People who are strongly dominant on one side (e.g., very right-handed) use that arm much more than the other side. This can lead to larger muscles on one side and differences in alignment. That may be what you are observing in the mirror.

Another possibility is spinal alignment. Even a small degree of scoliosis (abnormal curvature of the spine) can create differences in the shoulders and/or hips. The tops of the shoulders appear uneven. The hip is higher on one side than the other. The difference in hip alignment is most noticeable in pants length (one side always appears longer than the other).

A third, common cause of shoulder asymmetry is scapular position. The scapula is the shoulder blade. The scapulae (plural) are normally positioned on either side of the spine between the second and seventh thoracic vertebrae. Elevation or depression of the scapula can also give the appearance of a shoulder that’s higher on one side.

If you are concerned that there may be something going on that requires medical attention, see your doctor. A physical therapist can also assess your posture and alignment. There may be some simple postural exercises that can bring you back into a more normal, neutral position.

The rotator cuff is a group of four muscles and several tendons around the top of the humerus, the bone that connects the arm to the shoulder. It helps you move your arm in the many directions it’s able to. If you tear one of the tendons, you end up with a torn rotator cuff. This can cause quite a bit of pain and make it hard to use your arm properly.

Rotator cuffs are torn when the arm is subjected to heavy or sudden stresses. In the case of a baseball or football player, this can be from throwing the ball too hard too often. The tears are repaired with surgery, but how effective the surgery is depends on how badly it’s torn and how many of the tendons are torn. If you tear two or more tendons, your condition is called a massive rotator cuff injury.

Joint replacements are a major surgery that involves a lot of recovery and rehabilitation. At this point, the surgery is usually done for people who have problems with the joint itself, not the surrounding tissues.

Treatment for a rotator cuff injury begins with non-surgical treatment, which involves physiotherapy, medications for the pain and inflammation, and perhaps injections of corticosteroids into the area. If this doesn’t work, then surgery may be needed to repair the tendons. This type of surgery has a good success rate and after recovery, the patients are usually happy with the results.

Many studies have shown that patients hurt on-the-job and covered under Workers’ Compensation (WC) have worse results after rotator cuff repair compared to those who do not have WC claims. The reasons for this difference still aren’t clear.

A recent study from Brown University in Rhode Island may help shed some light on this. Researchers tested individual factors to see if they could find a specific cause for the worse results in WC patients. The research method they used was a multivariable analysis. This statistical analysis helps show the effect of each factor studied while controlling for other factors that could confuse the results.

They did this by just studying patients treated by one single surgeon. This approach helps eliminate differences from one surgeon to another. Each patient had a full-thickness tear with symptoms lasting for more than three months despite conservative care.

Several other measures were taken before and after surgery to help identify factors that could explain the differences in results between WC patients and non-WC patients. Each patient was examined and gave the surgeon a complete medical history. They also completed a series of questionnaires to assess pain level, function, expectations, general health, and psychosocial status.

After all the data was collected and carefully analyzed, the Workers’ Compensation group did have worse performance and worse improvement in all areas (compared to the non-WC group). When all other things were equal, the main difference was whether or not the patient had a WC claim. To put this in research terms, we would say that Workers’ Compensation status is an independent predictor of worse outcomes.

Sex, duration of symptoms, size of the rotator cuff tear, and number of other health problems did not seem to make a difference between the two groups. Everyone in both groups improved from before surgery to after surgery. But the general trend was for WC patients to have lower function on the SST and DASH tests. Level of pain and quality of life were worse for the WC patients. And they showed overall less improvement.

Why is this? Well, we still don’t know. There is always the possibility that secondary gain is the underlying factor. Secondary gain refers to the patient’s hope of receiving a financial reward for his or her injury. This study did not assess that factor directly. Measuring results before and after the claim has been settled may help shed some light on the effect of secondary gain.

For now, the authors could only say that a WC claim has a negative effect on the short-term results of a rotator cuff repair. And they pointed out that there are other variables they didn’t test for. Further studies are needed to assess the effect of anatomic factors (tendon quality, repair strength). Long-term results of this study (five to 10 years later) may show that when it’s all said and done, outcomes are equal.

The rotator cuff is a group of four muscles and their tendons that surround the shoulder. These soft tissues form an capsule or cuff around the shoulder. They help keep the joint in the socket and rotate the arm.

Rotator cuff surgery may be done as an open incision, mini-open, or arthroscopic technique. The torn tendon is repaired along with any other damage that have may occurred at the same time.

Most patients go through a specific rehab program under the direction of a physical therapist. It is expected that full motion and function will return in time. Persistent shoulder stiffness after rotator cuff repair can happen, although it is fairly uncommon.

If you are concerned that this stiffness is still present despite following your rehab program, you should make a follow-up visit with your therapist and/or the surgeon. There may be some further exercises that would help. Or it’s possible a second surgery may be needed. For example, the surgeon can release the shoulder capsule if it is too tight or has become bound down with adhesions and scar tissue.

Most of the time, conservative care with physical therapy is prescribed first before performing another operation. But your surgeon is the one who will make this determination.

It’s possible and even probable that many patients would recover faster and improve more with physical therapy, but it hasn’t been proven yet. In today’s health care environment, the burden of proof is on the health care professional. Insurance companies are looking for evidence to show that a long-term rehab program (more than six weeks) is needed.

Physical therapists are stepping up to the plate when it comes to conducting research to document the results of their work. But more high-quality studies are needed that do not overestimate the results of treatment.

Many times studies are published that do not provide a complete set of data collected on each patient population examined. This makes it hard to compare the results of the study with other studies presented in the literature.

When two different types of treatment are compared, it’s not uncommon for patients in one group to switch to the other group. Switching treatment is referred to as the cross over effect. Providing evidence-based guidelines can be difficult when this happens.

Some conditions are more likely to generate a physical therapy referral. For example, orthopedic surgeons often prescribe physical therapy after a severe injury to the leg and/or foot. But physical therapy may not be justified for someone who just had a partial meniscectomy (removal of knee meniscus or cartilage).

Most states have direct access laws now. This means the consumer can see the physical therapist without a physician’s exam first. Therapists are trained to recognize when patients need a medical referral. The therapist consults with physicians (and other appropriate health care providers) when it’s indicated.

Patients as consumers are in charge of their health. Your aunt is a good example of someone who understands what she needs and insists on getting it. This may become a more common practice as the aging baby boomers (adults born between 1946 and 1964) seek more medical care.

It’s impossible to tell without knowing your diagnosis and without examining you what would be your best treatment. However, for many shoulder injuries that involve nerves, for example, non-surgical treatment, or conservative treatment, is preferred over surgery. The problem is that conservative treatment is slow and can be discouraging.

Usually, there is a time limit for your doctor to tell if the conservative treatment is working. In some cases it’s six months, in others it’s longer. There are drawbacks and complications associated with surgery so doctors don’t like to take that risk unless there is no other option.

Your shoulder is a strong joint that has many nerves passing through it to feel the arms and the upper part of the chest and upper back. If the shoulder is injured, usually through a trauma, the nerves can be compressed – something is pressing down on the nerves and cutting off the sensation. In this case, there may also be a blockage of blood flow, depending on the extent of the injury.

It’s likely that your husband’s doctor was worried about the circulation in the arm and wanted to be sure that the nerves didn’t become permanently damaged.

Loss of shoulder motion like you are describing might be diagnosed as a frozen shoulder or adhesive capsulitis. There is a specific pattern of motion loss that points to a tightening or stiffening of the joint capsule (soft tissue around the joint holding it in place).

The capsular pattern with a frozen shoulder results in loss of rotation, forward elevation, and abduction (moving the arm away from the body). X-rays are negative unless there is a fracture or tumor. This is because changes in the joint contributing to a frozen shoulder are in the soft tissues, not the bone.

New research shows that frozen shoulders occur when tiny fibroblasts or adhesions develop. Biopsies of the tissue show signs of chronic inflammation. Specific inflammatory cells such as mast cells, T cells, B cells, and macrophages are present. Other studies have shown that vimentin (a cellular protein) is present whenever the anterior shoulder capsule is involved.

Again, these kinds of changes in the collagen structure simply don’t show up on X-rays. More advanced imaging may be helpful but is usually expensive and not required to make the medical diagnosis.

Anytime there is a sudden onset of symptoms with no known cause, it is referred to as an insidious onset. In such cases, a medical examination is advised.

It could be nothing more serious than a pulled muscle. But arm pain and loss of motion can also be caused by adhesive capsulitis (frozen shoulder). Although less likely, a silent heart attack, stroke, or diabetes must also be considered.

What causes a frozen shoulder? Experts are not entirely sure yet. Women between the ages of 40 and 60 are affected most often. Changes in the synovium (fluid lubricating the joint) have been observed in adhesive capsulitis (in both sexes). This may occur without a known cause.

Or a secondary frozen shoulder can develop after an injury such as a fracture, soft tissue damage, or surgery. Sometimes changes occur in the shoulder joint as a result of osteoarthritis that can also lead to adhesive capsulitis.

Taking a microscopic look at the tissue around frozen shoulders released while the patient was under anesthesia, scientists found signs of chronic inflammation. Specific inflammatory cells such as mast cells, T cells, B cells, and macrophages were present. Other studies have shown that vimentin (a cellular protein) is present whenever the anterior shoulder capsule is involved.

Most of the time, adhesive capsulitis comes on more slowly. But in up to one-third of all cases, patients report a situation like yours with rapid onset over a period of 24 to 48 hours. No matter what’s causing your new symptoms, don’t delay in getting a diagnosis. Let your physician have a chance to rule out the more serious causes. Hopefully, it will be a minor problem that’s easily treated.

Diagnosing a SLAP lesion can be a difficult task requiring expertise in clinical examination and radiographic evaluation. However, once the diagnosis has been made, then a plan of care can be determined.

Treatment may be nonoperative first. Athletes are shown how to change the way they do things in order to take the pressure off the structures and let them heal. Pain relievers, corticosteroid injections, and antiinflammatory drugs may be used.

A program of physical therapy is prescribed. The therapist’s focus is on reducing the glenohumeral internal rotation deficit (GIRD). The rehab program will also work toward improving the flow of movement and energy throughout the entire kinetic chain. Kinetic chain refers to various body parts connected and moving together (entire upper or lower extremity in connection with the body).

Sometimes surgery is needed to débride (clean up) any frayed pieces, reattach the labrum, and/or repair the torn tendon. There are many different ways to approach the surgical treatment of SLAP injuries. It may be a while before we know which surgery works best for each type of SLAP tear. Outcome studies assessing each type of tear are just becoming part of the published literature.

Surgeons are also seeing other injuries or diagnoses along with the SLAP tear. For example, shoulder instability with shoulder dislocation has been linked with SLAP injuries. Anterior (forward) dislocation leads to an anterior labral tear. When the force of the injury is enough to involve the rotator cuff, then the risk of a SLAP tear increases as well.

There can be cysts along with SLAP lesions. If the cyst is large enough or in just the right spot, nerve compression can occur. Both components are usually repaired to assure a good outcome. But more recent research has brought this into question. It seems that patients get just as good of results whether or not the cyst is removed or aspirated (deflated).

Much more study is needed to help improve the treatment of SLAP lesions. Type of injury, location of injury, and treatment of the lesion direct the clinical management of this problem. But more knowledge is needed of patient age, anatomy, and function of the labral mechanism. As our understanding of the risk factors and mechanisms for SLAP injuries increases, treatment will be refined with improved outcomes. Right now these things are hotly debated.