FAQ Category: Shoulder

A SLAP tear means the labrum is torn away from the acetabulum in two directions: forward (anterior) and back (posterior). The word superior tells us the tear is along the upper rim or top of the acetabulum.

This is a serious injury that doesn’t happen very often. Overhead athletes are at greatest risk. Cocking the arm back to throw puts the shoulder in a position that can cause a SLAP tear.

There are four basic types of SLAP lesions labeled I through IV. They represent type of tear, location of tear, and severity of tear. For example, with type I there is fraying of the labrum. In Type II the tear extends into the biceps tendon, which attaches to the labrum. Type III is a bucket-handle shaped tear. It does not include the biceps. And type IV is a bucket-handle shaped tear with involvement of the biceps tendon.

The physician uses a wide range of tests and measures to diagnose and classify a SLAP tear. Most physicians rely on a group of commonly applied clinical tests. If any of these tests are positive, then further diagnostic measures are needed.

Range-of-motion testing must be done comparing the involved side to the normal (pain free) shoulder. The examiner is specifically looking for a glenohumeral internal rotation deficit (GIRD). Without normal rotational patterns, athletes lose the ability to throw overhand effectively.

These clinical tests don’t usually tell whether the lesion is Grade I, II, III, or IV. Advanced imaging with magnetic resonance arthrography (MRA) is needed to confirm the clinical diagnosis. MRA is considered accurate, sensitive, and specific enough to rely upon.

The final diagnosis, of course, is made arthroscopically when the surgeon attempts to look inside the joint and surgically repair the damage. Studies do show the reliability of interobserver reliability for arthroscopic exams is very poor.

This means that if 10 physicians looked at the arthroscopic video to evaluate and diagnose the condition, only six of the 10 would agree. That is only slightly more than half, which means 40 per cent disagree on the diagnosis. This low level of agreement/disagreement suggests the need to look at arthroscopic exams very carefully before making a final diagnosis. Given this statistic, a second opinion may or may not help.

The subscapularis muscle is one of the four muscles and tendons that surround the shoulder called the rotator cuff. Rotator cuff tears (RCTs) usually involve the infraspinatus or supraspinatus tendons. But surgeons are starting to see more subscapularis tears in active seniors.

With today’s new technology, scientists have also discovered a concept called the tendon footprint. This refers to the shape of the tendon as it inserts or connects with the bone. Shape, width, and size of the subscapularis tendon have been mapped now.

The subscapularis footprint is shaped like the outline of the state of Nevada. It is trapezoidal with a wider area at the top. Knowing where the tear is located within the footprint helps direct treatment.

Degenerative processes are more common in older adults. For example, stress on the footprint (place where the subscapularis inserts) from failure of other rotator cuff tendons is more likely as we age.

Most people with a torn subscapularis tendon need surgery for a good result. The procedure can be done with an open incision or arthroscopically through several portals (small puncture holes). The surgeon may find the tear is impossible to repair. But usually, the tendon is sutured back in place. The natural footprint is restored as much as possible.

You are absolutely right about the need for some prescreening tests before starting weight training with older adults. Anyone age 60 and older should always seek medical counsel first before starting a new exercise program.

The presence of undiagnosed conditions such as aortic aneurysms, rotator cuff tears, and high blood pressure must be identified and treated before establishing or increasing a strenuous exercise program.

Once the client has been medically cleared for weight-training (or other types of exercise), simple tests can be applied to look for shoulder instability. Most of these are well-known to orthopedic surgeons, physical therapists, and athletic trainers.

But recent studies with more sophisticated technology has shown us that some of these tests (e.g., lift off, Napoleon, belly press) aren’t as reliable and sensitive as we once thought they were. In fact, for small or partial thickness subscapularis tears, these tests are very inaccurate.

The belly-off sign is very sensitive for all sizes of subscapularis tears. With the arm internally rotated and the hand resting against the belly, the patient tries to lift the hand away from the stomach while the examiner resists the motion. Inability to move the hand off the abdomen is a sign that the subscapularis is not functioning properly. But the test requires the patient to use the external rotator muscles. If these are torn in a massive rotator cuff, the test can’t be used.

A new test called the bear-hug test may be the answer. In this test, the patient places the hand of the involved shoulder on his or her opposite shoulder. The fingers are straight and pointing back. The forearm and elbow are lifted up (the point of the elbow is facing forward).

The examiner tries to pull the patient’s hand up and off the shoulder. The patient tries to keep the hand on the shoulder. With a normal, strong scapularis, the patient should be able to keep the hand down. With a subscapularis tear, the examiner will be able to easily lift the patient’s hand off the shoulder. Compared with other tests for subscapularis tears, the bear-hug is the most accurate. But more studies are needed to confirm the use of this test with partial- and full-thickness tears.

In the meantime, research efforts have been made to look at preoperative imaging as a diagnostic tool. CT scans and MRIs haven’t been very successful identifying subscapularis tears.

Arthroscopic exam still remains the most sensitive and reliable test. It is more invasive, especially for those patients who don’t have a rotator cuff tear. But it is the first-step in the treatment of rotator cuff tears. So, if there are any signs of a subscapularis tear, then referral to an orthopedic surgeon for an (arthroscopic) exam is advised.

Sport climbing refers to climbing up or down artificial walls and natural rock faces. There are preplaced outcroppings on the walls called anchors. The climber uses them to get a handhold or foothold during the climb. The climber is secured by a rope above. If he or she falls, the rope stops them. You may have seen some of these walls at parks, schools, or in gyms.

Sport climbing is one of the new activities known to result in shoulder injuries from overuse.
This form of exercise is very demanding on the shoulder muscles. Training is important to improve climbing performance and to prevent injuries.

But studies are very limited in this area. We really don’t have evidence-based research to suggest training guidelines yet. There is one study from Hong Kong comparing shoulder muscle strength and function between climbers and nonclimbers.

They specifically tested the shoulder flexors and extensors and found that both groups of muscles were stronger in the climbing group. But the extensors were twice as strong as the flexors.

It’s not clear if this ratio is needed for smooth, coordinated climbing. Or if climbers should train to match this type of strength ratio. Climbers must be able to recover from sudden falls without injury. It is especially important to avoid injury of the shoulder muscles that are needed for climbing movements.

The authors of the Hong Kong report suggest that further study is needed to understand the scale of muscular imbalance on shoulder function during sports climbing before a successful and specific training protocol can be developed.

You’ll need a medical examination to find out what soft tissue structures might have been injured. With the mechanism of injury you describe, it sounds like a possible rotator cuff injury. The rotator cuff is a group of four tendons and the muscles that envelope the shoulder and hold it in place.

Along with stabilizing the shoulder joint in the socket, each one of the tendons has a specific job. Placing your hand behind your back requires medial (internal) rotation of the shoulder. The primary muscle for that movement is the subscapularis.

Subscapularis injuries occur when the shoulder is suddenly laterally (externally) rotated or hyperextended with force. The arm is next to the body at the time of the injury. With an injury to the subscapularis, there is weakness in internal rotation and excessive shoulder external rotation.

An orthopedic surgeon will test each muscle of the rotator cuff to determine what might be wrong. Usually the history and clinical tests are enough to make a diagnosis. X-rays can rule out fractures. An MRI or a CT scan may be ordered, especially if the surgeon is considering surgery as a possible treatment option.

Studies show that early diagnosis and treatment yield the best results. Don’t wait too long before you have someone look at this and at least give you a diagnosis. It’s possible with time and a rehab program, healing and recovery will occur without surgical intervention. But getting started while the body is in a reparative stage is important.

Outcomes of surgery for a rotator cuff tear depend on a wide range of factors. Patient age, duration of symptoms, and time from injury to surgery can make a difference. Even more important is the type and severity of injury.

Most rotator cuff tears affect the supraspinatus tendon. If the force of the injury is enough, the tear can extend posteriorly (backwards) to include the supraspinatus tendon.

Less often, the subscapularis tendon is injured. If the force is great enough, the tear extends anteriorly. The long head of the biceps can be damaged. This causes a condition called biceps tendon disorder.

Early surgical repair is advised for tears that extend through half (or more) of the tendon. With no delays in treatment, there is less muscle atrophy, less fatty infiltration of the tendon/muscle unit, and less scarring in the area.

After three to six months from the time of the injury, pain and loss of motion are signs that surgery is still needed. More than six months after the injury, the surgeon will want to re-evaluate the shoulder and see if the tear can be repaired. Sometimes severe tears cannot be repaired. Instead, shoulder rehab is needed to regain as much motion and function as possible.

Arm injuries are common in sport climbing, especially injuries of the shoulder. The rotator cuff is a prime area for tendon damage and impingement (pinching) syndrome.

Some of the stresses on the shoulders and arms depend on the angle and/or incline of the climbing wall. Ease with which handholds and footholds can be reached is another potential factor.

Coordinated movements of the shoulder are needed for this sport. The rotator cuff must function with just the right amount of muscle contraction and cocontraction.Cocontraction refers to muscles on the opposite sides of the joint contracting at the same time.

Climbing techniques require a lot of body pull-up motions. The shoulder muscles must be strong enough to lift the entire body against gravity.

The best way to find out if your shoulder is stable enough for climbing activities is to have the muscles tested. Physical therapists offer isokinetic testing (e.g., Cybex system) to evaluate muscle strength under load.

Any weakness or imbalance will be revealed with this type of testing. It’s possible a strength training program could prepare you for this vigorous sport. One study comparing shoulder muscle strength of climbers versus nonclimbers found overall shoulder strength much greater among climbers. Shoulder extensors were twice as strong as the flexors.

Training toward this ratio may help prepare you and protect you once you get started. Start with the easiest climbing walls first. Gradually increase the speed and level of difficulty based on the results of your muscle testing and endurance during the activity. If there is any question or doubt about your ability or preparation for this actvity, an evaluation with an orthopedic surgeon might be a good idea first before participating in this actvity.

You may be referring to an arthroscopic procedure. The surgeon makes two or three puncture holes and slips a long, thin needle into the damaged area. A tiny TV camera on the end of the scope provides a look inside the joint. The type and location of tendon damage can be assessed using this technique.

But an open repair has some advantages. In this procedure, the surgeon can see the full extent of any damage. Details of the injury are clear and nothing is missed. Results are actually better after open repair compared to arthroscopic repair. There are fewer retears after open repair.

The main disadvantage of the open repair is that the deltoid muscle is split in half to give the surgeon access to the shoulder. The muscle is sewn back together afterwards, but it leaves the arm at a mechanical disadvantage until healing and full recovery take place.

Some surgeons begin with an arthroscopic examination. If the injury can be repaired arthroscopically, then they go ahead and complete the operation. But if the damage is extensive, then the shoulder can be opened up and the procedure completed.

Magnetic resonance imaging (MRI) can help in the decision-making process. The MRI helps the surgeon assess tendon damage, healing, and anatomy. Size and location of the tear can be established. It can be determined whether the tear is partial or full-thickness. This makes a big difference in planning the surgical repair.

Treatment of complete rotator cuff tears (also known as full-thickness tears) varies depending on the person’s age, activity level, and severity of the injury. There are three main treatment options: rehab, repair, and reconstruction.

Rehab refers to a program of conservative (nonoperative) care. A physical therapist will guide you through a program of motion and strengthening. Other appropriate activities will be used depending on your pain, function, and movement.

In other cases, if the tendon hasn’t retracted too far, it may be possible to repair the injury. This is done by reattaching it to the bone where it pulled away (or close to it). If the two ends of the torn tendon are too far apart, it isn’t possible to bring the two ends together. Or sometimes the two ends can be pulled together, but there’s too much pressure on the healing tissue. It just tears again when the person starts using the arm.

Reconstruction may involve shaving or removing the acromion. The acromion is a curved piece of bone that comes from the back of the scapula (shoulder blade) and forms a protective shelf over the shoulder joint. Tendons from the muscles of the rotator cuff attach to the bone underneath this shelf. Removing the acromion takes pressure off the rotator cuff.

A biceps interposition is another possible surgical technique used to bridge the gap between the two ends of the rotator cuff. The long head of the biceps tendon is cut close to its attachment at the glenoid labrum. The labrum is a dense ring of fibrous cartilage. It goes around the rim of the acetabulum (shoulder socket) to increase the depth and stability of the shoulder joint.

The surgeon uses a suture retriever to reach in and pull the ends of the RCT back together as closely as possible. The biceps tendon is then used as a graft. It is placed between the two torn ends of the RCT and stitched in place (interposition repair).

This bundle of soft tissue is then attached to the bone in a procedure called a tenodesis (tendon-to-bone attachment). Braided sutures and suture anchors are used to hold everything together while it heals.

If the injury is old, there can be a fair amount of scar tissue, degenerative changes of the tendon, and muscle atrophy. The presence of any of these factors can impact the treatment decision. In older adults, osteoporosis (brittle bones) can be a factor in types of repair/reconstruction possible.

The surgeon can use MRIs and arthroscopic exam to plan the best way to repair the damage. But sometimes, the exact surgical technique is determined at the time of the operation. Once the area has been opened up and the surgeon can see the exact type and location of the tear, then it’s more obvious the best approach to the problem.

Ironman competitions traditionally involved swimming, biking, and racing. With proper rehab and training, a shoulder replacement should not keep you out of the race. Older adults who participate in sports before surgery are more likely to return to that sport after surgery. This is when compared with patients who aren’t active before shoulder replacement.

Although swimming requires repetitive motion, it does not seem to prevent patients with total shoulder replacements from participating. The rate of implant loosening or revision surgery among swimmers is no different from non-swimmers with a shoulder implant.

In an ironman competition it can be difficult to take full strokes. With so many bodies in the water, there’s a lot of water turbulence and bumping of elbows. You may have to alter your stroke to compensate. Athletes try to conserve leg muscles for the cycling and running portions of the race. A modified stroke is also needed to enable you to lift your head above the water to see markers without interrupting your swim or wasting energy.

Expect a three to six month rehab program followed by specific training for your ironman event. A physical therapist can help you with a sports specific training program. Make sure you keep your follow-up appointments with the surgeon after the operation. This will ensure that there are no unseen complications such as implant loosening or subsidence (implant sinking down into the bone).

There are only two studies published on patients involved in sports and recreational activities after shoulder replacement. Both suggest from their results to expect an average of three to four months for partial return to sports. It will probably be more like six months (from the time of surgery) to full return to your game.

But the wait should be worth it. Patients who were active but limited by pain before surgery report that their game is even better after rehab and recovery. An average improvement after surgery of five strokes has been reported by other golfers who had shoulder replacement surgery.

Sports specific physical therapy can be very helpful. This is the perfect opportunity to work on improving your swing and replacing bad habits with new, more effective movement patterns.

You’ll want to check with your surgeon to find out his or her recommendations first. Many experienced weight-lifters are able to continue training carefully. They can resume their program as early as three days after surgery. Most are back in full swing by the end of a week.

Weight-lifters are pleased that without the pain, they can quickly get back to their pre-operative level of lifting. In fact, some even report exceeding their training weight now that the pain is gone.

If the surgeon knows your plans, it’s possible to modify the procedure just a bit to stabilize the joint for a quick return-to-sport. The coracoacromial ligament can be transferred over the end of the bone that has been cut. This helps protect and stabilize the joint. It makes power lifting more comfortable for many athletes.

Weight-lifter’s shoulder is a painful deterioration of the distal end of the clavicle (collar bone). The person feels an aching pain in the front of the shoulder at the acromioclavicular (AC) joint.

This is where the end of the collarbone (closest to the shoulder) attaches to the acromion. The acromion is a curved piece of bone that comes from the shoulder blade across the top of the shoulder. The clavicle and acromion meet to form the AC joint in front of the shoulder.

Repetitive trauma or stress from training and lifting causes tiny fractures of the bone in this area. Because the bone doesn’t have a chance to heal before the next training session begins, the bone actually starts to dissolve. Pain develops with associated weakness.

Weight-lifters aren’t the only ones affected. Female bodybuilders, air-hammer operators, handball players, and others can develop this problem. For that reason, it is also known as distal clavicular osteolysis. Osteolysis refers to the resorption of bone at the site of the injury.

Avoiding overtraining and smoking are two very effective ways to prevent this condition. If it does develop, take quick steps to modify weight-lifting techniques and avoid overtraining.

For example, you can narrow your hand spacing on the barbells. This takes the stress off the distal clavicle. End your bench presses two inches above the chest. Some lifters place a two-inch folded towel on the chest as a reminder.

The power clean or power jerk can also be modified. Don’t rack the bar. Start with the elbows even with or above the shoulders and lift. This eliminates the power pull. Certain activities such as the bench press, dips, and push-ups should be avoided for a while. Apply an ice massage and take ibuprofen after each workout.

There’s still quite a bit of debate on this point. Studies don’t show a big difference in results between these two approaches. The arthroscopic procedure is minimally invasive. There is less soft tissue disruption and a smaller incision. But there is some concern that this method leaves some people with a repair that won’t remain stable or hold up.

Surgeons tend to use open repair techniques for over-head throwing athletes. The belief is that they need a mechanically stronger repair. But there are other surgeons who report that they are using all-arthroscopic surgeries for all patients including athletes.

There are two other things to consider when making this decision. The first is return-to-sports and the level of activity you may achieve. It is possible to return to the game at your pre-injury level. But some patients who have the arthroscopic repair do so at a level below their former playing ability.

And secondly, it is possible to retear the repair. Retear rates compare equally between open and arthroscopic techniques. In many reported cases, the patients with retears did not follow the rehab protocol and did more than was advised.

The best way to know for sure what’s going on is to see your orthopedic surgeon. He or she can examine you and perform clinical tests to check the integrity of the rotator cuff tendons.

It may be necessary to have a MRI scan with dye injected into the shoulder joint. A retear is diagnosed if the MRI signal shows fluid has passed through the tendon where it is torn.

Diagnostic arthroscopy is the other reliable way to know for sure if the rotator cuff has torn again. This is a surgical procedure and requires anesthetic but the tear can be revised or repaired again at the same time. This saves you the expense of an extra step in between diagnosis and treatment.

Surgery may not be needed at all. If it’s a mild injury, you may be able to rehab the shoulder. After taking a history and examining you, your surgeon will be able to advise you more specifically.

Surgical manipulation of a joint refers to a procedure whereby the surgeon moves the joint slowly and gently through its full range of motion. The patient is anesthetized to allow for full relaxation of the muscles, which would hold and contract otherwise to avoid the pain of movement.

Once you are asleep, the surgeon moves your arm carefully through each motion: flexion, extension, and rotations (internal and external). The arm will also be moved across the body. This movement is called horizontal adduction.

Adhesions and fibrous scar tissue will be torn in the process. The surgeon feels and hears the snapping, popping, grating sound called crepitus that signals release of the adhesions.

Once the adhesions are released, the shoulder will move more smoothly and fully. The manipulation procedure is complete when the affected shoulder has the same range-of-motion as the uninvolved side.

There’s some debate among orthopedic surgeons on this point. Having both procedures at the same time saves money and the inconvenience of two operations. But in some young adults, manipulation may be all that’s needed.

With a good rehab program, they can regain motion and strength without a major rotator cuff repair. This is more likely to occur when the tear is mild (as opposed to a massive tear).

On the other hand, some studies have shown that both procedures can be done during the same operation with equally good results. Recovery is a little slower for patients with adhesive capsulitis (frozen shoulder). But pain relief is immediate and equal to patients with a rotator cuff tear without stiffness.

Joint replacements can be a wonderful life-changing surgery. By removing the painful joints and replacing them with mechanical ones, people can regain proper movement with little pain. However, joint replacements are not for everyone.

The treating doctor has to assess if the injury or deterioration in your shoulder is something that would be fixed by a replacement – not all shoulder problems are. The doctors also have to look at risk when assessing if a patient is medically well enough to undergo surgery and if providing surgery may or may not cause complications.

Finally, some doctors want patients to wait as long as they can before performing a replacement because the new joints have a certain life span and the doctors would prefer to avoid having to do a second surgery down the line, if at all possible.

If you are not happy with your care, perhaps you should seek a second opinion and you may ask the doctor as many questions as you feel are necessary.

Rotator cuff injuries can be difficult to diagnose. It is indeed true that many older adults with degenerative soft tissue changes have no symptoms. They are said to be asymptomatic.

Studies show that it is possible to have a full-thickness tear of the rotator cuff without any symptoms. Finding a clinical test that can accurately diagnose a rotator cuff tear has been a challenge. There are four different tendons that form the rotator cuff. There’s a different clinical test for each one.

But sometimes it’s impossible to separate out the supraspinatus from the infraspinatus (two of the commonly involved tendons). The surgeon may have to rely upon ultrasound or other more advanced imaging to make an accurate diagnosis. Many prefer arthroscopic exam because the repair can be done at the same time.

Ultrasound does have the advantage of being able to compare one side to the other without invasive surgery.

The shoulder is a complex joint with many degrees of motion and many muscles to provide that motion. The main group of four tendons that surround and move the shoulder joint is called the rotator cuff.

These four tendons start out as four separate muscles. But by the time they attach to the shoulder, they are enmeshed as one unit. If the problem is in the rotator cuff, it takes a number of tests to sort out which muscle is affected and why. It could be a tendinitis (inflammation) or tendinosis (degeneration).

There could be a partial- or full-thickness tear of one (or more) of the tendons that make up the rotator cuff. And there isn’t have one test that can sort them all out accurately. Usually, the physician does as many clinical tests as needed to direct the rest of the examination.

Advanced imaging is often needed to rule out or confirm a tear in the rotator cuff. X-rays only show structural changes in the bone (e.g., fracture, narrowed joint space, bone spurs, arthritic changes). Any injuries of the soft tissues resulting in tears require ultrasound, MRI, or arthroscopy to diagnose accurately.