FAQ Category: Shoulder

It is hard to say if one technique is indeed “better” than another, as they have not been directly compared in the research. However it is useful to look at the results of studies using each technique and consider outcomes and complications. In this study, with a fairly high number of participants (thirty-two) there were very few complications and high success rate. This paper mentions another study (Guan and Wolf) that reported on six patients who had a similar reconstruction but with the use of a tendon from a second surgical site (gracilis, semitendinosus, or palmaris longus). At a follow up time of fourth-four months five of these six patients had no pain and had returned to normal activities. Another study (Bae et al.) reported on nine patients with tendon graft from another body part, with ninety percent of patients reporting full recovery after fifty-five months. According to these other results it appears that all these techniques are successful for the outcome, however it is difficult to directly compare the results. The main difference to consider is with a tendon graft from another body part there will be a second incision site, which can create it’s own complications.

The recovery protocol reported in this study indicates the arm was in a sling with a body belt for the first six weeks. During this time passive forward flexion to the shoulder level and passive external rotation to neutral were allowed. After the first six weeks active-assisted range of motion was begun in midrange as well stretching into full range. Scapular postural isometrics were also initiated after six weeks with the exclusion of pectorals major activity. After twelve weeks strengthening in the full range was introduced with progression guided by discomfort. Noncontact sports were allowed following six months as long as the joint was pain free and full motion was available. Participation in full contact sports was allowed following six months if a full push up was possibly without pain or scapular dysfunction for repeated repetitions.

The best outcomes of rotator cuff repairs come from a variety of factors.  Personal factors, like the location and extent of the repair, as well as the patient’s age and overall health play a big role in success rates.  Surgical technique choice and length of time spent in a sling following do not play as big of a role. What you can do to help make your repair successful is to follow the instructions of your surgeon and physical therapist, respect the healing times (wear your sling!), and have patience with your recovery.

The latest research suggests that there is no benefit to using platelet-rich plasma during a rotator cuff repair to speed up the tendon repair site and that it can actually increase the risk of infection.  However, keep in mind that your surgeon will make his best judgment call on technique depending on numerous factors that you should have a discussion with him about.

There are a lot of different post-operative rehabilitation protocols for rotator cuff surgery and varied research to support which are most effective. One of the more widely used protocols, which seems to be the one that was used by your neighbors surgeon, involves immediate post-operative passive range of motion for the first six weeks followed by strengthening and active range of motion exercises. This protocol when developed was based on an open repair of the rotator cuff versus the current standard of arthroscopic repair, in which the inflammatory response, risk of scarring, and prolonged stiffness is considered to be less common. With the advent of arthroscopic surgery resulting in decreased risk of prolonged stiffness , it may not be as important to start passive range of motion immediately after surgery.

A recent study published in the Journal of Bone and Joint Surgery suggests that it may be more important to focus rehabilitation on decreasing retear rates using a period of immobilization after surgery rather than starting passive range of motion immediately after surgery in order to minimize stiffness. One hundred participants who met specific criteria and underwent arthroscopic repair of the rotator cuff were randomly sorted into two groups. One group was immobilized after surgery for four weeks, the other was immobilized for eight weeks. After the allotted time of immobilization each participant underwent rehabilitation with a physical therapist that included passive range of motion then progressed to active range of motion and strengthening.

At follow up conducted at six months and 24 months after surgery, there were no statistical differences between the groups with retear rates, passive range of motion or clinical scores. There were more reports of stiffness by participants who were immobilized for eight weeks compared to those immobilized for four weeks. With no benefit in healing or diminished retear rate gained by immobilization for 8 weeks, it is deemed most beneficial to promote immobilization for four weeks after rotator cuff repair. The retear rate in this study was 10 per cent, compared to previously reported rates of 20 per cent-40 per cent in studies that involved early passive range of motion before four weeks.
Your surgeon likely wants to minimize the chances of retear of the rotator cuff repair while at the same time decreasing risk of prolonged stiffness, thus choosing to immobilize your shoulder for 4 weeks before beginning physical therapy.

Utilizing a traditional rehabilitation protocol involving immediate physical therapy for passive range of motion, reports vary between 20 per cent and 40 per cent of rotator cuff repairs resulting in a retear. There have been many improvements made in suture techniques to decrease this rate but little change in the rehabilitation protocol. Animal studies have shown that a period of immobilization following rotator cuff repair decreases the retear rate.

A recent study published in The Journal of Bone and Joint Surgery investigated the effectiveness of immobilization after surgery in human subjects. The goal was to determine if longer periods of immobilization resulted in any clinical differences in outcomes, including shoulder range of motion, retear rates and clinical outcome scores. One hundred participants who met specific criteria and underwent arthroscopic repair of the rotator cuff were randomly sorted into two groups. One group was immobilized after surgery for four weeks, the other was immobilized for eight weeks. After the allotted time of immobilization each participant underwent rehabilitation with a physical therapist that included passive range of motion then progressed to active range of motion and strengthening.

At follow up conducted at six months and 24 months after surgery, there were no statistical differences between the groups with retear rates, but the overall retear rate for both groups was 10 per cent. This much lower than retear rate reported (20-40 per cent) with other studies that involved immediate passive range of motion after surgery. If you want to diminish your chances of retear consult with your surgeon to determine if a period of immobilization after surgery would be advised.

Frozen shoulder, or adhesive capsulitis is charaterized by a loss of both active and passive range of motion at the glenohumeral joint. It is classified as either (1) primary idiopathic or (2) secondary to another pathologic process, and can often be associated with diabetes or thyroid disease. Treatment with nonoperative management is highly successful and should be considered the first option. While some are told to just wait it out and it will heal on its own, conservative treatment may also include a steroid injection, physical therapy, or both. Research indicates that formal physical therapy combined with a cortisone injection for the treatment of adhesive capsulitis was significantly better than no treatment at three month follow up, but both groups were similar at one year.

Depending on how long you have had your frozen shoulder and the resources available to you in terms of physical therapy and your health insurance coverage, your doctor may have decided that it is best just to wait it out. It is certainly reasonable to discuss the possibility or a cortisone injection and/or physical therapy with your doctor in order to speed up your recovery or ease your symptoms. Aside from conservative treatment, very rarely operative treatment is an option. Operative treatment is considered with recalcitrant adhesive capsulitis or when conservative treatment fails as can be the case more often with younger patients or those with diabetes.

Rotator cuff pathology is probably the best known shoulder joint injury, particularly in athletes involved in throwing sports, swimming or racquet sports, and can vary from tendinitis to a full thickness tear. Aging is associated with an increase in rotator cuff tears, both partial and full thickness. Smaller tears are often successfully treated with arthroscopic debridement, but this procedure is not as successful for full thickness tears thus leading to surgical repair of the tear. Research indicates that the return to sport rate for older adults after rotator cuff surgical repair is quite favorable. While only a 32 percent return to prior competitive level of sport was found in professional pitchers, a study looking at older athletes found that all recreational pitchers, mean age of 59, were able to return to prior level of pitching after surgery. They rated themselves at 92 per cent of their original function. It is important to understand with this data that the level of sport that the recreational pitchers were returning to was significantly lower than that of professional pitchers, thus making return to prior level of sport much more feasible after surgery.

For many years, the terms adhesive capsulitis and frozen shoulder were used to describe the same condition. Patients experience shoulder pain and loss of shoulder motion. The problem comes on slowly over a period of time and seems to affect women more often than men (especially women between the ages of 40 and 60).

But experts recognize now that there are many different shoulder conditions that can present with these (or similar) symptoms. So the old term “frozen shoulder”, once used to describe any painful, stiff shoulder is now more refined. The term “adhesive capsulitis” may be a more accurate description for some patients.

As the name suggests, adhesive capsulitis affects the fibrous ligaments that surround the shoulder forming the joint capsule. This condition is referred to as primary adhesive capsulitis to differentiate it from “frozen shoulder” (secondary adhesive capsulitis).

Primary adhesive capsulitis is formed by inflammation, fibrosis, and contraction of the capsule with tiny adhesions holding the capsule to the bone. The normally loose parts of the joint capsule stick together. The result is pain and loss of motion from a mechanical (tissue) problem (adhesions causing tightness).

The condition referred to as a frozen shoulder usually doesn’t involve the capsule. Secondary adhesive capsulitis (or true frozen shoulder) might have some joint capsule changes but the shoulder stiffness is really coming from something outside the joint. Often, the short rotator muscles around the shoulder spasm. Sometimes, adhesions form inside the joint itself (rather than in the capsule).

Some of the conditions associated with secondary adhesive capsulitis (true frozen shoulder) include rotator cuff tears, biceps tendinitis, and arthritis. Any of these problems can seriously limit the shoulder’s ability to move, and causes the shoulder to “freeze.” Risk factors for adhesive capsulitis include: diabetes, thyroid problems, Dupuytren contracture, treatment for breast cancer, autoimmune diseases, and previous heart attack or stroke.

Current concepts in diagnosis and treatment of adhesive capsulitis were recently published. One of the most distinguishing characteristics of primary adhesive capsulitis is decreased shoulder external rotation when the arm is held next to the side. Active and passive shoulder motions will be equally limited when the capsule is involved. When these two types of motion differ, the problem may not be primary adhesive capsulitis.

Sometimes it is difficult to tell if motion is limited by capsular tightness versus the patient’s pain. That’s when it might be helpful to inject the joint with a numbing agent (e.g., lidocaine). Retesting the patient’s shoulder motion without the influence of pain can help differentiate between true primary adhesive capsulitis and some other cause of shoulder pain (and loss of motion). X-rays may be helpful in identifying these other causes of shoulder pain and blocked motion (e.g., osteoarthritis, dislocation, bone spurs, fractures, tumors).

Another useful diagnostic test to determine whether or not the joint capsule is involved is an arthrography. A dye is injected into the joint. Normally, the shoulder joint can hold about 15 milliliters of fluid. The person who has primary adhesive capsulitis will have a limited capacity because the portion of the capsule at the bottom (called the axillary fold) is contracted. No fluid can enter this normally pocket-like structure.

MRIs have limited ability to aid in the diagnosis of primary adhesive capsulitis. But an MRI can help rule out other causes and an MRI with contrast dye (arthrography) can show the presence of thickening in the joint capsule and ligaments. And when the MRI no longer shows the fat pad between the coracohumeral ligament and the coracoid process, the presence of primary adhesive capsulitis is confirmed.

Shoulder manipulation (moving the shoulder through its full range of motion while the patient is asleep with an anesthetic) can be helpful for some shoulder problems. But it is not usually the first choice in treatment for a frozen shoulder.

Before determining the appropriate treatment, an accurate diagnosis is required. For example, the physician must sort out whether the patient has a true “frozen shoulder” or something else referred to as adhesive capsulitis.

For many years, the terms adhesive capsulitis and frozen shoulder were used to describe the same condition. Patients experience shoulder pain and loss of shoulder motion. The problem comes on slowly over a period of time and seems to affect women more often than men (especially women between the ages of 40 and 60).

But experts recognize now that there are many different shoulder conditions that can present with these (or similar) symptoms. So the old term “frozen shoulder”, once used to describe any painful, stiff shoulder is now more refined. The term “adhesive capsulitis” may be a more accurate description for some patients.

As the name suggests, adhesive capsulitis affects the fibrous ligaments that surround the shoulder forming the joint capsule. This condition is referred to as primary adhesive capsulitis to differentiate it from “frozen shoulder” (secondary adhesive capsulitis).

Primary adhesive capsulitis is formed by inflammation, fibrosis, and contraction of the capsule with tiny adhesions holding the capsule to the bone. The normally loose parts of the joint capsule stick together. The result is pain and loss of motion from a mechanical (tissue) problem (adhesions causing tightness).

The condition referred to as a frozen shoulder usually doesn’t involve the capsule. Secondary adhesive capsulitis (or true frozen shoulder) might have some joint capsule changes but the shoulder stiffness is really coming from something outside the joint. Often, the short rotator muscles around the shoulder spasm. Sometimes, adhesions form inside the joint itself (rather than in the capsule).

Some of the conditions associated with secondary adhesive capsulitis (true frozen shoulder) include rotator cuff tears, biceps tendinitis, and arthritis. Any of these problems can seriously limit the shoulder’s ability to move, and causes the shoulder to “freeze.” Risk factors for adhesive capsulitis include: diabetes, thyroid problems, Dupuytren contracture, treatment for breast cancer, autoimmune diseases, and previous heart attack or stroke.

Arthroscopic release is considered “best practice” for shoulder motion limited by capsular tightness. This procedure has replaced manipulation under anesthesia (MUA) as the treatment of choice. Studies show that patients who have arthroscopic release have better (and more long lasting) pain relief and improved shoulder range of motion with arthroscopic treatment compared with MUA.

And as mentioned, preliminary testing is recommended to make sure the pain and loss of motion is really coming from the joint capsule and not from inside the joint. Once the diagnosis has been made, then treatment can be prescribed.

Physical therapy is the first line-of-treatment. It takes time to calm the pain signals and gain motion back, so a period of conservative care over several months is necessary. During this time, nonsteroidal antiinflammatory medications are often recommended for their short-term effects of providing pain relief. Steroid injections into the joint also provide a temporary decrease in pain and may aid in reducing inflammation in the early stages of the condition.

When conservative care fails to bring about the desired results, treatment may be expanded to include nerve blocks, hydrodilation (injecting a saline solution into the joint to expand/rupture the capsule), or manipulation under anesthesia (surgeon moves arm through full motion while patient is asleep).

When all else fails, surgery may be the last step. Of course, arthroscopy (looking inside the joint) is the final step in confirming the diagnosis. Arthroscopy is used to see inside the joint and release adhesions, scar tissue, and/or the capsule itself. Physical therapy after manipulation is required in order to maintain shoulder motion after manipulation or surgery.

In a recent article, Dr. Theodore Blaine from Yale University School of Medicine wrote about the latest in biologic treatments for shoulder pain. In particular, Dr. Blaine’s area of expertise is the nontraditional treatment of shoulder arthritis. Nontraditional treatment refers to the nonsurgical, biologic treatment of shoulder pain using medications, injections, cytokines, growth factors, platelet rich plasma, and stem cells. Here’s a brief summary of recent developments in this area.

Medications: Physicians continue to rely on the old standbys in this area (acetaminophen or Tylenol, nonsteroidal antiinflammatories, and corticosteroids). Studies show that acetaminophen remains a popular choice for relief of mild shoulder pain due to osteoarthritis. Acetaminophen combined with Tramadol (Ultram), a more narcotic-like (stronger pain reliever) is used for patients with severe pain.

Nonsteroidal antiinflammatory drugs (NSAIDs) offer better pain relief than acetaminophen but newer studies have shown some problems with rotator cuff tendon healing when taking these medications. NSAIDs seem to help most by improving patients’ ability to sleep and participate in physical therapy.

The use of oral (by mouth) steroids has fallen out of favor as studies show these medications provide only very short-term improvement in pain. Comparing groups of patients with shoulder pain taking steroids versus a placebo — 12 weeks later, the placebo group actually had better results.

Injections: Likewise, corticosteroid injections directly into a joint offer short-term pain relief, which in turn, gives patients better motion and function. There is some evidence that corticosteroids also reduce inflammation and may work better than nonsteroidal antiinflammatory drugs (NSAIDs) for some causes of shoulder pain (e.g., rotator cuff disease, bursitis).

Other types of injections include hyaluronate and botulinum toxin or BOTOX. Hyaluronate increases fluid within the joint and makes motion smoother and easier with less compression and shearing of the joint surfaces. Studies done by Dr. Blaine show that hyaluronate is a safe and effective treatment for shoulder osteoarthritis that has not responded to more traditional treatment with medications. The FDA has not yet approved hyaluronate for treatment of shoulder osteoarthritis.

BOTOX actually paralyzes muscles but also stops pain at the nerve endings. Although BOTOX has not been approved for use with shoulder pain, there appears to be little risk in using this injection therapy. This may be another nontraditional treatment technique for future use.

Cytokines: Cytokines are regulating molecules in the immune system and may assist in reducing inflammation. Cytokines may have a future role in providing a better solution to shoulder pain without the adverse effects of medications and injections. Areas of research right now are focused on the use of cytokines with patients who have bursitis and those with diabetes and rotator cuff disease.

Growth factors: Another possible way to encourage faster, better healing after rotator cuff surgery may be in the use of growth factors. Type I and Type III collagen fibers must be replaced and growth factors such as bone morphogenetic proteins (BMPs), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), and transforming growth factor-B (TGF-B) may turn out to be the right tool for this. Studies are only in animal models at this time.

Platelet-Rich Plasma. Much has already been studied and written about regarding the use of growth factors found in platelet-rich plasma (PRP taken from the patient’s own blood). These growth factors may be able to aid in the repair of damaged soft tissues. Researchers are looking at various effects of PRP on rate of recurrent rotator cuff tears, tendon and muscle strength after treatment, effects on small versus large rotator cuff tears, and long-term results.

Stem Cells. Stem cells are the basic cells that can turn into any other kind of cell, including tendon. Utilizing stem cells to repair damaged tendons by the regeneration of tendon cells in rats and rabbits have shown mixed results. This is another biologic treatment tool that may yet be used but much more research is needed before the hows and whats of tendon regeneration via stem cells is ready for human use.

Finding ways to enhance healing of the rotator cuff (especially after surgical repair) remain a challenge for future research studies. The nontraditional approach using biologic agents such as growth factors, stem cells, pharmacologic agents (or some combination of these) may have a central role in future treatments for shoulder pain.

More time, effort, and money is being spent on exploring nontraditional treatment of shoulder arthritis. Nonsurgical, biologic treatment includes the use of medications, injections, cytokines, growth factors, platelet rich plasma, and stem cells.

Stem cells are the basic cells that can turn into any other kind of cell, including tendon. Utilizing stem cells to repair damaged tendons by the regeneration of tendon cells in rats and rabbits have shown mixed results. This is one of several biologic treatment tools that may yet be used but much more research is needed before the hows and whats of tendon regeneration via stem cells is ready for human use.

Right now, physicians continue to rely on the old standbys to control the painful symptoms of rotator cuff pathology including acetaminophen or Tylenol, nonsteroidal antiinflammatories, and
corticosteroids. Studies show that acetaminophen remains a popular choice for relief of mild shoulder pain due to osteoarthritis. Acetaminophen combined with Tramadol (Ultram), a more narcotic-like (stronger pain reliever) is used for patients with severe pain.

Nonsteroidal antiinflammatory drugs (NSAIDs) offer better pain relief than acetaminophen but newer studies have shown some problems with rotator cuff tendon healing when taking these medications. NSAIDs seem to help most by improving patients’ ability to sleep and participate in physical therapy.

The use of oral (by mouth) steroids has fallen out of favor as studies show these medications provide only very short-term improvement in pain. Comparing groups of patients with shoulder pain taking steroids versus a placebo — 12 weeks later, the placebo group actually had better results.

Until stem cell research finds a safe and effective way to use this tool for tendon regeneration, conservative care will remain pharmacologic (medications). If and when that doesn’t yield the desired results, then injections may be the next step. Corticosteroid injections directly into a joint offer short-term pain relief, which in turn, gives patients better motion and function. There is some evidence that corticosteroids also reduce inflammation and may work better than nonsteroidal antiinflammatory drugs (NSAIDs) for some causes of shoulder pain (e.g., rotator cuff disease, bursitis).

Other types of injections include hyaluronate and botulinum toxin or BOTOX. Hyaluronate increases fluid within the joint and makes motion smoother and easier with less compression and shearing of the joint surfaces. Studies show that hyaluronate is a safe and
effective treatment for shoulder osteoarthritis that has not responded to more traditional treatment with medications. However, the FDA has not yet approved hyaluronate for treatment of shoulder osteoarthritis.

BOTOX actually paralyzes muscles but also stops pain at the nerve endings. Although BOTOX has not been approved for use with shoulder pain, there appears to be little risk in using this injection therapy. This may be another nontraditional treatment technique for future use.

Bringing more tools to the conservative side of treatment for shoulder pain from arthritis is important as more and more younger people are affected by this problem. Pain relief and improved function are the short-term goals.

Finding ways to enhance healing of the rotator cuff (especially after surgical repair) remain a challenge for future research studies. Biologic
agents such as growth factors, stem cells, pharmacologic agents (or some combination of these) may have a central role in future treatments for shoulder pain but are not widely available at this time.

There are many different reasons why elite baseball pitchers may need shoulder surgery. But the biggest question is always, How long will it be before I can go back to pitching? Some answers can be found in a recent research report from the Division of Sports Medicine (Department of Orthopedic Surgery) at Rush Medical College in Chicago, Illinois.

Surgeons there searched several electronic data sources for studies that might address this question. They found six that qualified with a total of 287 elite pitchers. All were men, most were professional athletes, and all had reparative or reconstructive shoulder surgery.

Almost all of the pitchers (99 per cent) injured their dominant (pitching) arm. And many (like yourself) had more than one shoulder injury requiring surgical correction. Injuries included rotator cuff tears, impingement, joint laxity, joint degeneration, labral tears, and internal impingement.

The authors were interested in establishing the rate of return to sports participation among these elite baseball pitchers after surgery. They found that 68 per cent of the players were able to get back into action (pitching competitively) approximately 12 months after surgery.

Some players were able to return to pitching within nine months after the surgery. Others were not ready for a year and a half (18 months). Very few actually made it back to sports participation the same year they had the surgery. This was especially true for those who had rotator cuff or labral surgery.

If 68 per cent were able to return to pitching, what happened to the other pitchers? Twenty-two per cent (22%) never made it back and ended up retiring from professional baseball. Those who returned to pitching reported some noticeable differences from before their injuries. For example, they pitched far fewer innings post-operatively compared with pre-injury. Certainly, the successful group was able to pitch more than they could after the injury or just prior to surgery.

What was important to the players was pitch accuracy, speed, and endurance. Follow-up over the next three and a half years showed a gradual, continued improvement in all areas of performance (e.g., strikeouts, walks, hits per inning pitched). Complaints reported by pitchers included early fatigue (compared to pre-injury status) and a sense of loss over pitch control. Measurements taken did show a slight decline in maximum pitch velocity (from 94.2 miles per hour to 90.1 miles per hour).

Pitching at the professional level requires a fine balance between movement (mobility) and stability. With only slightly more than two-thirds of the pitchers returning to play following shoulder surgery (and very few during the same season), every effort to rehab with a conservative approach is advised.

But since this is no longer an option for you, be aware that surgery may not result in a full return-to-play. And if you are able to return to pitching, you may not reach pre-injury levels of pitching. Your surgeon is the best one to advise you directly based on the specific details of your injuries and your situation. Be sure and ask for whatever recommendations and guidelines he or she may have for you and good luck!

Many overhead throwing athletes find that pitch accuracy, speed, and endurance can be compromised by injury and/or recovery after reparative or restorative surgery for that injury. And as you already know, overhead throwing (i.e., pitching) requires a fine balance between movement (mobility) and stability (keeping the shoulder in the socket). The perfect pitch doesn’t come back immediately after surgery without considerable rehabilitation and practice.

In fact, among elite professional (major league) pitchers, only about two-thirds (68 per cent) even make it back to the mound. The rest find it necessary to retire earlier than intended. Treatment under the care and supervision of a sports physical therapist is often recommended. Rehab may take weeks to months to iron out the kinks such as the “wobble” you mentioned.

The physical therapist will assist you in regaining normal shoulder motion, kinematics (movement), and proprioception (joint sense of position). To regain your pre-injury pitching performance requires careful attention to all the components needed for pitching velocity (speed) and control. And even then, according to studies, there is a chance that you will never regain all that you lost or return to your pre-injury level of performance.

Still — it is worth a try. What have you got to lose except maybe that “wobble”?! Based on studies published on this topic, you can expect recovery and rehab to take many weeks to months. Some players report a gradual return of their abilities and pitching performance over a period of two to three years.

Total shoulder replacement for severe joint osteoarthritis has come a long way since its first use. But it isn’t perfect yet. Ten to 15 per cent of patients receiving this implant later develop loosening of the glenoid component (socket side of the implant).

The reason for glenoid component loosening is the focus of a recent study from the Cleveland Clinic in Ohio. What they found may be of interest to you. We don’t know what you had. But the type of implant used for patients in the study was a polyethylene (plastic) press-fit (not glued in but pressed against the bone so that more bone would fill in around it) design. With that particular implant type, a peg in the center of the socket implant helps hold it in place until bone in-fill takes place.

Loosening is observed on X-rays as osteolysis (bone loss as the body resorb bone cells) may be associated with a condition known as retroversion. Retroversion refers to a tipped back position of the socket. Because the socket does not line up symmetrically with the head of the humerus, retroversion may contribute to the osteoarthritic degenerative changes and later to the osteolysis leading to loosening.

In this study, 66 patients who received the DePuy Anchor Peg Glenoid Component were followed up. All surgeries to implant the shoulder replacement were done by one surgeon. When there was too much retroversion, the surgeon did his best to correct the problem. He did this by shaving or cutting away excess bone along the front of the glenoid. The goal was to create a glenoid (socket) that was perpendicular to the scapula (body of the shoulder blade where the glenoid is located).

In some cases, the surgeon was unable to obtain a perfect fit with complete correction. To get complete correction of glenoid retroversion would require taking off too much bone. It was better to remove as much bone as possible to re-align the glenoid but without taking so much that it was no longer possible to insert the glenoid component.

To measure results, X-rays were taken before and after surgery and compared. About half of the patients also had pre-operative CT scans ordered when X-rays were not enough to fully see the glenoid. Repeating these imaging studies postoperatively made it possible for the surgeon to evaluate the bone, assess alignment (e.g., retroversion, accuracy of glenoid component to scapula interface), and look for any signs of implant loosening around the central peg.

It turned out that pre- and postoperative glenoid retroversion was the main factor in osteolysis and peg loosening. More than 15 degrees of tilt still remaining after surgery contributed to early loosening. It is believed (but has not been conclusively proven yet) that the retroversion causes increased load on the humeral head.

The surgeon concluded by suggesting that whenever possible, glenoid retroversion should be corrected to within 15 degrees before placing the implant into the shoulder. This also means that many things must be taken into account when preparing for shoulder replacement.

The surgeon is advised to use advanced imaging studies to look for pathology (i.e., problems with alignment, presence of bone deficiency). Both X-rays and CT scans should be taken pre-operatively (CT scans before surgery were not standard practice at the time of this study). And special care must be taken when selecting the implant used in order to accommodate for pathology and alignment problems observed preoperatively.

This information may help you in discussing your situation with the surgeon. Retroversion may not be an anatomic feature for you but if it is, these suggestions may help. In any case, careful evaluation of your situation may help identify risk factors that can be managed to avoid future problems with implant loosening.

Alignment of the glenoid (shoulder socket) in the scapula (shoulder blade — where the glenoid is located) is a key feature necessary for a smooth moving shoulder joint. The head of the humerus rotates inside the glenoid (socket) so a good match means full, normal motion in an arc of 360 degrees.

Poor alignment for any reason can put increased pressure or uneven pressure on the humeral head (round end of the humerus or upper arm bone that fits into the socket). The increased load can wear the bone down resulting in osteoarthritic degenerative changes. One of the pathologic changes that can be present in patients who develop these degenerative changes is known as retroversion. This term describes a tipped position of the socket as it sits inside the scapula. Normally, the relationship between the socket and scapula should be one where the socket is perpendicular to the scapula.

Studies show that 10 to 15 per cent of patients receiving a total shoulder replacement later develop loosening of the glenoid component (socket side of the implant). Loosening is observed on X-rays as osteolysis (bone loss as the body resorbs bone cells). It appears that retroversion (the tipped back position) of the socket may contribute to the osteoarthritic degenerative changes in the first place and may also be linked with osteolysis leading to loosening.

When there is too much retroversion, the surgeon tries to correct the problem. This correction can be done by shaving or cutting away excess bone along the front of the glenoid. The goal is to create a glenoid (socket) that is as close to perpendicular to the scapula as possible.

In some cases, the surgeon is unable to obtain a perfect fit with complete correction. To get complete correction of glenoid retroversion would require taking off too much bone. It is better to remove as much bone as possible to re-align the glenoid but without taking so much that it was no longer possible to insert the glenoid component.

Experts suggest that whenever possible, glenoid retroversion should be corrected to within 15 degrees before placing the implant into the shoulder. Surgeons are advised to use advanced imaging studies to look for pathology (i.e., problems with alignment, presence of bone deficiency) preoperatively. It sounds like your surgeon made every effort to do this for you but you may want to revisit this conversation at your next appointment and ask for more details.

The diagnosis of shoulder osteoarthritis usually leads to successful results (less pain, better motion and function) with a shoulder replacement. But there are certain patients for whom studies show conventional shoulder replacement doesn’t always result in good outcomes. And there are folks like yourself who would rather avoid this type of surgery.

So, if the traditional shoulder replacement isn’t the right fit for you, then what else can be done? According to shoulder surgeons at The Cleveland Shoulder Institute, there are two separate categories of potential treatment: types of arthroplasty (surgical repair of the joint) and nonarthroplasty (but still surgical) alternatives.

Arthroplasty options include: shoulder resurfacing, using a short-stem humeral implant, and glenoid “reaming” without an implant (called ream and run). Humeral head resurfacing has been around for 25 years but the short-stem humeral implant is fairly new technology. “Ream and run” involves smoothing the glenoid (socket side) of the shoulder joint and restoring the round shape as much as possible. Nonarthroplasty treatment suggested includes debridement with capsular release, microfracture, autologous chondrocyte implantation, and osteochondral allograft resurfacing.

Here are a few more details about these alternative options to traditional shoulder replacement that may assist you in talking with your surgeon about what’s right for you. The main advantage to shoulder resurfacing and a short-stem humeral component is that these techniques preserve (save) bone. Only the damaged portion of the shoulder is replaced (not the whole shoulder). Bone spurs (called osteophytes are shaved away. The normal anatomy can be restored with less bone removal. Bone preservation makes it possible to delay (but not prevent) total shoulder replacement if and when further surgery is needed.

There is also a newer approach to resurfacing the shoulder joint and that’s called biologic glenoid resurfacing. In this case, the socket side of the joint (rather than the head of the humerus) is resurfaced. This can be done with a variety of different soft tissues to smooth the joint surface. The technique is called interpositional arthroplasty and uses human skin matrix, human tendon graft from a donor, the patient’s own connective tissue from the fascia lata along the outside of the thigh, or pig graft material.

On the nonarthroplasty side of things, the focus has been on trying to repair the damaged cartilage. The goal is to provide relief from pain and improve function. This is done by removing torn, damaged, or loose pieces of joint cartilage and smoothing or filling remaining holes, lesions, or “defects.”

Microfracture aids in repairing the joint surface by causing bleeding into the joint. The body creates new fibrous cartilage in the area where tiny holes have been drilled through the joint surface into the bone marrow. Alternatively, the surgeon can use cartilage cells (either harvested from the patient or from a donor) to fill in and then smooth over defects. Using the patient’s own chondrocytes (cartilage cells) is ideal because there’s a greater chance for cells to survive the transplantation process. But patient grafts also come with potential for problems at the donor site.

These are all things you can bring up and discuss with your surgeon in making the decision about what is the best, right treatment decision for you. There are options these days and hopefully more to come in the near future as alternative treatments are proposed, used, studied, and reported on. Good luck!

Like you, not everyone is a good candidate for a total shoulder replacement. But suffering for another 10 (or more) years while waiting to “qualify” for a new shoulder isn’t an acceptable alternative either. Recently, surgeons from the Cleveland Shoulder Institute in Ohio offered their best advice about how to treat three groups of patients who might not be right for a shoulder replacement but need treatment just the same.

In particular, young patients (younger than 60 years old) with osteoarthritis, adults with posttraumatic arthritis, and individuals with specific lesions (damage, defects) to the head of the humerus (upper arm bone) fall into this category.

The biggest concerns are for how long the implant will last in someone who may live another 20 years (or more) and the increased likelihood of revision (second) surgery. The most common problem that develops in the younger age group is loosening of the implant.

Your question is: if the traditional shoulder replacement won’t work for you, then what else can be done? The Cleveland surgeons suggest there are two separate categories of potential treatment: types of arthroplasty (surgical repair of the joint) and nonarthroplasty (but still surgical) alternatives.

Arthroplasty options include: shoulder resurfacing, using a short-stem humeral implant, and glenoid “reaming” without an implant (called ream and run). Humeral head resurfacing has been around for 25 years but the short-stem humeral implant is fairly new technology. “Ream and run” involves smoothing the glenoid (socket side) of the shoulder joint and restoring the round shape as much as possible.

Nonarthroplasty treatment suggested included debridement with capsular release, microfracture, autologous chondrocyte implantation, and osteochondral allograft resurfacing. In the future, long-term results of these alternative approaches will aid shoulder surgeons in determining which technique is best for each patient. For now, evidence is limited but outcomes are promising.

Here are a few more details about these alternative options to traditional shoulder replacement in young patients with osteoarthritis. The main advantage to shoulder resurfacing and a short-stem humeral component is that these techniques preserve (save) bone. Only the damaged portion of the shoulder is replaced (not the whole shoulder). Bone spurs (called osteophytes are shaved away. The normal anatomy can be restored with less bone removal. Bone preservation makes it possible to delay (but not prevent) total shoulder replacement if and when further surgery is needed.

There is also a newer approach to resurfacing the shoulder joint and that’s called biologic glenoid resurfacing. In this case, the socket side of the joint (rather than the head of the humerus) is resurfaced. This can be done with a variety of different soft tissues to smooth the joint surface. The technique is called interpositional arthroplasty and uses human skin matrix, human tendon graft from a donor, the patient’s own connective tissue from the fascia lata along the outside of the thigh, or pig graft material.

On the nonarthroplasty side of things, the focus has been on trying to repair the damaged cartilage. The goal is to provide relief from pain and improve function. This is done by removing torn, damaged, or loose pieces of joint cartilage and smoothing or filling remaining holes, lesions, or “defects.”

Microfracture aids in repairing the joint surface by causing bleeding into the joint. The body creates new fibrous cartilage in the area where tiny holes have been drilled through the joint surface into the bone marrow. Alternatively, the surgeon can use cartilage cells (either harvested from the patient or from a donor) to fill in and then smooth over defects. Using the patient’s own chondrocytes (cartilage cells) is ideal because there’s a greater chance for cells to survive the transplantation process. But patient grafts also come with potential for problems at the donor site.

With the information provided here, you can talk with your surgeon about what’s available and what might be your choices and options.

Many adults (mostly women) between the ages of 40 and 60 years of age develop shoulder pain and stiffness called adhesive capsulitis. Most people are more familiar with the term “frozen shoulder” to describe this condition. But frozen shoulder and adhesive capsulitis are actually two separate conditions. A more accurate way to look at this is to refer to true adhesive capsulitis (affecting the joint capsule) as a primary adhesive capsulitis.

As the name suggests, adhesive capsulitis affects the fibrous ligaments that surround the shoulder forming the capsule. The condition referred to as a frozen shoulder usually doesn’t involve the capsule. Secondary adhesive capsulitis (or true frozen shoulder) might have some joint capsule changes but the shoulder stiffness is really coming from something outside the joint.

Some of the conditions associated with secondary adhesive capsulitis include rotator cuff tears, biceps tendinitis, and arthritis. In either condition, the normally loose parts of the joint capsule stick together. This seriously limits the shoulder’s ability to move, and causes the shoulder to freeze.

Steroid injections are sometimes recommended if and when the patient fails to improve with conservative care such as physical therapy, activity modifications, and antiinflammatory or analgesic (pain relieving) medications. But there is some controversy over the best dosage.

The optimal dose of steroid remains unknown. Currently, there are two different doses that are used most often (20 mg and 40 mg). Triamcinolone acetonide is one of the common corticosteroid choices because of its long-acting effects and relatively low side effects. However, it should be noted that current practice is not based on scientific evidence, but rather, experience, cost, and availability of the drug.

You may be interested in a recent study from South Korea, surgeons from the Ajou University Medical Center propose that a high-dose corticosteroid would perform better than low dose in terms of reducing pain and restoring function. To test their hypothesis, they set up a randomized, triple-blind, placebo-controlled dose-comparative study. Triple blind means that no one (not the patient, not the person injecting the drug, and not the evaluator) knew who was getting what (drug, drug dose, placebo).

There were 53 total patients divided (randomly) into three groups: low-dose corticosteroid (20 mg triamcinolone acetonide), high-dose steroid (40 mg of the same drug), and placebo (saline injection). The two dosages selected were based on current practice by most physicians. Injections were guided using ultrasound for accurate placement of the drug or placebo. Everyone in all three groups was given a 10-minute follow-up exercise program to do three times daily for 12 weeks.

Outcome measures included pain level, range-of-motion, function, and level of disability. All patients were tested before treatment and again after treatment at regular intervals (one week, three weeks, six weeks, and 12 weeks after injection).

There is much concern about using high-dose corticosteroid drugs because of the potential for negative (adverse) effects. Other studies have shown that higher levels of steroid can cause complications and problems. For example, changes in skin coloration, tendon ruptures, nerve lesions, and loss (atrophy) of tissue have been reported. But too low of a dose might not provide the desired change in symptoms, so determining the optimal dose for this particular problem would be very helpful.

Everyone in the study mentioned got better. The two steroid groups had significantly more improvement than the placebo group. But there were no significant differences between the low- and high-dose patients in terms of pain, motion, and function. A few patients experienced some reactions to the drugs (e.g., facial flushing, dizziness) but no one had any infections, skin or soft tissue changes, or other adverse effects.

The authors concluded that a 20-mg dose of steroid injection given early on in the course of adhesive capsulitis is advised. This gives the same benefit as higher dose treatment but with lower risk for local and systemic side effects.

They further commented that this particular drug is a long-acting corticosteroid. Different results might be obtained if using a short-acting steroid. This is also a short-term study and results may change as time goes by. Further follow-up of these patients will be done and outcomes reported at a later date.

Reverse shoulder arthroplasty has become increasingly popular for shoulder replacement surgery when patients have a massive rotator cuff tear. The other procedure you mentioned (“hemiplasty”) is probably really hemiarthroplasty. Let’s take a look at what these two methods are and some comparative results from a recent study.

In the study we have in mind, results for severely damaged shoulders from massive rotator cuff tears using the reverse shoulder arthroplasty were compared with hemiarthroplasty. Now for a brief description of these two surgical approaches.

The “normal” artificial shoulder was designed to copy our real shoulder. The glenoid component (the socket) was designed to replace our normal shoulder socket with a thin, shallow plastic cup. The humeral head component was designed to replace the ball of the humerus with a metal ball that sits on top of the glenoid.

This situation has been compared to placing a ball on a shallow saucer. Without something to hold it in place, the metal ball simply slides around on the saucer. In the shoulder that “something” is the rotator cuff and the muscles that attach to the tendons. Without a rotator cuff to hold the metal ball centered in the plastic socket, the metal quickly wore out the plastic socket and the joint became painful once again.

The answer to this dilemma was to rethink the mechanics of the shoulder joint and design an artificial shoulder that worked differently than the real shoulder joint. The solution was to reverse the socket and the ball, placing the ball portion of the shoulder where the socket used to be and the socket where the ball or humeral head used to be.

This new design led to a much more stable shoulder joint that could function without a rotator cuff. The artificial joint itself provided more stability by creating a deeper socket that prevented the ball from sliding up and down as the shoulder was raised. The large deltoid muscle that covers the shoulder could be used to more effectively lift the arm, providing better function of the shoulder. The final goal is to have a shoulder that functions better, is less painful, and can last for years without loosening.

With the hemiarthroplasty operation only half of the hip is removed and replaced. (Hemi means half, and arthroplasty means joint replacement.) The hemiarthroplasty replaces only the ball portion of the shoulder joint, not the socket portion.

As this study showed, by comparing 102 patients who received the reverse shoulder arthroplasty with an equal number of patients who received a hemiarthroplasty, results could be compared equally. Items compared included differences in operating times, survivorship of the patient and/or the implant, and revision rates (i.e., second surgeries affecting the implants). In each group, half the patients were women and half were men.

Outcomes were first compared and reported six months after the first surgery. Everyone was followed for at least three years. Some patients were in the study for up to 11 years. They found that reverse shoulder arthroplasty did, indeed, provide better function and results were considered “superior” to that of the hemiarthroplasty.

Healing and recovery seemed to take longer in the hemiarthroplasty group. Younger patients in both groups had the worst function. And patients in the reverse shoulder group had higher rates of complications (e.g., dislocations, infections, ongoing pain, loosening of the socket).

Overall, the results support the use of reverse shoulder arthroplasty (over hemiarthroplasty) primarily for older patients with a degenerative shoulder joint and humeral head collapse from a massive rotator cuff tear. In fact, the authors suggest “use of the reverse shoulder arthroplasty should continue to be restricted to elderly patients.”

This information is just a stepping stone for you. Once you have met with your orthopedic surgeon and received his or her recommendations, they you will have a better idea of your options when making the final decision. We hope this additional information will help in the decision-making process.