FAQ Category: Shoulder

Estimates of periprosthetic humerus fractures range from less than one per cent up to three per cent. Most of these breaks occur right during the shoulder replacement surgery. In fact, they account for about 20 per cent of all problems that do occur.

As stated in your patient education materials, studies show that the rate of humeral (upper arm bone) nonunion is higher when the patient has a prosthesis (implant). A fracture of the upper arm (humeral shaft) by itself is a lot simpler than one with an implant down inside the bone.

Anytime the patient tries to move the shoulder or elbow, the force that’s transmitted goes right through the fracture site. That disrupts the end of the bones and the blood flow to both sides. The result is a delay in fracture healing.

At the same time, the tip of the implant down inside the humeral shaft may cause the two ends of the bone to shift apart even further whenever the arm is moved. This distractive force must be limited in order to facilitate healing. If every time the body tries to lay down new bone material to cross the gap the two ends of the bone move, then healing is disrupted and the fracture site won’t heal.

Anyone who is in poor health, has poor nutrition, or has diabetes or other serious health concerns is at risk for these kinds of complications. Talk to the surgeon if your mother-in-law has any of the risk factors discussed.

There are specific steps the surgeon can take during the procedure to ensure safety of the bone and prevent fracture. Even so, a fracture can occur despite all precautions. That’s why the surgical team warns patients ahead of time to prepare you for any and all possibilities.

There are many possible reasons why a bone fracture occurs intraoperatively. Sometimes it’s completely unavoidable. There are some known risk factors such as decreased bone mass (osteopenia or osteoporosis). Shoulder instability from a previous rotator cuff tear can make a difference.

Fractures of this type occur most often during a total shoulder replacement (versus a hemiarthroplasty where only one side of the shoulder joint is removed and replaced). Sometimes the surgeon has trouble getting to the shoulder socket. The angle and force needed may be too much for the brittle bones.

Older women seem to be at increased risk for humeral (upper arm) fractures. They are especially at risk if they also have rheumatoid arthritis or other health issues such as diabetes contributing to delayed or poor healing.

Surgeons must be aware of potential risk factors for fracture. Surgical approach and techniques must be chosen carefully with these risks in mind. Patient position during the operation is important. The elbow should never be used as a lever to get increased shoulder motion when under anesthesia.

Soft tissue release around the shoulder may be needed before moving the arm through its full range of motion. Special care must be taken when reaming out the humeral bone to place the stem of the implant inside. Hand reaming instead of power reaming is advised. The bone should be compressed, rather than removed, in patients who have low bone density.

These are just a few of the many considerations surgeons must include in the surgical process. When many risk factors present at the same time, then the risk of fracture goes up. Even being aware of all the risks doesn’t guarantee complications won’t occur. The surgeon can’t always predict who might develop intraoperative fractures.

Shoulder pain is a common problem among athletes of all kinds. Cheerleaders are athletes in every sense of the word. They use wide arcs of motion in their arms, which can cause a variety of problems.

Some possible causes of posterior shoulder pain in this type of athlete include tendinitis (inflammation of the tendon) or tendinosis (degeneration of the tendon without inflammation). Rotator cuff or labral (cartilage) tears are also possible.

We assume these possibilities have been ruled out but it’s always good to ask. One other less common cause of posterior shoulder pain is the quadrilateral space syndrome (QSS). QSS is easily overlooked in athletes but can severely limit overhead function.

The underlying problem in QSS is a compression or pinching of the axillary nerve as it exits the back of the shoulder. Quadrilateral refers to the four-sided shape of the anatomy (both muscles and bone) where the nerve is located.

QSS can best be diagnosed using an axillary nerve block. A numbing agent such as lidocaine is injected into the area. If the painful symptoms go away after the injection, the test is considered positive.

Sometimes the injection is enough to treat the problem. In other cases, surgery is needed. Most often, a course of physical therapy is tried first to avoid surgery. The therapist may be able to reduce pressure on the nerve and help it glide freely through the soft tissues. Manual therapy including nerve mobilization techniques is used.

Quadrilateral space syndrome is a rare but potentially disabling condition affecting overhead athletes most often. Swimmers, pitchers, and gymnasts are at risk for QSS. Evidently, so are javelin throwers.

In QSS, fibrous adhesions form around one of the nerves in the shoulder. The specific nerve affected is the axillary nerve. This nerve comes off a group of nerves in the neck and shoulder called the brachial plexus. The axillary nerve branches off right at the armpit.

Then it travels through the quadrangular space with an artery and vein in the same area. The quadrilateral space is formed by muscles on the top and bottom and along the inside of the space. The outer edge of this space is formed by the neck of the humerus (upper arm bone).

When adhesions form around a nerve, the nerve can no longer slide and glide inside its tunnel during movement. The scar tissue pulls, pinches, and compresses the nerve. Pain occurs at rest and is made worse with overhead movements.

There is treatment for this problem. A physical therapist can help break up the adhesions and restore the natural movement of the nerve inside its sheath (outer covering). This can be done in one to four sessions for most patients.

If this treatment doesn’t work, then surgery may be needed. The surgeon moves the muscles away from the nerve and then releases the adhesions from along the entire length of the nerve. Care is needed to avoid damaging the nerve or nearby blood vessels.

With successful treatment, overhead athletes can return to full participation in their chosen sports activity.

Massive rotator cuff tears from injury or trauma usually require reconstructive surgery. Without it, the shoulder can become painful and very unstable. But there are some patients who seem to be able to rehab and strengthen their shoulder without surgery.

Good-to-excellent shoulder function is possible when other muscles within the shoulder complex are trained to maintain proper balance. For example, the deltoid muscle (along the outside of the arm) lifts the arm away from the body. Without the rotator cuff, contraction of the unopposed deltoid muscle causes the humerus (upper arm bone) to glide up into the shoulder socket.

This type of upward glide called superior translation can cause pinching of the soft tissue structures in the shoulder. The result can be an impingement syndrome. But the remaining muscles and tendons of the rotator cuff that weren’t damaged can be strengthened and trained to overcome this problem.

Studies show that large and massive tears that are repaired often tear again. The recurrent tear may not be a complete rupture, so there is some stability remaining from the first repair. In such cases, patients can maintain excellent shoulder function. And if you don’t stress the soft tissues with repetitive overloading, surgical repair may not be necessary the second time.

Some rotator cuff tears can be treated conservatively with rehab. But these are usually not in athletes who are using the arm repetitively and with increased loads.

If you are not an overhead-throwing athlete, then surgery may not be needed. It is possible to strengthen the other muscles of the shoulder. The goal is to keep the overall balance in all motions. If the pull of the muscles is stronger in one direction or at a certain angle, then motion may be limited and/or painful. Keeping the overall balance in motion assures there will be normal, pain free movement.

Normal shoulder function depends on an intact rotator cuff, rotator cuff muscle force, and the force or strength of the deltoid muscle. When the deltoid contracts, the arm moves away from the body in a motion called abduction.

If there’s a tear in the rotator cuff, an imbalance occurs. If the deltoid contracts without the counterbalancing contraction of the rotator cuff, the upper arm glides upward into the shoulder socket. This is called superior translation. The result of this abnormal motion can be a painful impingement syndrome.

Studies show that the uneven forces around the shoulder after a rotator cuff tear can actually lead to further damage to the rotator cuff. Early surgery to repair the tear can keep this from happening. The decision whether or not to do surgery depends on your age, level of activity, and type and size of tear.

You may have had what experts refer to as a corticosteroid flare. In a small number of patients, the body reacts negatively to the injection. Local irritation in the form of pain and/or a skin rash occurs.

This response occurs within the first eight to 24 hours after injection. The benefits of the injection (pain relief and reduced inflammation) are usually still experienced.

No one is sure just why this reaction occurs. It may be an immune reaction to the preservative in the product. Or it may be a response to the corticosteroid. Some experts have suggested needle penetration into nerve endings may be the cause. Others say that if this were the cause, then more patients would have the flare reaction.

When corticosteroid flare occurs, ice can be applied to the injection site. Your doctor may prescribe anti-inflammatory medications and analgesics (pain relievers). Analgesics used for this problem may include narcotic medications.

Physical therapy may be helpful when there is a subacromial (SA) bursitis or impingement syndrome. SA bursitis is a condition caused by inflammation of the bursa. The SA bursa is a small, fluid-filled sac that forms a cushion between bones and tendons or between muscles and joints.

SA impingement or pinching of the bursa and tendon occurs when the arm is raised up overhead. The supraspinatus tendon of the shoulder and its bursa get pinched between the head of the humerus and the end of the clavicle (collarbone). The bursa is the area where the steroid injection is directed.

Once the inflammation is under control, the therapist will help you learn how to move your arm properly. The goal is to avoid pushing the supraspinatus tendon up against the acromion (end of the clavicle). In some cases, this condition occurs because of injury or weakness to the supraspinatus. This tendon is part of the shoulder rotator cuff.

In other cases, weakness or imbalance of the scapula (shoulder blade) contributes to the problem. This is called scapular dyskinesia. The scapula and shoulder move together in a smooth and rhythmical way. When this is disrupted by scapular dyskinesia, then shoulder impingement can occur. The therapist will guide you in getting back your normal scapular position and motion.

If the shoulder is unstable, physical therapy is aimed at improving the function of the muscles that provide dynamic shoulder stabilization. A strengthening program to restore normal movement patterns may be needed.

You may have seen a supportive sling with an abduction pillow. The bolster or pillow keeps the arm away from the body. This direction of motion or positioning is called abduction. The abduction sling is used most often after surgery for a rotator cuff tear (RCT) with a superior labrum anterior and posterior (SLAP).

The rotator cuff is a group of four tendons that surround the shoulder like a sleeve. The tendons and the muscles attached support, stabilize, and move the arm in the shoulder socket. A SLAP lesion is a tear of the labrum. The labrum is a rim of cartilage around the shoulder socket. It gives the shallow socket more depth for stabilizing the head of the humerus (upper arm bone) in the glenoid fossa (socket).

There are certain movements which must be avoided after this type of shoulder reconstruction. The abduction splint helps keep the arm in the correct position until healing takes place. Moving the arm across the body or overhead isn’t allowed for six weeks. Performing these movements too soon could damage the repair.

Rotator cuff tears can be partial or full-thickness lesions. Suture anchors are used in the repair. These stitches have a sliding, self-locking knot that permits surgeon to perform secure repair procedure without tying knots on top of tissue. The suture anchor makes it possible to reattach torn tissue without interfering with joint motion. The number of suture anchors used depends on the size, shape, and location of the tear. And the type of technique used to repair the damage can also make a difference.

Some tears are crescent-shaped while others are L- or U-shaped. There can be more than one tendon involved requiring more sutures. The surgeon usually uses between one and four anchors to repair a rotator cuff tear. An equal number of sutures may be needed when there is an additional tear of the labrum. The labrum is a fibrocartilage ridge around the shoulder socket. It can tear from front-to-back requiring an extra surgical step to reconstruct the shoulder.

If you have concerns or doubts about the stability of your son’s shoulder, ask the surgeon more about it at the next follow-up appointment. After the procedure, there is a strict protocol to follow. The patient must avoid overhead motion or internal rotation such as reaching the hand across the chest.

A rehab program under the supervision of a physical therapist is started around six weeks and continues for up to six months. Full function is restored six to 10 months after surgery.

The most definitive test is an arthroscopic exam. The doctor inserts a long, thin needle into the area with a tiny TV camera on the end. The camera transmits a live video picture of the structures to a monitor. The surgeon can then repair the damage at the same time.

Before surgery (or if surgery isn’t done), there are some clinical tests that can be done to help diagnose this problem. Unfortunately, there isn’t one single test that can tell for sure when there is a labral tear. Recently, a study from Korea tested 10 different tests used to examine the shoulder.

They found that combining a couple tests together helped improve the chances of identifying a labral tear. They were able to specifically find which tests work well together and report them. Physicians, physical therapists, and athletic trainers use these tests routinely.

It’s likely that your surgeon used some of these tests along with your history and symptoms to make the tentative diagnosis. You may not need any further testing if you aren’t planning to have surgery. A rehab program can be prescribed on a trial basis. If you don’t see any improvements and you want to consider have a shoulder reconstruction, then further testing may be needed.

SLAP stands for superior labrum anterior and posterior lesion. It refers to a long tear of the cartilage around the shoulder socket. It extends from the front to the back. Type II tells us that the long head of the biceps tendon is also torn along with the labrum.

Overhead athletes are most likely to injure themselves as a result of major trauma. It is possible to tear the labrum without an injury. The early symptoms include pain along the back of the shoulder that gets worse with certain positions or movements. Some patients report a click without pain during movement.

The physician examining a patient with a type II SLAP lesion will usually palpate tenderness, tension, and/or pain over the biceps tendon. Special tests can be done that reproduce the painful symptoms of this condition. They do so by compressing or pinching the torn labrum and nearby soft tissues.

Other SLAP injuries have different symptoms and clinical presentations. The key difference with the type II is the detached biceps tendon.

Shoulder arthroplasties, or replacements, have a good success rate. The average results are that 87 percent of patients still have their original shoulder replacements after 15 years.

It isn’t always possible to predict who will do well following a replacement surgery and who will not. The strength of the bones and the muscles around the joint plays a role in the healing process and if the replacement will hold. However, sometimes there are unforeseen events, such as an infection in the joint or hardware breakdown.

When a shoulder has deteriorated so badly that surgery is needed, a replacement is most often the preferred surgery. However, not everyone can have a shoulder replacement for a variety of reasons. If, for example, the bones aren’t strong enough, the replacement can’t be held in place.

Shoulder fusions are usually the last choice surgery. It is chosen because the surgeon feels that he or she doesn’t have enough to work with to install a replacement.

One of the main advantages to humeral resurfacing arthroplasty is the fact that bone is saved and a total shoulder replacement (TSR) is still possible later, if needed.

Shoulder resurfacing smooths the diseased bone and covers it with a metal cap. The head of the humerus (upper arm bone), surface of the acetabulum (shoulder socket), or both may be involved with a resurfacing procedure.

But if this procedure fails for any reason, then the patient can have a revision surgery to remove the bone and replace it with a TSR. Infection leading to loosening of the implant is the most common reason to remove and replace the joint resurfacing.

But if your implant wasn’t loose at the time of the revision operation, then something else may have been causing your painful symptoms. There isn’t always a way to know for sure what this might have been. It could be there was an alignment problem with the joint resurfacing implant.

Or the shape of the humeral or the acetabulum may have been slightly off-center leading to mechanical problems. Sometimes cystic changes and capsular thickening occur within the joint leading to problems.

Last, but not least, microscopic neurovascular damage at the time of the first procedure could have lead to chronic pain. This may or may not improve with revision surgery.

Joint resurfacing has become an increasingly popular treatment alternative to a total shoulder replacement (TSR). Today, athletes continue to train and participate in sports well past their 20s. Severe arthritis of the hip, knee, or shoulder can lead to a decline in play.

Joint resurfacing of the hip and shoulder are now possible. Instead of replacing the entire joint, the surface is smoothed and a metal cap put over it. This makes it possible for the athlete to continue playing. A TSR can be done later if there are problems with the resurfacing.

TSRs don’t last a lifetime, so the joint resurfacing procedure buys some time and helps maintain function in the process. But it’s not clear how long the joint resurfacing implant will last or what level of activity it can handle.

There are no specific activity dos and don’ts for patients or athletes with shoulder joint resurfacing. So far, studies do not show any problems with implant loosening or joint surface wear and tear in the short-term (one to two years). No one knows yet just how the implants hold up over the long haul.

Most surgeons advise their patients with joint resurfacing to avoid contact or collision sports. The concern is for bone fracture around the implant. Many patients automatically reduce their activity level for fear of implant failure.

Until more information is available, each athlete must make his or her own decisions with guidance from the surgeon. Overall health, strength, conditioning, and type of sport may be factors to consider. Regular follow-up with X-ray exam is recommended until further guidelines are published.

Making the proper diagnosis is key. They are frequently overlooked. Ninety percent of the time, conservative treatment rather than surgery is adequate. Conservative treatment includes ice initially, then the use of heat. Immobilization for three to four weeks is usually necessary. Physical therapy for strengthening of the muscles around the shoulder blade is often prescribed. Repeat imaging such as computed tomography is used to monitor the healing progress of the fracture.

In a healthy individual, it usually takes six to eight weeks. There is good blood supply to the shoulder blade which probably helps with the healing prognosis. However, tobacco use, other health problems such as diabetes or poor nutrition may delay healing of the fracture.

The best treatment for traumatic shoulder injuries can be difficult to determine for each patient. History, clinical exam, and imaging studies help guide the surgeon.

When there is minimal soft tissue damage, conservative care may be all that’s needed. Rehab can be effective in returning players to their chosen sports. But if there is damage to the cartilage around the shoulder socket, then the risk of dislocating it again goes up.

More serious injuries such as Bankart lesions often require surgery. The labrum, a fibrous ring of cartilage attached to the bone, tears away from the bone with a bone fragment attached. Without the labrum, the depth and stability of the shoulder socket is altered. Chronic dislocation can occur.

Arthroscopic surgery to repair a Bankart lesion is possible now. The operation is much less invasive and the recovery time is shorter. Players can resume noncontact sports four to six months after the procedure. Contact sports may require a longer time to rehab.

Many people dislocate the shoulder one time and seem to recover just fine. But there are others who end up with a chronically dislocating joint. There are a variety of factors that may contribute to this.

Some people are born with greater laxity or looseness of their soft tissues and joints. If they don’t build up the muscles around the joint, they may be at a slightly greater risk of dislocation than someone with more tightly woven soft tissue fibers.

Certain movements may lead to a second dislocation. For example, if the shoulder dislocated anteriorly (forward), then hyperextension combined with abduction and external rotation can pop it out again. This would be the position volleyball or tennis players use to serve the ball.

If the labrum was torn during the first injury, the risk of redislocation goes up. The labrum is the dense fibrocartilage ring that is firmly attached to the shoulder socket.

The labrum provides depth and stability to the joint. Without an intact labrum, the head of the humerus (upper arm bone) can slip out of the socket. Changes in other soft tissues around the shoulder can also contribute to multiple dislocations. And the more times the shoulder dislocates, the greater the damage to the bone, capsule, and ligaments.