FAQ Category: Shoulder

Avascular necrosis (AV) is the death of bone tissue from a loss of blood supply. In the shoulder, a break in the bone can disrupt blood flow to the head of the humerus (upper arm bone) causing AV.

Problems start to occur if the bone fails to heal and/or if there are several bone fragments that don’t heal. The head of the humerus may start to collapse. The shape of the humeral head may also be distorted.

Any change in the position or alignment of the bone can affect the final result. Even if the shoulder joint is replaced, imbalance of the soft tissues may still present problems.

Studies show that the position of the greater tuberosity is especially important. This is an outcropping of bone that forms a bump where tendons and ligaments attach.

Any distortion of the humeral head can cause the greater tuberosity to move further back or away from the humeral head. The end result can be very unsatisfactory when pain and loss of motion lead to loss of function.

Judging the effects of a delay in surgery can be difficult. Malunion, failed fracture healing, and distortion of the anatomy are far more important and predictive of the final result. Given the two-month coma and recovery before surgery, your options may have been very limited at the time.

If your upper arm (called the humerus) was broken, you may be at risk for some serious complications. Avascular necrosis (AV) is the biggest problem. This is a loss of blood supply to the head of the humerus. Without enough oxygen and nutrients, the bone starts to die.

A severe rotator cuff tear (RCT) may not be something that can be repaired. If there is severe damage to the joint surface along with a RCT, shoulder replacement may be the best choice.

Patients with poor fracture healing, soft tissue imbalances, and collapse of the humeral head may have a poor result. If the shape of the humeral head changes, further imbalances will occur.

The farther the greater tuberosity is from the humeral head, the worse the prognosis. The greater tuberosity is a bump on the bone where tendons and ligaments attach.

If the break doesn’t heal properly, a shift in the position of the greater tuberosity can result in loss of motion, pain, and poor patient satisfaction. It may be that a joint replacement is the best option for you. Ask your surgeon to explain your particular situation. Find out more about the reason for his or her advise to have a shoulder replacement.

The patient is usually placed in a sidelying position when the surgeon suspects a tear in the posterior labrum. Posterior refers to the back of the shoulder joint.

The labrum is a rim of dense, fibrous cartilage that is attached to the shoulder socket. The labrum helps form a deeper cavity for the head of the humerus (upper arm bone) to fit into.

Sometimes the labrum tears away from the bone and takes a piece of the bone with it. The surgeon must lift the labrum up, smooth the bone underneath, and then reattach the cartilage. Traction is needed in order to help the surgeon see inside the joint and access the damaged areas.

A special arm traction device is used. It places the arm in the position needed by the surgeon and holds it there during the operation. A small amount of weight (usually 10 pounds) is used. This is not enough to dislocate the shoulder. This technique is safe for the patient and effective for the surgeon.

It sounds like your daughter is going to have arthroscopic surgery. This means the surgeon uses a long, thin needle inserted through the skin into the joint. There’s a tiny TV camera on the end of the needle that projects a picture up on a screen for the surgeon to watch.

This enables the surgeon to see inside the joint. It helps him or her move the surgical tools needed to make the repair. The portals are the places where the needle is inserted. It’s important to find clear channels where the needle can slide into the joint without puncturing or damaging other tissues.

Where the surgeon inserts the scope depends on the suspected location of the tear. The first step in the repair process is to look inside the joint and find the tear. The surgeon examines the location and extent of the damage. This allows him or her to plan the next step in the repair process.

The scope must be inserted in a direction that allows the surgeon to see the opposite side of the joint. So, if the scope is inserted through an anterior approach (front of the shoulder), then the back or posterior portion of the joint can be seen.

Sometimes the surgeon uses one portal to identify the problem but a different portal to fix it. Again, this is based on the information gathered during the diagnostic exam. Some places are harder to reach than others. The surgeon must choose the portal that will give the best access to the damaged area without causing further damage getting there.

There are many reasons why rotator cuff repairs fail. Knowing the mode of failure helps the surgeon determine what should be done. Did the sutures fail to hold? Where did the failure occur (tendon, bone)?

Comparing the mode of failure with the type of repair is the next factor. Did the surgeon use the three-suture or the multi-suture method? And how much of a failure occurred?

Usually failure of the cuff repair is measured by the separation of the tendon repair site. A five-millimeter (or more) gap is a partial failure. More than a 10-millimiter gap at the repair site suggests a total failure.

Bone density is another key factor. Tunnels are drilled through the bone and the sutures threaded through the tunnels. The sutures can pull through the bone if the bone density isn’t strong enough or there isn’t enough bone mass.

At your next appointment with the surgeon, ask for a review of what happened. Find out what your options are and your surgeon’s recommendation. Your decision will be influenced in part by your age, activity level, and occupation.

The open rotator cuff repair has been the standard operation for many years. Long-term studies show it has an 85 to 95 per cent success rate. Patients experience pain relief and improved function.

At the same time, arthroscopic surgery has made it possible to do a mini-open rotator cuff repair. This procedure still provides good pain relief and even better functional results. Studies show 93 per cent improved function at mid-term follow-up.

Studies comparing the two methods still conclude that the open repair has the best long-term results. The success of the operation depends on three basic factors. These include the strength of the tendon-to-bone fixation, strength of the suture, and strength of the suture-to-tendon fixation.

Failure of fixation after the first rotator cuff repair occurs in 13 to 68 per cent of all cases. The wide variability in this failure rate is affected by these three factors. Results after re-repair aren’t very good. There’s only a 20 per cent chance of a good to excellent result.

Using the right sutures and suture placement is important in getting a fixation strength that’s equal to or greater than the force of the muscle pull. An open repair makes it possible for the surgeon to see everything more clearly and make the best repair for the damage present.

Massive rotator cuff tears are still largely done with the open method. Arthroscopic techniques are confined to small tears that can be repaired easily.

HAGL describes a humeral avulsion of the glenohumeral ligaments. Humeral refers to the humerus bone (the upper arm bone). Avulsion means the ligaments have torn away from the bone.

It is most common in young athletes injured while playing rugby, football, basketvall, or volleyball. This injury has also been reported while participating in activities such as diving, surfing, and skiing.

The glenohumeral ligaments are a group of four ligaments and two separate bands of tissue. Together, they hold the head of the humerus in the acetabulum, which shoulder is the shoulder socket.

Without these ligaments in place, the shoulder is unstable. It may repeatedly dislocate causing pain and discomfort. Depending on how much damage has been done, conservative care may be all that’s needed. More often, surgery is done to repair the damage and stabilize the shoulder.

With the proper treatment and follow-up rehab, many athletes are able to return to their sport. The key is accurate diagnosis and treatment to repair all parts that have been damaged.

Traumatic shoulder injuries can be very complex and difficult to diagnose. Yet without an accurate diagnosis, surgery can be incomplete. If there are unrecognized ligaments or cartilage torn, the patient may end up with continued painful symptoms even after surgery.

X-rays can show damage to the bone such as fractures or even bony avulsions. An avulsion means a small piece of the bone and whatever ligament or tendon it was attached to has pulled away from the main bone.

But an MRI is needed to show damage to soft tissue structures that might go undetected otherwise. Injecting a dye allows the surgeon to see if normal fluid in the joint has moved into areas where it shouldn’t be.

This is a sign that a ligament is torn. Based on the location of the tear, damage to specific ligaments can be identified. Changes in the normal shape of the soft tissues is also diagnostic of certain lesions.

For example, there is an overlap of tissue under the shoulder that allows the arm to move overhead smoothly. This is called the axillary pouch. Normally the axillary pouch is a U-shaped feature when seen on MRI. But when the inferior glenohumeral ligament is torn, this pouch becomes a J-shape.

The more information the surgeon can gather before operating, the better. A successful surgical procedure depends on reconstructing the shoulder by repairing all damaged tissue.

You’ll want to discuss this decision with your surgeon. He or she may have a preference based on training and experience and/or based on specific factors that only apply to you.

The Bankart repair is for a shoulder injury of the labrum. The labrum is a dense ring of fibrous cartilage that is attached to the acetabulum (socket) of the shoulder joint. It gives the socket a little more depth and stabilizes the head of the humerus (upper arm bone) in the joint.

Repeated shoulder dislocations in the forward direction cause the labrum to tear away from the acetabulum. Surgery is needed to shave any loose fragments and reattach the labrum. The operation can be done with an open incision, which involves cutting through the subscapularis tendon.

Open repair gives the surgeon a better view of the area but has the downside of causing damage to the soft tissues. Fibrosis and scarring can occur during the healing process. These factors can delay recovery.

The closed or arthroscopic method involves the insertion of a long, thin needle into the joint. A tiny TV camera on the end of the scope gives the surgeon a view inside the joint without opening it up.

There is a minimal scar (puncture size) and less risk of complications. Arthroscopic surgery is also shorter with less postoperative pain. And according to a recent study, muscle strength returns to normal sooner with arthroscopic surgery. So if you are an athlete or sports participant, this feature may be of some particular interest to you.

Your rehab and recovery may depend on the type of surgery you have. Some surgical procedures are more involved than others and require a longer period of immobilization before rehab can begin.

The operation can be done by one of two main methods: open versus closed. The open incision method is done arthroscopically and may cause weakness in the internal rotator muscle strength. The tendon of this muscle (the subscapularis muscle) is cut or dissected during an open repair. Scarring and shortening of the tendon after surgery can delay recovery.

Some studies show that open surgery to stabilize the shoulder can also lead to atrophy and fatty infiltration of the subscapularis muscle. The result can be muscle insufficiency and weakness.

A recent study comparing muscle strength after both open and closed operations showed that the long-term results aren’t any different. By the end of 12 months, patients in both groups had full return of shoulder motion and strength.

But patients who had the closed (arthroscopic) repair had a faster and better recovery in the short-term. By the end of six weeks, the arthroscopic group had 80 per cent of normal strength. By the end of three months, more than 90 per cent of normal strength had returned.

Not only that, but an aggressive rehab program can be started sooner for patients who have arthroscopic surgery. This may put you closer to your goal of returning to sports play sooner than later. You can expect at least a three- to four-month rehab period after surgery.

Fractures of the shoulder can be very slow to heal, especially in the older adult population. Sometimes it depends on the type of fracture. A single fracture line may heal faster than a comminuted fracture. Comminuted refers to the fact that the bone broke into many tiny pieces.

It’s often the case that other injuries occurred along with the fracture. Cartilage and soft tissues can be damaged as a result of such an impaction injury. And studies show that older patients take longer to heal than younger adults.

Supervised range of motion and other exercises are important in the recovery process after a shoulder fracture. Such a program may be needed long after the fracture heals.

But if pain persists beyond the expected time given the patient’s age and general health, then further testing may be needed. MRIs are useful to detect tears of the rotator cuff and labrum. The labrum is a thin but dense ring of fibrous cartilage. It’s firmly attached to the acetabulum (shoulder socket). It provides depth and stability to the joint.

Surgery may be needed to repair this type of soft tissue damage before the patient can regain motion and function. You may want to go with your father to his next follow-up appointment with the physician. He or she can explain the management plan. There may be reasons why your father is not a candidate for surgery. Or he may be right on schedule with rehab and doing well for his age and condition.

Sometimes shoulder fractures can be treated conservatively without surgery at all. But when this isn’t possible, then surgery to repair the damage may be needed.

As you know, the procedure may be open with a wide incision or closed using small openings for the arthroscope to enter the joint. There is no set standard for when to use each of these methods.

If the broken pieces of bone move, the fracture is <idisplaced. Amount of fracture displacement can dictate the type of treatment. Small fracture displacements may not require surgical repair. When surgery is done, open repair is still considered the standard approach.

Arthroscopic exam does allow the surgeon to see what kind of damage has been done to the soft tissue structures around the joint. It also helps avoid cutting through the deltoid muscle.

But if the X-ray shows a large fracture fragement, poor bone quality, or significant displacement, then arthroscopic repair is not the best option. Arthroscopic treatment also takes longer than an open repair. If the patient has any other health issues, arthroscopic repair may not be best for that individual.

Frozen shoulder is also known as adhesive capsulitis. It is a loss of shoulder motion due to tight soft tissues around the shoulder. A restricted joint capsule is also part of the problem. Pain and limited motion usually result in loss of function as well. Muscle weakness and atrophy then develop from disuse.

The actual cause and underlying pathology behind a frozen shoulder are still unknown. People with diabetes, heart disease, and rheumatoid arthritis are at increased risk for frozen shoulder syndrome. Trauma to the shoulder can also lead to adhesive capsulitis.

There are several theories to help explain this condition. Anything that changes the way the shoulder moves and results in impaired shoulder movements can lead to shoulder capsule adhesions.

Adhesions are little areas of scar tissue that bind two areas of tissue together. When there are adhesions, the joint capsule doesn’t move smoothly. Then the soft tissues around the joint start to contract and tighten up.

A cycle of pain-spasm-loss of motion-pain can develop. This keeps the individual from regaining lost motion. In addition, there is an area of extra capsular material called the capsular redundancy or axillary recess that gets stuck.

This part of the capsule is at the bottom of the shoulder joint. As the arm moves up overhead, the capsule unfolds to allow smooth gliding action. When adhesions develop within this fold, the capsule can no longer unfold and motion stops.

Again, no one is sure which comes first: loss of capsular motion and unfolding or impaired shoulder motion. Treatment for the frozen shoulder syndrome focuses on restoring both.

The shoulder is a common site for injection. A combination of lidocaine (a numbing agent) and a corticosteroid drug (anti-inflammatory) are used. Your doctor will determine the exact location to place the injection.

There are three areas in the shoulder that can be injected. The first is the glenohumeral (GH) joint. The second is the acromioclavicular (AC) joint. The third is the subacromial space.

The area injected depends on the location of your pain. Bursitis is one of several possible causes of shoulder pain that can be helped with an injection. With careful technique, the injection can pinpoint the exact problem spot. Painful symptoms are reduced or eliminated. Motion and function can be restored.

There are a few possible side effects from this type of treatment. You may not get the pain relief you want if the injection doesn’t go exactly where it’s needed.

Sometimes the steroid drug can cause changes in the skin or tissue in the area of the injection. This is more likely in patients who have had a series of injections but it can happen after only one injection.

In general, injection of a numbing agent and steroid for shoulder bursitis is a safe and effective way to treat a chronic problem.

Bursitis is an infection, irritation, or inflammation of a bursa. The bursa is a small fluid-filled sac or cushion. There are many bursae throughout the body. They are found where a muscle or tendon slides across bone.

Bursae decrease friction between two moving surfaces. With aging, they can become paper thin. Then they no longer provide the necessary cushion. When the two body parts start to rub together, bursitis can occur. Sometimes repetitive motion causes the bursae to become inflamed.

The shoulder is a very complex joint with many moving parts, ligaments, tendons, and muscles. There is a fairly large bursa between the rotator cuff and the head of the humerus (upper arm bone). The rotator cuff is a group of four muscles and tendons that surround the shoulder joint.

An orthopedic surgeon can help diagnose the problem. A careful history and examination may pinpoint the exact cause of your painful symptoms. There is treatment available for bursitis, if that’s what’s causing your pain.

The only way to be sure that your injury is a rotator cuff injury is to have it diagnosed by your doctor. To do this, you may have x-rays, an ultrasound or an MRI (magnetic resonance imaging) that allows the doctor to see the soft tissue and any damage.

Another test, called an arthrogram may be done. This is also an x-ray, but dye is injected into the shoulder first so that the joint can be seen more clearly.

Pain in your shoulder can be a few different things, including a torn rotator cuff. Only your doctor can tell you for sure if you do have tears in the tendons.

Signs and symptoms of a torn rotator cuff include:

Pain, particularly when you try to do every day activities such as putting your jacket or sweater on or reaching up

Aching or discomfort if you try to lie on the affected side to sleep

Difficulty reaching behind your back

Not being able to move your arm the full range that your shoulder should normally allow

If you do have a torn rotator cuff, you should have this verified by your doctor. Some tears should be repaired by surgery. Minor tears and some larger ones can be managed without surgery but you should do this with your doctor’s help to prevent further injury.

Some ways of helping a painful shoulder that your doctor may recommend are:

Alternate periods of ice and heat to reduce swelling inside the shoulder and to relax the muscles

Non-steroidal anti-inflammatory medications such as aspirin or ibuprofen to relieve the pain and reduce swelling

Keep your shoulder still; this could mean using a sling, or just being very careful

Don’t lift or stretch over your head

After a few days, exercising your shoulder with special exercises to strengthen it, keep it limber, and to prevent further injury

Although surgery may seem like a quick fix, many people with rotator cuff injuries are treated with physiotherapy and exercise. Surgery is only used if the injury doesn’t seem to be healing. Because it can take a while for the injury to heal, your doctor has to wait to decide if you should have further treatment or not.

Besides exercise, some doctors use steroid injections into the shoulder to help relieve swelling and pain.

Many patients find out after the fact that more than one tendon was affected by the initial trauma or injury. Studies report more than half who injure the subscapularis also hurt the biceps tendon. The biceps is the muscle that bends the elbow. It is definitely the prime mover when doing bicep curls.

The report you gave is common when the biceps is damaged. Soreness, spasm, and sometimes the Popeye sign are present. The Popeye Sign refers to a bulge in the biceps caused by the muscle retracting after it tears.

If that is the cause of the problems you’re having, then rehab and strength training may not be helpful. You may need an additional surgery to repair the biceps tendon.

A follow-up appointment with your surgeon might be a good idea. X-rays, MRIs, and/or ultrasound studies will help give a better idea of what’s going on.