FAQ Category: Shoulder

If you haven’t already seen either your primary care physician or an orthopedic surgeon, that might be your first step. A clinical exam and some imaging tests (X-rays, MRI) will probably help identify the problem.

A traumatic injury through the elbow to the shoulder can cause damage to a number of different structures in the arm. The doctor will make sure there isn’t a fracture that hasn’t healed. The muscles, ligaments, and shoulder capsule will need to be examined.

The most common shoulder injury from this type of fall is a rotator cuff tear. Painful and weak motion suggests a major tear in one or more of the four muscles of the rotator cuff. Painless and weak is more typical when the tendon has ruptured completely.

The rotator cuff covers the shoulder and helps stabilize the head of the humerus (upper arm) in the shoulder joint. Sometimes other injuries accompany a rotator cuff tear. This is impossible to tell without further testing.

Sometimes a specific rehab program can give good results. But in some cases, surgery is needed. Again, a medical exam is needed to know for sure the cause of your symptoms and the best course of action.

It’s true a dislocated shoulder can dislocate again. But it’s also true that many people who’ve had a shoulder dislocation recover fully. They never dislocate again. Unfortunately, we don’t have any way to predict who might need surgery and who can get along without it.

A recent study from the California Permanente Medical Group confirms this fact. They studied 131 adults from age 18 to 82 who had a first-time shoulder dislocation. Looking back over five years of data collected on this group did not offer any conclusive predictive factors.

Younger patients involved in contact or collision sports were more likely to dislocate the shoulder a second time. Likewise, younger patients whose jobs required lifting the arms overhead were at greater risk of re-dislocation. But not everyone in this group did suffer a second dislocation.

Why did some dislocate again and others didn’t? We don’t know. Analysis of all the data collected never identified any specific factors to predict the outcome. That being the case, the authors of the study did not see a need to push for surgery early on.

The need for immediate surgery after a first shoulder dislocation is not predictable. Many patients opt to wear a sling for a week or so. Then they start to gradually work on getting their motion and strength back. Sometimes people don’t even bother with the sling.

Each patient must make his or her own decision about whether or not to have surgery. Is it their dominant arm? That’s important because in older adults, a shoulder dislocation can set them back in terms of function. Was the doctor able to put the shoulder back in place easily? If so, that would suggest minimal additional trauma to the soft tissues around the joint.

Was an X-ray, CT scan, or MRI done to show any damage done to the area? A torn rotator cuff or fractured bone might swing the decision more toward surgical intervention sooner than later.

A study to show the natural history of a first-time shoulder dislocation in people of all ages and occupations has been done. Natural history refers to what happens (final outcome) if the person is followed over a period of years. They reported that not all people needed surgery.

Those who had a rotator cuff repair did not dislocate again. Many patients who didn’t have surgery recovered fully. After five years, their shoulder was as stable as those who did have the repair operation.

The results of studies like these help us all realize that everyone is different. It’s not always possible to predict the best course of action. Sometimes, after looking everything over, it’s clear what to do. In other cases, doctors encourage their patients to take the conservative route. They advise patients to try rehab first, because they can always have the surgery later if that seems best.

The diagnosis of thoracic outlet syndrome (TOS) is usually made based on the history and special tests conducted by the doctor. You may remember some of these tests.

They are called provocative tests because they put your body in a position to stretch or compress the neurovascular bundle (nerves and blood vessels). The result is a reproduction of your symptoms.

You may have turned your head toward the painful side while the doctor took your pulse. The test is positive for TOS if your pulse disappeared after you turned your head. Another test is to raise your arms overhead for three minutes while opening and closing your hands. This test is positive for TOS if your symptoms start or get worse.

An X-ray might be helpful. It can show if there are any anatomic changes such as an extra rib or bony projections that are longer than normal causing problems. Anything that can put pressure on the blood vessels or the nerves can contribute to TOS.

MRIs are actually a good tool. They can show all of the anatomic changes in both the bones and soft tissues. For example, fibrous bands of tissue across the nerves often present at birth have been identified as part of the problem.

But you may not really need an MRI. Studies show that the clinical provocative tests are good indicators that TOS is the source of your symptoms. And the treatment is diagnostic because if your symptoms go away after treatment, you know it was TOS.

It’s nice to know the particulars behind the problem. Knowing there are fibrous bands of tissue or cervical ribs can help the physical therapist treating you. But the tests are expensive and the provocative tests may be enough to make the diagnosis.

Thoracic outlet syndrome (TOS) involves the neurovascular bundle of the neck and arms. Specifically, there is the brachial plexus (group of nerves) and the blood vessels. Symptoms occur when there is pressure on either of these structures as they pass from the neck down the arms.

Symptoms include neck, arm, and hand pain. Many people are awakened at night with hand numbness and tingling. In the morning, their hands are stiff and swollen. The symptoms are often brought on or made worse by working with the arms overhead.

This occurs for several reasons. The upward rotation and outward motion of the shoulder blade causes the pectoralis minor muscle to clamp down on the subclavian artery and brachial plexus just under the collarbone where the collarbone and shoulder joint meet.

Sometimes there are congenital fibrous bands that also put pressure on the neurovascular bundle. Congenital means it’s something you were born with. And in some people, there is an extra rib that can also apply pressure to these structures.

There is successful treatment possible for many patients. A physical therapist can help change the person’s posture enough to take pressure off these areas. The therapist can help manually stretch the muscles and any fibrous bands that might be involved. And the patient can be taught specific stretching exercises to lengthen the muscles as they cross over critical structures.

In rare cases, surgery can be done to remove the extra rib or release the fibrous bands compressing the neurovascular bundle.

The type of procedure you’ve just described is called a distal clavicle resection. Clavicle refers to the collar bone. Resection means to remove something. Distal describes which end was taken out.

In a normal, uninjured AC joint, the clavicle connects smoothly and evenly with the acromion. The acromion is the piece of bone from the shoulder blade that curves over the shoulder. When this joint is injured, it can separate creating an AC joint separation.

There are various degrees of separation labeled from one (I) to four (IV). Unless it’s a type IV injury, most types are treated with conservative (nonoperative) care. Whenever surgery is done, the standard operating procedure is to remove the distal clavicle.

This step helps reduce pain and loss of function. Without good reduction (putting the clavicle back in place), the clavicle gets trapped by the muscle causing chronic pain. In some cases, removing the distal clavicle is preventative to avoid the risk of chronic pain that can occur if it’s not taken out.

Most AC joint separations can be treated nonoperatively. Surgery doesn’t restore the joint. It puts all the parts back together to help prevent pain and loss of function. Surgical repair is reserved for patients with painful problems that don’t get better with conservative care.

For the overhead athlete, reconstruction makes the most sense if the problem occurs toward the end of the season. This gives you a jump start on rehab and recovery before the next season begins. Without surgical repair, you may miss an entire season.

It’s not clear yet if surgery done sooner than later has a better outcome. The best type of operation is still being studied. In a recent review article, three types of surgical methods were described. But the authors point out that studies have not been done to compare which one works best.

For now, when surgery is needed, the tear is usually repaired with a piece of ligament taken from between the clavicle and the coracoid process. The coracoid process is a bony projection coming off the shoulder blade. This operation is called a Weaver-Dunn reconstruction.

Other methods of repair involve transferring a piece of tendon from somewhere else in the body. It can be looped around the two bones to hold them together. Or the surgeon can drill a hole through the bone to create a tunnel. The donor tissue is looped through the tunnel and tied down.

Once your shoulder is examined, the surgeon can advise you as to the best course of action. With conservative care, you may be back to play after only six to eight weeks of rehab. This could take longer after surgery.

Of course, the best thing to do is to discuss this with your own doctor, but there are some general things that you can expect.

Your shoulder is made of a socket and ball, as well as muscles, tendons, and ligaments that hold it all together. The ball part in the replacement is generally made of metal. This is attached to your humerus either with a straight fit or with bone cement. This ball fits into the socket, which is called the glenoid component.

After the surgery, you will likely have to use a sling to keep the weight of your arm from pulling on the shoulder. A physiotherapist will show you how to strengthen your arm and shoulder and your doctor will tell you when you can stop using your sling. It is very important that you follow the instructions closely to increase the chance of a successful surgery.

Knee and hip replacements are much more common because we bear weight on these joints all the time and they can wear out after a while. However, shoulder replacements aren’t rare. Because the shoulder is a ball and socket type of joint, the shoulder is anchored down with muscles, tendons, and ligaments. They must all stay healthy for the shoulder to move around and give you enough strength to lift things.

Some people develop problems with their shoulders because of repetition over the years or through over use, as with ball players. Other problems, like arthritis or trauma to the shoulder can cause deterioration, leading to the need for a replacement.

The rotator cuff is a group of muscles and tendons that surround and stabilize the shoulder. Injury or rupture to any one of those tendons constitutes a rotator cuff tear (RCT).

Surgeons agree that RCT repairs can be difficult. It’s especially hard to predict who is going to need what kind of surgery or what the result will be. Some of the decision is based on the location of the tear. If it’s close to the edge of the shoulder socket, there can be difficulties. Or if the tear is too long or too wide, a different decision may be made compared to smaller, thinner tears.

The surgeon must carefully balance all the muscles around the shoulder to get the best result. They can only do this in the operating room once it’s clear where and what is the problem.

The surgeon may have given your daughter more information than she remembers or is remembering to tell you. If you are planning to go with your daughter on the day of surgery, you’ll have a chance to talk with the surgeon then. Plan ahead and ask one or two of your most important questions at that time.

Or perhaps if you ask your daughter a few carefully chosen questions now, it will help her see the importance of asking more about her own surgery. On the other hand, some people prefer to let the surgeon take care of the problem without knowing the details.

Your surgeon will probably review the report with you and give you more specific and accurate details. A massive tear of the rotator cuff tendons around the shoulder usually means there are at least two tendons torn. And the tears are significant in size (length and/or width).

There are many ways to treat a rotator cuff tear (RCT). The surgeon may form a preliminary decision based on your clinical exam and the results of MRIs. Once inside the shoulder, then the location, shape, and size of the tear guide what type of surgery is needed.

Small tears can be treated with debridement. The surgeon removes any frayed edges or free floating pieces that may have torn off completely. The edges are smoothed down in hopes that they will reattach or re-adhere to an area close by. This type of procedure is called debridement.

For larger tears, a partial or complete repair is done. The joint capsule and some of the ligaments around the joint may be cut or released. This allows the surgeon to rebalance the shoulder where it belongs. Mobility is improved and tested in the operating room. Then the surgeon uses sutures to hold it in place until everything heals again.

It’s likely you’ll be seeing a physical therapist for instructions and a rehab program. The exercises and timing of the program are determined by the type of tear and repair you have done. You can expect a three month period of rehab. This will be followed by some life-long activities and exercises needed to keep a healthy shoulder.

Shoulder impingement is a condition involving the entire shoulder complex. Some experts even say it starts from the ground up. It occurs when soft tissue structures get pinched as the arm is raised up over head or rotated. It is usually a sign that something is not quite right in the shoulder.

Many people have avoided surgery for a shoulder impingement problem. The first step is a proper examination. A sports medicine specialist (physician or physical therapist) can help you with this.

Understanding the anatomy, biomechanics, and kinetics of normal motion is essential in identifying what’s wrong. Movement of the shoulder (including the scapula or shoulder blade) must be examined. Past injuries and any residual effects must be taken into account.The examiner will look for muscle weakness, imbalance, or contracture (shortening).

Once the problem and its origin are identified, then an appropriate treatment program can be established. Exercises to improve motion and strength may be prescribed. Sleeper stretches are often used to improve stiffness and tightness in the posterior shoulder.

Sleeper stretches are done lying on the affected side. The elbow is bent and the arm is forward at shoulder level. If you are on your right side, place your left hand on top of the right hand and gently guide the forearm down toward the floor. This exercise should also be done with the arm above and below shoulder height.

Depending on what the examiner finds, you may be given other stretches or exercises to do. A concerted effort over four to six weeks should bring relief from your symptoms. If you are still having significant locking or catching of the shoulder during movement, then surgery may be needed.

Arthro refers to the joint. Path lets us know there is some pathology or damage done. In the case of rotator cuff tear (RCT) arthropathy, there has been some wear and tear on the joint because of the RCT instability.

When the four muscles of the rotator cuff function normally, they hold the head of the humerus inside the shoulder socket. This stable compression allows the shoulder to move easily in so many directions.

Without this compressive stability, the head of the humerus can start to slide up and out of the socket. This movement is called migration. Eventually the head of the humerus comes up against the bottom of the acromion. The acromion is the piece of bone that comes across the top of the shoulder from the scapula (shoulder blade).

The patient has pain, loss of motion, and loses function. Many other changes occur inside the joint. Tiny pieces of cartilage break lose inside the joint. The lining of the joint called the synovium starts to thicken. Calcium crystals form, further damaging the joint and soft tissues.

Rotator cuff arthropathy can be treated with a conservative management program. Non-steroidal antiinflammatories and a rehab program with a physical therapist are advised. If this doesn’t work, then surgery may be needed.

Your sister may have a condition called rotator cuff tear arthropathy. This refers to an insufficient (weak) muscle that doesn’t hold the head of the humerus firmly inside the socket. The humeral head may even slide up out of the center of the socket. Uneven wear over time can cause joint damage. All of these changes are part of the arthropathy.

Doctors aren’t sure why this condition develops in some people with a rotator cuff tear but not others. There may be subtle anatomic changes that make a difference. For example, the geometry (shape) of the bones that form the socket and bony arch over the shoulder might be a factor.

Or perhaps the length of the ligaments varies enough to change the compressive forces in the shoulder. Anything that alters this force generated by the rotator cuff can contribute to an imbalance and instability of the shoulder.

Repetitive use of the shoulder and age are additional factors. The natural history of rotator cuff tears (in other words, what happens over time) isn’t well-known. Many people have rotator cuff tears and don’t even know it.

At this point in time, there’s no way to predict what will happen for you. Most experts would advise you to establish an exercise program to keep up the motion and strengthen in both your shoulders. It won’t hurt and it may help prevent future deterioration or injury.

Rotator cuff tears occur most often in young athletes and sports participants. The force of a stress greater than the strength of the muscle/tendon unit results in a tear of the tissues where the tendon joins the muscle.

The most common site of injury is the myotendinous junction. This is a region of highly folded tissue between the end of the muscle fiber and the tendon. These folds increase the surface area for force to be transmitted through the soft tissues. The junction of tendon to muscle is especially vulnerable to injury where the inflexible tendon meets the stretchy muscle.

In older adults, changes in the surrounding structures may contribute to rotator cuff tears. For example, bone spurs often form. Jagged edges rub against the tendon and cause the tissue to tear or rupture. In such cases, it’s not enough to repair the torn tissue. It is necessary to remove the bone spur(s) to keep it from happening again.

In other cases, the tissue gets stuck or impinged between two moveable parts of the shoulder complex. Sometimes the surgeon has to shave the bone down or even remove the end of the bone to keep this from happening.

When you see your surgeon again, don’t hesitate to ask him or her to explain again what happened in your case. The more you can understand about your own injury and recovery, the better. Preventing rerupture or other injuries from happening is an important part of patient education.

Retears of the torn rotator cuff vary from patient to patient. It can be difficult to predict who might be at risk. Patients with severe or massive tears are certainly at increased risk. Small tears are less likely to retear. Conversely, large tears are at increased risk for rerupture.

Only about five per cent of the patients with small tears retear at a later time. That’s compared to 40 per cent for patients with massive, complete tears. As you might expect, the condition of the tendon at the time of the surgery makes a difference.

Size of the tear and tissue quality must be considered. A tendon with frayed and retracted ends can be a problem. The surgeon may not be able to sew the ends together or attach the tendon to the bone where it belongs. Shoulders with poor tendon quality and severe muscle degeneration are more likely to need traditional open surgery. Arthroscopic repair may not be adequate.

Some surgeons are using a double-row of sutures now to help stabilize the repair site. Studies have shown greater fixation strength using this method. The contact area is improved with double- versus single-row sutures.

So you see, there are many factors to consider. And we haven’t even mentioned patient compliance with the rehab process. Patients who don’t follow the surgeon or the therapist’s directions are also at increased risk for rerupture.

The surgeon may be able to identify the risk factors at play in your case. You may want to ask him or her this question at your next follow-up appointment.

The cartilage you have described is called the labrum. After a labral tear, the shoulder can become unstable. Repeated shoulder dislocations often lead to the recommendation of surgical repair. Repair is especially important for athletes who need a strong overhead motion.

Traditionally, the labrum has been repaired using an open incision. This allows the surgeon to see more clearly while making the repair. The cartilage can be repaired and the capsule tightened at the same time. The capsule is a fibrous covering around the shoulder to give it support and stability during motion.

Special sutures called anchors are used to tack down the cartilage. Studies show it’s important to have enough anchors and to put them in the right place. The open incision makes it easier to reach down under along the bottom of the labral tear and insert the needed anchors.

The one disadvantage of the open surgery is that the subscapularis muscle is cut away and then later reattached. This can result in significant shoulder stiffness. It’s difficult to externally rotate fully. This position is important for overhead serves or any overhead motion in sports.

The arthroscopic surgery is minimally invasive. Very small incisions are made but it’s also more difficult to place the anchors along the bottom of the tear. It is not necessary to cut through the subscapularis muscle.

Early efforts to use arthroscopic surgery for this repair did not always have good results. Results appear to be improving with improved surgical technique. Studies consistently show that surgeons who do more of these procedures have better results. Likewise, hospitals where a larger number of any one surgical procedure is done seem to have better results.

You should really talk with the surgeon about your questions and concerns. There may be reasons why the first surgery failed that can be avoided the second time. For example, it’s very important that the patient follow the surgeon’s instructions after the procedure.

Immobilization in a sling is usually advised for four to six weeks. The patient must keep the arm next to the body at all times except when bathing under the armpit. The sling is removed once or twice a day to keep the elbow from getting stiff. But it’s very important to avoid moving the shoulder until the surgeon approves.

Sometimes the type of surgery makes a difference for this problem. Arthroscopic repairs are less invasive but have a higher risk of failure. Using this approach, it can be difficult to place sutures far enough down on the tear. Sometimes there aren’t enough sutures used. Combining any of these risk factors together can have poor results.

A recent study from California reported on 30 cases of revised Bankart repairs. All patients were athletes involved in overhead sports. After an arthroscopic repair they all had a traumatic event causing the shoulder to dislocate again. A second operation was needed.

This time they had an open revision surgery. The results were good for most of the patients. Many were able to return to their previous level of sports activity. Follow-up over the next four years showed continued good results. All patients in the study rated their satisfaction as good or excellent.

X-ray technicians face many challenges everyday getting unusual and difficult X-rays. X-ray equipment is much more versatile than in the past. The camera used to take the image can be moved into a wide range of positions and angles.

Even so, the shoulder can be a special problem. Good X-rays can be difficult to get if the patient can’t move easily or if he or she is in extreme pain. The good news is that there is a new position used for shoulders that’s been around for the last five or six years.

It’s called the wheelchair axillary view. The patient remains in his or her wheelchair or they can sit on a standard chair. The arm is moved away from the body slightly. The X-ray plate is placed under the arm between the elbow and the side of the body.

The technician should be able to get a good image in this seated position. It will show fractures, dislocations, and any damage to the joint surface. The patient doesn’t have to be moved and can usually hold the arm in this position easily even if there is a serious injury.

Evaluating the injured or unstable shoulder can be very challenging. Posterior dislocations and some fractures just don’t show up on a standard X-ray. The most commonly used position for an X-ray of the injured shoulder is called the Velpeau axillary view.

The patient is positioned supine (lying on the back) and/or standing up and leaning slightly backwards. The X-ray beam is directed down from the top of the shoulder through the joint to the bottom of the axilla (armpit).

If the patient can’t assume either of these positions, then the wheelchair axillary view can be used. In this case, the patient sits in a standard chair or wheelchair. The arm is slightly abducted (moved away from the body). The X-ray beam is still directed down through the shoulder from top to bottom. The patient isn’t stressed or uncomfortable with this method.

It’s possible the first X-ray of your neighbor was from an oblique angle, which doesn’t always show a posterior dislocation. It’s also possible that the X-ray technician didn’t know about the wheelchair axillary view. The position used with your neighbor may have resulted in a distorted or less than clear X-ray from movement or poor positioning.

There are any number of reasons why these things happen. Imaging studies are a helpful tool, but they aren’t always 100 per cent accurate.