FAQ Category: Shoulder

Brachial neuritis is a fairly uncommon disorder that affects the shoulder and/or one or both arms. Brachial refers to the group of nerves in the neck and arm called the brachial plexus. Neuritis means an inflammation of the nerve.

Patients notice a sudden start to their symptoms. Some report a burning or sharp pain. Others report a throbbing sensation. The pain starts in the neck and moves down one or both arms. The pain may last a couple hours but often persists for several weeks.

For some people there’s no known cause of this condition. Others link it to a viral infection, heavy exercise, surgery, or immunization (vaccination). About half the people affected have no idea what might have triggered the neuritis.

Your pain should gradually get less and less. As the pain goes away, muscle weakness becomes more obvious. Over time, the weakness may be accompanied by muscle atrophy (muscle wasting). Recovery is a very slow process, often taking a year or more. Some patients still notice mild weakness or sensory loss.

Most doctors advise their patients with brachial neuritis to limit their activity until strength is fully (or nearly completely) recovered. A rehab program can help you regain motion and strength. Depending on what your doctor tells you, it may be more realistic to shoot for next year’s iron man competition.

A medical evaluation will be needed to find out the cause of the problem. The doctor will take this information and ask other questions to find out more about what happened. Pain with loss of muscle strength suggests a nerve injury.

Shot-put athletes can put a stretch or traction force on the long thoracic nerve causing a nerve palsy. With the arm in the overhead position, they turn the head and neck to the opposite side before throwing. With the added weight in the hand, this can put a tremendous strain on the nerve.

EMG testing of the muscles may be needed to make a final diagnosis. If it turns out there is a long thoracic nerve palsy, then treatment is started right away. Your son will have to avoid shot-put activities for awhile. Certain muscles will be strengthened while others are given a rest.

If symptoms don’t go away or improve, surgery may be an option. Tendon and muscle transfers are used to help one muscle function in place of another. In some cases, weakness may persist for years.

Early diagnosis and treatment are important to avoid long-term problems. Don’t delay in making an appointment for an exam.

Many things have changed over the past 30 years in the way acromioclavicular (AC) joint separations are treated. Surgery used to be the initial treatment for type III AC injuries.

With a type III separation, the AC ligaments are torn and the AC joint is dislocated. Surgery was designed to repair or reconstruct the ruptured soft tissues. This type of treatment is still used for some patients. But more surgeons prefer nonoperative care today.

With conservative care, the joint is held in place or immobilized with a sling to allow scar tissue to fill in and around the torn capsule. Past studies over the last 30 years haven’t been able to show better results with surgery compared to using a sling.

There have been many changes in surgical technique and graft materials in the last 10 years. In the future, we may see the pendulum swing back toward the use of surgery as the preferred initial treatment for type III AC separations. For now immobilization followed by a rehab program seems to be favored by most surgeons.

Many diseases, conditions, and injuries are described using grades, stages, or types. Usually these classifications or groups represent a range from mild to severe. They are often numbered 1, 2, 3, 4 or I, II, III, IV. Sometimes one problem is even classified using more than one method.

Acromioclavicular (AC) separation was first classified as I, II, and III in the early 1960s. Three additional grades (IV, V, VI) were added in 1984. Type I is a sprain of the AC ligaments. The ligament isn’t torn and repair isn’t needed. Nothing else around the joint is damaged.

The AC ligament is torn with a Type II injury. The muscles around the joint aren’t injured. Type III occurs as a result of a severe trauma to the joint. Type III is equal to a dislocation of the joint. An X-ray of this type will show one clavicle (collar bone) lifted up above the other clavicle. The clavicle is no longer level with the acromion bone on the other side of the joint.

Types IV, V, and VI are all grades of Type III. Each type is a little more serious than the number before it. Type IV is also a dislocation of the AC joint. Instead of being displaced (pushed) up, the clavicle is moved backward or pushed into the trapezius muscle. Type V is the worst form of Type III injury.

Frozen shoulder also known as adhesive capsulitis is used to describe a loss of shoulder motion caused by changes in the shoulder joint capsule. The capsule is an envelope of connective tissue that surrounds the shoulder joint.

Injury and inflammation can start the process leading to adhesive capsulitis. Painful motion causes the person to stop moving the shoulder, and it gets bound down. It can also occur as a result of other conditions such as diabetes, heart disease, and lung disease.

It was once thought that changes throughout the capsule are what caused the tightness. It is true that with a frozen shoulder, there is fibroplasia throughout the capsule. Fibroplasia refers to the formation of fibrous scar tissue.

But surgeons found that by releasing just the anterior (front) part of the capsule restores shoulder motion. Further research showed that a particular protein called vimentin is what really leads to anterior contracture (tightness) of the capsule.

By releasing the anterior capsular structures, motion is restored throughout the joint for most people. Frozen shoulder can range from loss of external rotation and abduction (moving the arm away from the body) to a complete loss of all motion. More extensive surgery may be needed for more extreme cases.

Collagen is an important protein that provides structural support for almost all tissues and organs in the body. The word collagen comes from the Greek meaning glue producer.

There are at least 28 known types of collagen in the body. Scientists are discovering more types every year. Most of the structural collagen in the body is Type I. This type forms skin, tendon, bones, and teeth. Type II is found in certain types of cartilage such as the ear, nose, and joints.

Type III collagen is seen mostly in blood vessels and organs. It is also the most common kind found in the developing fetus (child in uterus). Other types of collagen form parts of the eye, tendons, bone, and lymphatic vessels.

Types I and III collagen are found in the shoulder both normally and as a result of fibrous scar tissue. Research has shown that inflammation is not really present in a frozen shoulder. It’s more likely the presence of a protein called vimentin in the anterior or front part of the shoulder capsule. Finding out what causes the increased vimentin to form is the next step.

Shoulder problems can be difficult to diagnose. Even when orthopedic surgeons agree as to the cause of the underlying problem, there may be different ways to describe or classify the condition.

For example, rotator cuff tears (RCTs) can be classified in nine different ways. Three of those methods are similar so for the sake of argument, we could say there are really only six methods.

Even so, if every surgeon used the same method, they still wouldn’t always come up with the same opinion. Experience and training may account for some of these differences. Some orthopedic surgeons specialize in shoulder problems, taking an extra training period called a fellowship.

Arthroscopic exam is really the best way to sort out the exact cause of the problem. There are reasons why an arthroscopic exam isn’t done routinely on everyone with shoulder pain.

Sometimes it’s less costly to treat the condition for a short time and then re-evaluate. The more expensive testing can be done later if treatment fails to help improve symptoms. Knowing for sure what is the cause of the problem does help direct the patient to the most appropriate treatment for that problem.

There are many ways to describe and classify rotator cuff tears (RCTs). In most cases, the surgeon first determines if the tear is a partial or full-thickness tear. They look to see which side the tear occurs on (bursal or articular).

In other words, is it right next to the bursa or on the side where the tendon attaches to the joint? The bursa is a small fluid-filled sac located at the point where a muscle or tendon slides across bone. The bursa reduces friction between the two moving surfaces.

Using an arthroscopic exam, the surgeon identifies the size, shape, and depth of the tear. A commonly used method to describe location of RCTs is the Patte classification. Tears are classified as stage one (I), two (II), or three (III). In stage I, the tendon is torn close to the place where it inserts into the bone.

Stage II describes a tendon tear close to the level of the humeral head. The humeral head is the round knob at the top of the humerus (upper arm bone) that fits into the shoulder socket.

Stage III is a RCT much closer to the shoulder socket called the glenoid cavity. The glenoid is part of the shoulder blade.

You may have to ask your surgeon to explain a grade two tear based on whatever system he or she is using.

The procedure you had with radiofrequency to heat and shrink the shoulder capsule is called thermal capsulorrhaphy. Although it has become a popular treatment option, long-term studies are lacking.

Case studies of individual problems have been reported silimar to yours. Loss of cartilage throughout the joint can occur. It’s thought that thermal energy is either more than expected or continues causing damage after it is stopped.

There’s some concern that the probes used to deliver the heat aren’t accurate. As a result, excessive heat is used causing cartilage cells to die. Other problems from this treatment have also been reported. Nerve damage and damage to the capsule can lead to recurrent shoulder instability.

Over tightening the shoulder causing loss of motion and decreased function are reported with traditional open surgical treatment of shoulder instability. Long-term reports of such cases suggest over tightening with loss of motion can lead to arthritis.

It’s unlcear what the best treatment is for this complication. Conservative care with a physical therapist to increase range of motion may be helpful. A second surgery may be needed to avoid developing osteoarthritis (OA) from over compression of the joint. The surgeon can release some of the soft tissues around the front of the shoulder.

If painful OA does occur, then a shoulder replacement may be needed. A partial replacement called a hemiarthroplasty may be all that’s needed. Your surgeon will help you decide what’s the next best step. Your age, general health, and shoulder condition will all be considered in making the best treatment decision for you.

The majority of studies show that age does not affect long-term outcomes for this type of surgery. Outstanding workers’ comp claims is a bigger predictor of poor outcome. Most older adults are not involved in this type of controversy.

Older adults are more likely to experience rotator cuff problems. In a review of 50 studies, only four per cent of the patients under the age of 40 had a rotator cuff tear. This was compared to 54 per cent in patients more than 60 years old.

Older adults report improved pain relief and function after rotator cuff tear repairs. Even with poorer tendon quality due to aging, results after surgical repair can be very good. Younger patients are more likely to report satisfactory results but that doesn’t mean older adults can’t have excellent outcomes.

Charting the course of a disease or condition from beginning to end is called the natural history. No one really knows the natural history of unrepaired rotator cuff tears.

Patients who have the surgery can be followed and studied. And in fact, most people with full-thickness tears do have the surgery done. Many patients with unrepaired rotator cuff tears aren’t seeing a physician over the long term for follow-up.

Some studies have been done to collect data on patients who have a pain free rotator cuff tear that eventually develops painful symptoms. That’s when surgery is most often indicated and suggested.

But before surgery is done, conservative care is almost always suggested. Six-weeks to three months’ treatment with a physical therapist is advised along with nonsteroidal antiinflammatory drugs. If there’s been no improvement after this amount of time, then surgery should be reconsidered.

Upper limb pain disorder (ULPD) is a term that was first used to describe chronic pain affecting the arm from the shoulder down to the hand. Some people use the term interchangeably with carpal tunnel syndrome (CTS). Others consider ULPD and CTS as two separate problems.

The etiology or cause of ULPD remains unknown. Given a group of adults all doing the same repetitive task, over time, only some will develop ULPD. The rest will have no symptoms of any kind.

Various models have been proposed to describe or explain the changes that occur. Some studies focus on psychologic and social factors. Others suggest changes in how sensory messages are processed.

Research does support that some symptoms occur after pain has been present three months or more. But these late changes appear to be more related to the central nervous system than from pressure on the nerves to the arm or hand.

More studies are needed to sort out the cause and effects of ULPD. Finding out which comes first: the symptoms or changes in how sensations such as temperature, vibration, and pain are processed will help direct treatment. Ideally, prevention of these problems is the goal.

There is a condition like what you described called snapping triceps syndrome (STS). It is seen most often in men who lift weights or do pushups.

When the elbow is fully bent (flexed) or extended straight after being fully flexed, the medial tendon of the triceps muscle along the inside of the elbow dislocates. It moves out of the groove where it is normally located, and snaps over the bone along the inside of the elbow.

The condition is diagnosed based on the symptoms and confirmed with an MRI. Images of the elbow are taken when it is bent and while it straightens into extension. Realtime ultrasound can also be used to show the snapping structures.

What is actually causing the dislocation remains unknown. At first it was thought that the muscle firing pattern was abnormal. But studies have not been able to show a difference in muscle activation patterns between patients with STS and normal, healthy adults with no elbow symptoms.

Since the problem occcurs most often in weight lifters and men who perform pushups, there may be a connection between the size and bulk of the muscle and this snapping dislocation that occurs with elbow movement. Further studies are needed to prove or disprove this theory before we will know what to do about the problem.

The rotator cuff (RTC) is a group of four muscles and their tendons that surround the shoulder. The RTC forms an envelope around the shoulder joint to help support and move it. This structure also compresses the head of the humerus to hold it in the shoulder socket.

RTC disease can refer to any number of problems in the RTC. This could be a tendinitis, acute strain, or tear of one or more of the tendons. Rotator cuff tears can be partial-thickness or full-thickness depending on whether or not the tear goes all the way through the tendon. A full-thickness tear is also called a tendon rupture.

Making a correct diagnosis is often difficult. Using the term rotator cuff disease identifies the general (but not the specific) problem. Sometimes this term is used as a provisionaldiagnosis. Further imaging testing or arthroscopic exam is needed to identify the exact diagnosis.

There are many different indicators to help patients and surgeons make this decision. Pain that is chronic and disabling is the first measure used by many patients. Loss of shoulder motion combined with pain often leads to loss of function.

When you can no longer do everyday activities easily, then it may be time to give a joint replacement a second look. X-rays are helpful to show how much and what kind of joint damage is present. The joint space is measured and the presence of any bone spurs is noted. Condition of the bone (mass and density) is also assessed.

If you haven’t tried conservative care (exercise, physical therapy, antiinflammatories), then a four to six month trial is always recommended first. Your age, general health, and activity level are all considered when making this decision.

There are several reasons why you may be experiencing a change in strength and function after a total shoulder replacement (TSR). The first is simply pain relief. Range of motion and strength are both decreased by pain. Before the joint replacement, it just hurts too much to move the arm or stress the joint. This makes it look like you are weaker than you really are.

During the operation, adhesions around the shoulder complex are released by the surgeon. Breaking loose these tiny points of scarring and fibrous tissue can actually free up the muscles to move more smoothly through greater motion with increased strength.

Sometimes during the procedure, tendons in the shoulder are cut and reattached in a slightly different location. The new position is designed to improve the balance and function of the joint. What you might notice from this is an increase in strength.

And finally, it’s possible that your rehab program is paying off! If you’ve been diligent to follow your exercise program you should see a gradual improvement in motion, strength, and function.

There are many possible sources of shoulder pain. The rotator cuff (RTC) may be one of them. Damage to the RTC ranges anywhere from an acute strain to a full tear with many variations in between.

MRI assesses the integrity of the rotator cuff tendons (there are four tendons total). Signal intensity helps show areas of irregularity and thinning. Usually a patient history (how the injury happened, what makes it better or worse) and physical exam are also needed to make the final diagnosis.

Whether or not to have an MRI is your decision. Your physician can help you by offering pros and cons based on his or her findings after the history and exam. The cost of the procedure may be one consideration.

But keep in mind that the MRI helps pinpoint the exact problem. This makes it possible to plan the most appropriate treatment known to work for that problem. You save time and money this way and optimally gain pain relief and improved function faster. This allows you to get back to your normal daily activities, including work.

Overhead athletes often have quite a bit of give or laxity in the joint. This is especially true of forward motion of the head of the humerus (upper arm bone) in the shoulder socket. Too much laxity can lead to instability and dislocation.

There are some tests that can be done to check your joint laxity and look for shoulder instability. Some of these tests are performed by the doctor while you are in the office. Others must be done with imaging studies such as MRIs or CT scans.

By putting the shoulder in certain positions, the doctor can test for the strength and integrity of shoulder ligaments, tendons, and the joint capsule. These soft tissue structures are what hold the joint in place while still allowing motion.

Treatment is determined by the amount of laxity present and the underlying cause. When ligaments are too loose, stretched out, or torn, the muscles around the joint can be strengthened. Four main muscles surround the shoulder and form the rotator cuff. If the capsule is torn and/or the tendons of the rotator cuff are damaged, then surgery may be needed.

From your description, it sounds like a mild problem with either joint laxity or minor instability. A rehab program may be the best option, but a medical evaluation is needed first. Once the problem is examined and the cause is determined, then the proper treatment can be applied.

You may be describing some tests that can be done to show how well the head of the humerus (upper arm bone) glides and slides. This is called glenohumeral translation.

It’s a very important internal motion of the shoulder that allows the shoulder to move so far in so many directions. In fact of all the joints, the shoulder is the most mobile because of these extra or accessory motions.

The humeral head glides in five different directions: up (superior glide), down (inferior glide), away from the body (lateral glide), forward (anterior glide), and backward (posterior glide).

A decrease in any of these translations will affect your shoulder range of motion. Too much slide or glide increases the shoulder looseness or laxity. Excess joint laxity can lead to joint instability and dislocation.

One way to gauge how well you are doing after the type of injury and surgery you’ve had is to test joint accessory motions. This helps the doctor and therapist plan the right treatment for you.

Next time someone starts moving your shoulder this way, stop and ask them to explain what they are doing. Most healthcare providers are more than happy to help patients understand what they are doing and why they are doing it.