FAQ Category: Shoulder

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.

Shoulder pain and loss of motion are common symptoms of calcific tendinitis. Patients can be very debilitated in their daily activities from this problem. Typically there are no symptoms until the condition is on the mend.

If you can wait long enough, the problem will resolve on its own. That’s why it’s considered a self-limiting condition. Physical therapy for joint mobilization has been shown to give patients good results. Shock wave therapy is another treatment option that is safe and effective.

If the symptoms don’t go away, surgery can be done to remove the calcium deposits and wash any other tiny crystals from the joint. The problem can come back but it is not a certainty. Many patients are never bothered again.

There’s been a dramatic increase in the number of exercise- and sports-related injuries in adults aged 50 to 60. Since most of these adults were born during the post World War II baby boom era, these problems are being referred to as boomeritis.

Tacking the ending or suffix: itis on a word indicates inflammation. So a bursitis would refer to inflammation of the bursa in a joint. Boomeritis is just a nickname for who (you, the baby boomer) and what (inflammation from overuse) but doesn’t identify the true underlying problem. You could have a bursitis, shoulder impingement problem, or tendinitis.

If you are unclear about your problem and what to do about it, don’t hesitate to call your physician back and discuss your situation further.

The MRI gives a density signal for soft tissues that helps identify damage or injuries. The surgeon is able to locate individual tendons and look for tears in the rotator cuff.

The rotator cuff is a group of four muscles and their tendons surrounding the shoulder joint. They form an envelope of support and provide stability for the free-moving shoulder.

A normal, healthy tendon produces no signal on an MRI. When a tendon is partially torn, the scan shows a high signal intensity at the site of the lesion. If the tendon is completely torn, the image shows a bright fluid through the entire thickness of the tendon.

In general, MRI has a high sensitivity for finding rotator cuff tears. Other shoulder problems may not be as clear or as easy to see on an MRI.

It may be difficult to answer your question directly without knowing more about the shoulder injury and type of surgery done. In general, older adults have degenerative changes in the joint and soft tissues around the joint. Rotator cuff tears (RCTs) are common.

There can be tears in the joint cartilage or just frayed edges that need smoothing down. Sometimes repairing the torn rotator cuff is all that’s needed. If the torn cartilage isn’t bothering the patient, then it’s not always in their best interest to repair it. The result can be the loss of motion and worsening of symptoms you described.

In other cases, the rehab program after surgery is the key factor. The patient must follow the surgeon’s and the physical therapist’s directions carefully. Too much movement too soon can cause the repair to fail. With the right program, loss of shoulder motion can be avoided.

It might be best to make a follow-up appointment with the surgeon and go with your mother. Her age may be a factor; sometimes older adults just need more time to progress through the rehab program. She may need an extra step in the rehab process.

Magnetic resonance arthrography (MRA) uses an injected dye and special X-ray called fluoroscopy to find labral (cartilage) and ligament tears. The dye seeps into any openings, cracks, or tears that shouldn’t be there.

MRA is a sensitive and reliable test. That means it correctly shows a labral tear when there is one. Studies show MRA is most accurate finding anterior tears (95 per cent) sensitivity. Ligamentous tears above or below the shoulder are less sensitive).

Arthroscopic exam is equally effective in making this diagnosis. The advantage of arthroscopy is the ability of the surgeon to go ahead and repair the tear immediately. The disadvantage of arthroscopic exam is that it requires surgery. MRA does not require anesthesia, any punctures, or open incisions of the shoulder.

Your recovery time may depend on the type of surgery you are having. Labral tears of the shoulder can be repaired using an open versus an arthroscopic method. The final results are nearly the same, but studies show the arthroscopic group has fewer problems afterwards. There is also a shorter hospital stay and less blood lost with arthroscopic surgery.

If we use the military model, expected return to full athletic participation would be after four to six months. Since the goal of military medicine is to return the soldier to duty as soon as possible, it makes sense to use this model with young, athletes in equally good shape.

The rehab program after labral tears in the military is broken down into three main phases. Each stage lasts about four weeks (one month). During Stage 1, the patient is immobilized in a sling. Special shoulder and elbow exercises are allowed as taught by the physical therapist.

Stage 2 works to restore motion without damaging the repair. The therapist will teach you how to protect the surgical site while gaining shoulder motion. Stage 3 focuses on strengthening the muscles around the shoulder. The program progresses from there until the patient is ready for full, active duty. In your case, that would be a return to your preinjury levels of sports play.

Good question! Carrying a heavy load up a mountainside is no time to regret bringing the wrong kind of backpack. Many experts suggest a backpack with a frame to help support and distribute the weight. New packs come with an internal frame to avoid the pressure of the bars against your back.

But be aware that while frames may spare your back, they don’t necessarily protect your shoulders. Too heavy of a load across the neck and shoulders can cause nerve pressure and damage. For this problem, it’s advised to find a backpack with adjustable and padded shoulder and sternum (across the chest) straps.

The idea is to prevent the straps from pulling your shoulders too far back and down from your normal posture. This kind of position can put traction on the nerve with the same risk for nerve palsy.

A waist support is essential to prevent the risk of nerve pressure. This is especially true for anyone carrying a heavy load while using your hands to climb. Finally, even the best backpack won’t prevent neck, back, and arm pain or palsy if it’s too heavy and/or carried for too long. How much you pack into a good backpack is just as important as the backpack design and features.

The stinger-burner syndrome is a burning pain and loss of sensation in the neck and shoulder. It’s usually short-lasting and occurs after the neck has been bent to one side. Stretching of the nerves between the head and shoulder cause these symptoms.

Stinger-burner syndrome is very common in football and wrestling where this type of sudden stretch can occur. After the initial sensation of burning pain, the player may report the arm and hand feeling heavy or dead.

Most players recover in a matter of minutes. They may not even report it to their coaches. It’s estimated that half up to two-thirds of all football players experience this syndrome at least once in their career. In a small number of players, the problem can persist and even be permanent.

Studies have shown and confirmed the value of the abduction immobilizer you describe. Putting the arm in slight abduction (the arm is 45 to 60 degrees away from the body) improves blood flow to the rotator cuff. It also reduces any tension on the repair.

This special sling is especially important during the early phases of healing. Most surgeons recommend its use for the first four to six weeks after surgery. You are already one-third to one-half of the way there. If you can hold out another two or three weeks, you will have a better result than if you remove this bulky splint.

You should be able to remove it daily in order to do your exercises. Otherwise, it’s strongly advised that you keep it on to avoid overstressing the healing tissue. It should be work full-time at least until the end of the fourth week. Some surgeons suggest wearing it for comfort for the next two weeks before gradually eliminating it.

The rotator cuff is a group of four muscles and tendons that converge on the shoulder. Together they form a sheath or envelope that wraps around the shoulder. The fibers interlock and crossover forming layers that are all connected together.

This protective overlap makes it possible for one muscle to take over and help function for another. This concept is called redundancy in function. Rehab can focus on strengthening the muscles that aren’t torn and restoring the torn tendons as much as possible.

A physical therapist can perform a special massage called transverse friction massage to help align the healing fibers. Instead of adhesions and scarring going in all directions, the fibers line up in parallel. This helps keep the shoulder supple and moving smoothly.

Not all tears do heal without surgery. Various factors such as patient age, condition of the tissue, and depth of the tear determine the final outcome. Results also depend on whether more than one tendon is involved and the location of the tears.

The hornblower’s sign is the patient’s inability to outwardly rotate the shoulder. This is the position a hornblower would hold his or her arm to get the horn to the lips. It’s a sign that one of the muscles to the shoulder (the teres minor) is torn.

The hornblower’s test is a very sensitive test. If it’s positive, then the surgeon knows the teres minor cannot be repaired with a standard operation. A tendon transfer may be needed.

A long rehab program is needed after tendon transfer. Muscle reeducation is required for a good result. If the patient is unable to cooperate or stick with it long enough, then nonoperative treatment may be the best choice.

A physical therapist will work with your husband to gain control of his symptoms. Pain, loss of motion, and decreased function are common problems. Once the pain is under control, then a strengthening program can begin.

Massive, chronic tears of the rotator cuff (RCTs) can’t be repaired in the standard, conventional way of reattaching the torn tendon where it belongs. In older adults, the tear may have been present for so long that the area has filled in with fatty tissue. In such cases, the rate of retear is very high when a repair is attempted.

Treatment is possible but just what’s the best treatment is judged on a case-by-case basis. After the surgeon examines the patient, imaging studies are taken. X-rays, CT scans, and MRIs each give a slightly different view of what’s going on inside and around the shoulder joint.

Arthritis in the joint makes the treatment decision more difficult. The patient’s age, activity level, amount of muscle atrophy, and fatty infiltration are all taken into consideration. Sometimes the best treatment plan is nonoperative. Inflammatories, steroid injections, and physical therapy may be advised.

When surgery is recommended, it may be to debride the area (clean it up). Or a tendon transfer may be possible. In this case, the surgeon takes a muscle from some other area and transfers it to the shoulder. The transferred tendon functions like the torn tendon of the rotator cuff. A tendon transfer is a complex operation. A long rehab program is likely so the patient must be motivated and active enough to do it before tendon transfer is considered.

When the shoulder is unstable and the rotator cuff tear is inoperable, then a shoulder replacement may be the best treatment choice. Many irreparable RCTs can be managed nonoperatively. This may be what your mother’s surgeon was suggesting.

More and more surgeons are going with arthroscopic exam and repair at the same time. It is much less invasive than an open operation. With arthroscopic exam, muscles don’t have to be cut and the joint capsule is only minimally impacted compared to an open incision procedure.

In the case of the subscapularis muscle, its condition isn’t clearly seen during open incision surgery. In fact, the surgeon can get a much better look using arthroscopes with different angles.

A recent study testing shoulders and comparing the results with arthroscopic exam placed subscapularis tears at a much higher prevalence (30 per cent) than previously observed. The authors suggested the higher numbers were a direct result of performing arthroscopic exams.

Arthroscopic exam enables the surgeon to get a good look in and around the shoulder from all sides and from a wide range of angles.

Clinical tests to detect tears of the subscapularis muscle are less accurate than tests for the other tendons of the rotator cuff. This is most likely because of where the subscapularis muscle is attached and how it functions.

Two clinical tests are commonly used: the lift-off test and the belly-press. Two other tests are also available: the Napoleon test and a new test called the bear-hug test.

When used all together the tests are able to predict the size and place of a tear about 60 per cent of the time. The other 40 per cent can only be seen on arthroscopic exam.

With small tears, a program of conservative care such as you were given is the first choice in treatment. An earlier diagnosis may not have changed the course of care you received. If the patient reinjures the arm (making a larger tear) or has a large tear to begin with, then surgery is more likely.

Joint infection after joint replacement is not very common. When it does happen, the results can be very serious. Most of the time, infections are caused by the immune system failing to do its job. When the immune system is not functioning properly, it’s called immunosuppression.

Many health conditions can actually impair the immune system and keep it working overtime or not at all. This can include diabetes, rheumatoid arthritis, and lupus. Other outside causes of joint infection include chemotherapy for cancer or corticosteroid drugs for chronic inflammatory conditions.

Several studies report repeated local injections with steroids into the joint can also lead to joint infection.

Infections can occur in the acute phase (right away up to three months after the operation) or years later. Pain and altered lab values are the most common signs and symptoms of this condition.

Joint replacements are wonderful but they aren’t 100 per cent perfect yet. In the case of a serious fracture with bone loss, it may be impossible to restore the normal length of the humerus (upper arm bone).

A change in the length of the bone alters the way the muscles pull to move the arm. Sometimes during the operation, muscle tension is changed: the muscle tensioning can be too much or not enough.

These kind of problems are more likely with a humeral fracture or tumor. It may be referred to as an inferior instability. The best way to find out what to do is go back to your orthopedic surgeon. An X-ray and examination are needed to find out what’s causing the problem. You may be a good candidate for a rehab program but further surgery may also be the answer.

Treatment and especially successful treatment of severe rotator cuff tears has been a challenge for many years. This is especially true when the patient also has severe shoulder joint pain.

A new shoulder implant is being used and studied for this kind of problem. It’s called the Reverse Shoulder Prosthesis (RSP). It has a ball and socket design that helps restore shoulder function and relieves pain in patients with a rotator cuff-deficient shoulder.

It does this by changing the way the soft tissues pull on the shoulder. Instead of pulling the humerus (upper arm) in towards the scapula (shoulder blade), the force is directed through the center of the humerus.

Changing the direction of the force of the rotator cuff on the shoulder joint creates stability in the joint. Instead of an upward movement of the humeral head with respect toward the socket in the scapula and a loss of joint space, the RSP resists the pull of the muscles. The design is perfect for patients with a deficient rotator cuff that can’t be repaired in a shoulder joint with severe athritis.

A reverse shoulder replacement also known as a reverse shoulder prosthesis or RSP is a unique implant. It’s used for the patient with an irreparable rotator cuff tear who has severe shoulder arthritis.

The shoulder is a ball and socket joint. The head of the humerus (upper arm bone) is a round ball that fits into the acetabulum or socket. Without the rotator cuff to keep the joint in balance, the humerus tends to move up too close to the shoulder blade. The patient ends up with a painful impingement as the soft tissues get pinched during movement.

A RSP takes care of this problem by changing the direction of the force in the shoulder. The top portion of the humeral head is cut off and a cup-shaped socket is inserted into the bone. A flat plate is placed on the socket side and a round three-quarter spherical ball called a glenosphere is attached.

The first design of reverse shoulder replacement did have some complications related to mechanical failure of the implant. Researchers found that getting the right size and fit for each patient is important. Once the implant came in a variety of sizes, then soft-tissue tension could be altered for each patient’s shoulder.

Having a better understanding of what happens in a shoulder with a deficient rotator cuff helped surgeons change the operative technique. They also changed from a smaller nonlocking screw to a larger locking cortical screw to hold the baseplate in place against the bone.

They also found that when the baseplate is put in with a slight tilt, the shear forces across the bone were evened out more. Changing the center of rotation for the shoulder by screwing the glenospere closer to the bone also improved stabilization and reduced stress. All of these changes have reduced the problems with this procedure.