FAQ Category: Shoulder

There may be a link here. Bacterial infection of any joint can occur whenever there has been damage to the joint. Since bacteria are carried through the body via the bloodstream, you may have been at increased risk from both the torn rotator cuff and lack of movement without the exercises.

Movement and exercise helps keep the blood flow moving to various body parts. The blood helps carry dead cells, bacteria, and other debris away from the joint.

The older you are, the more likely you are to be affected. Other risk factors for joint infection include illness or disease such as heart disease, liver disease, diabetes, or treatment with chemotherapy for cancer.

There are three tests of function used by physical therapists that may help you chart your own progress. The first is the hand-to-neck test. Using a mirror, reach up with both hands and touch the back of your neck as if you were lying out under the stars with your hands behind your head.

Can you reach the neck? Touch the neck? Reach the middle of the back of the neck? Does the motion look the same on the ‘good’ side compared to your ‘bad’ side?

Next reach your good hand behind your back. Slide the hand as far up your spine as you can toward the shoulder blade. Do the same test with your involved side. Compare how far you can reach on the good side compared to the injured side.

For the last test, use your good hand to reach across the front of the body and place your hand on top of your opposite shoulder. Now slide the hand as far down the back as you can toward the shoulder blade. Switch hands and do the same thing with the other hand. Again, compare how far you can reach using your ‘good’ hand versus the hand on the side of your frozen shoulder.

You can measure progress in small increments using these tests. If you have a camera, have someone take photos of all three tests on both sides to help you compare.

The tests themselves are highly reliable and valid. A recent study showed these three tests in particular have both high interrater and intrarater reliability. This means that the tests give the same results when given by different people and that the same person giving the test more than once will get the same results.

These tests do measure a patient’s function. For example the hand-to-neck position is one used to comb or fix the hair. Reaching behind the back is a motion needed to perform toileting functions. Reaching the hand across the body toward the other shoulder is important when bathing and dressing.

Patient cooperation and motivation are important factors in these types of function-based tests. The therapist will be able to compare the results of your mother’s movement tests from day-to-day and week-to-week to measure progress. Unusual results or wide swings from one extreme to another may be caused by the dementia. If that happens, then the test results aren’t valid.

There is a treatment method called thermal capsulorrhaphy used to treat shoulder instability. Usually the patients have injured the soft tissues around the joint or the cartilage around the shoulder socket.

The laser or radiofrequency energy heats the tissue up enough to damage some of the cells. As the tissue cools down, it contracts or tightens up. The process of healing the damaged tissue brings about more normal cells to replace the “loose” ones.

Immature or undeveloped tissue doesn’t shrink like adult tissue. The bonds that form and hold the cells together aren’t strong enough to withstand the heat. The proteins “melt” turning the tissue into jelly. The end result is an unstable rather than a “tight” joint.

Just the opposite happens in older adults. There are so many cross-links in aging tissue (that’s what makes us stiff), shrinkage is very limited. It’s unlikely this treatment would be recommended for your daughter. She may benefit more from a strengthening program. A physical therapist may be the best one to assess the stability of her joints and advise you.

It’s always best to ask your surgeon what is his or her post-operative protocol. The operation you describe is most likely a procedure called thermal capsulorrhaphy.

Laser or radiofrequency energy is used on the joint capsule to shrink the collagen tissue. The effect is to “tighten up” the joint and improve stability. This type of heat treatment causes cell damage that decreases the stiffness of the capsule for the first two weeks.

If you wear a sling at all, it will be during this period of time. After two weeks, the healing pattern changes to active repair. The body tries to heal the tissue that was heated up. By the end of six weeks, basic healing has occurred. By twelve weeks the tissue has stabilized to a more normal level.

Sometimes the heat treatment is done in a grid pattern. This method tends to speed up healing. You may not need any immobilization with this approach. Your surgeon is the best one to decide what’s needed based on the type of damage and amount of heat applied.

Sometimes thermal capsulorrhaphy is done along with other surgery to repair torn tendons, muscles, capsule, or cartilage. Combining surgery with capsulorrhaphy may change the post-operative treatment.

In a normal, healthy adult, bone fractures usually take four to six weeks to heal. If there are other health problems such as heart disease or diabetes, healing can take longer. Recovery is also slower in anyone who smokes or uses tobacco products.

Without surgery, an injury of this type would be treated with a shoulder sling. The arm is immobilized to prevent the fracture from separating, which would then require surgery. The sling can also help with pain management.

X-rays are taken at the time of the injury and repeated in about four to six weeks. If healing is coming along, then a program of physical therapy is advised. The therapist will teach your husband how to stretch and strengthen the arm.

Usually the results are good to excellent but it does take time. Function returns a little at a time. Pain goes away gradually, too. Recovery can be a lot slower if there is soft tissue damage. This is especially true if the ligaments were torn at the same time the bones were broken. In these cases, if the shoulder is unstable, then surgery may be needed. Recovery is much longer with surgery.

Shoulder injuries can be hard to diagnose. A good starting point is an exam by an orthopedic surgeon and an X-ray. In fact, a series of X-rays may be needed to get the right angle to see everything.

Major trauma of this type has been linked with a shoulder injury called a floating shoulder. With a floating shoulder there is a fracture of the collarbone and the shoulder blade. The shoulder socket can actually detach and move forward and down. That’s what can give the arm a drooping look.

Or sometimes when the arm has been pulled like you described, a traction injury occurs. This means the nerves got stretched. Nerve damage can result in a drooping arm, too.

Early treatment is always advised for the best long-term result. Working with horses, your sister will need arm strength and motion. This may be the best way to convince her to see a doctor sooner than later.

It’s possible your son is having some shoulder instability. The head of the humerus, a round ball at the top of the upper arm bone may be moving backwards out of the joint. This is called subluxation if it’s not fully dislocating.

Repetitive loading in the blocking position can put the shoulder at risk for instability from dislocation. You should talk with the coach or trainer but the best thing may be to see an orthopedic surgeon. X-rays, scans, and special tests may be needed to accurately diagnose the problem.

A special rehab program designed for this problem should be tried before jumping into surgery. Most of the time there’s a muscle imbalance that can be overcome with the right kind of strength training. The joint itself may have to regain its full joint sense of position called proprioception. The physical therapist will also address this problem during rehab.

Early detection and intervention are the keys to getting back on the field and staying there without further injury. Don’t put this off when it may be a small problem and before surgery or other invasive treatment is needed.

You are describing what sounds like a posterior shoulder instability. If it dislocates more than once, it’s called a recurrent instability. If you can pop it in and out yourself, it’s a voluntary instability.

Treatment for voluntary shoulder instability, especially in the posterior direction is a highly debated topic. Surgery isn’t usually recommended for voluntary shoulder instability. The recurrence rate after soft tissue repair is too high (as much as 72 per cent).

Conservative care may be a better approach to this problem. Physical therapy is advised to help you strengthen the muscles around the joint. Biofeedback is often used to help retrain the muscles in addition to strengthening them. They must learn when and how to contract and with the right amount of force for the action.

Activity modification is another big part of nonsurgical repair for voluntary recurrent shoulder dislocation. The first step is to avoid dislocating the joint. The therapist will tell you if there are other motions to avoid during the rehab process.

It sounds like you are describing a test called the relocation test. This is a test of shoulder instability. When positive, the first position (arm out to the side, palm up) causes the patient extreme anxiety or fear that the arm is going to dislocate again.

Downward pressure against the head of the humerus in this position prevents partial dislocation called subluxation or full dislocation. This test actually stabilizes the joint. It feels better because the humeral head is pushed back into the socket.

The doctor uses this test along with several others to tell 1) is the joint stable and 2) if not, how loose or unstable is it? Sometimes patients have pain with this test but no apprehension. That is not as diagnostic as the patient who has apprehension and pain at the same time.

There are many clinical tests used by physicians to assess the shoulder joint. Some tests look at the joint itself. Others test muscle strength or weakness. Still other tests help identify problems with the ligaments, cartilage, or tendons. Putting all the tests together along with the history of what happened guides the doctor’s diagnosis.

Some tests are more specific than others. Specificity refers to how often the test is positive when there’s a true problem. Other tests have greater sensitivity than specificity. Sensitivity shows the ability to show a true negative test. The best test has both high sensitivity and high specificity.

Researchers study clinical tests one by one to measure their specificity and sensitivity. Depending on the problem, they can use X-rays, CT scans, MRIs, or arthroscopy to confirm the findings.

These studies have shown us that pain isn’t the best indicator of what’s wrong. Apprehension (fear that the shoulder is going to dislocate) is a much better sign of shoulder instability. If you can’t relax enough to get a true test result, then the test(s) can be done again under anesthesia. The doctor may also use an arthroscope to look inside the joint while you are sedated. This is the best way to know for sure what’s wrong.

Sometimes joint infection after surgery requires a procedure called debridement. The surgeon goes back into the joint and cleans it out. In the case of someone who is being treated for an embolus (clot), another operation may have to be delayed.

Some surgeons advise treating infection first with antibiotics before performing surgery. Patients who have had surgery to treat infection often have a lower functional level after the operation. Usually a six week’s course of antibiotic therapy is required.

Studies show the results are better when this course of action is followed. In your husband’s situation, the six weeks’ time may be all that’s needed to completely resolve the embolus. If the infection doesn’t clear up, then the implant may have to be removed and replaced.

More and more people are having shoulder replacements. That means better results for everyone as surgeons become more familiar with the operation and as surgical methods improve. Implants will probably also get better as technology improves.

In the meantime, with more shoulder replacements, the number of problems can also go up. Revision surgery is possible but considered complex and difficult in many cases. The results of revision surgery may depend on the problem to begin with. Outcomes such as improved motion and function are less predictable if the muscles aren’t balanced properly. Soft tissue reconstruction can be very technically demanding.

Loosening of the implant parts is the most common reason patients need a second operation. The socket side is more likely to come loose than the ball and stem side. The surgeon’s decision about what to do is based on quality of bone stock at the time of the operation. Problems with infection or fracture of the bone or the implant can delay healing and complicate treatment.

Most, but not all, patients are satisfied after shoulder revision surgery. A stable shoulder with improved motion and function are usually the final outcomes.

Not all TV drama is real or accurate. Screen writers do try to research conditions, illnesses, and medical procedures and present them accurately.

In the case of shoulder dislocation, there are several ways to “reduce” or put the joint back in place. The most common method of shoulder reduction after dislocation is the traction counter-traction technique. The doctor pulls on the hand of the dislocated arm.

At the same time, pressure is applied into the armpit in the opposite direction. This method of shoulder reduction is often painful and doesn’t always work.

Using sedation such as general anesthesia relaxes the muscles around the joint. This allows the head of the humerus to slide over the rim of the socket and slip back into the joint.

What you saw on TV could have been the traction-counter traction method of reduction. Another way to do this is an old method called the Milch technique. The Milch method is a safe and easy way to reduce a dislocated shoulder joint. The patient’s arm is moved by the doctor or examiner into a position of 90 degrees of abduction and flexion as if to put the hand behind the head.

The head of the humerus slips back over the rim of the socket and fits back into the joint. No anesthesia and no surgery is required. Because it’s not a recent discovery and because it’s an old method, all doctors today may not know about the use of the Milch method to avoid surgery for shoulder dislocation.

It may be a good idea to make a follow-up appointment with an orthopedic surgeon. The ER doctor most likely made this recommendation. Under the stress of the moment, patients don’t always hear or remember what the ER doctor or nurse tells them.

Many emergency department staff will put younger patients (less than 20 years old) in a shoulder immobilizer (sling) for up to six weeks. The rate of recurrence (a second dislocation on the same side) is high in this age group. Other patients may be immoblized for a shorter period of time such as three to four weeks.

Healthy adults usually recover quickly after shoulder dislocation. No specific rehab is needed but may be helpful to prevent future problems. After an exam, your doctor will be able to advise you further about your case. Each patient may require something a little different based on how stable the joint is, how strong the muscles are, and how severe the dislocation was.

Yes and no. Rotator cuff tears (RCTs) are easy to identify with arthroscopic exam. But this requires surgery and is invasive and expensive. Arthroscopic examination is 100 percent accurate.

Physical tests and imaging studies vary in specificity and sensitivity. Specificity refers to the ability of a test to determine a true negative response. Sensitivity shows the ability of a test to determine a true positive response. Sometimes a test has high specificity but low sensitivity or vice versa. The ideal test has high specificity and high sensitivity.

A simple X-ray isn’t helpful in finding RCTs. Shoulder arthrography (injecting dye into the joint) is invasive and not always accurate. Ultrasound can be useful and is noninvasive but not always reliable. MRIs are the most sensitive and specific but very costly.

Researchers are doing studies using a handheld muscle testing device called a dynamometer to identify RCTs. A recent study from Australia showed this test has a 83 percent sensitivity and 79 percent specificity. The device is held against the patient’s arm as he or she presses against it by using muscle contraction force. A torn tendon gives a weak muscle test.

If there aren’t clear signs of a RCT you may be a good candidate for a rehab program. Most surgeons require at least six to eight weeks of conservative care for small RCTs. Time may be on your side — with rehab and a little extra time, your symptoms will likely either improve or get worse. Sometimes the diagnosis of a RCT needs this kind of approach.

Orthopedic surgeons know from personal experience and the results of published studies what works best for each type of injury. A single episode of dislocation may not need the cost and possible complications from surgery. A short course of physical therapy may be all that’s needed.

The surgeon bases his or her decision on several factors. The history (how it happened) and then the results of the physical exam are taken into consideration. There are some specific tests the doctor will carry out to assess how stable (or unstable) your shoulder joint is.

At least two episodes of dislocation are usually needed before surgery is considered. An MRI will show if the important ligament-labral complex has been torn or detached. This area of soft tissue and cartilage helps hold the shoulder in place. Without it, surgery is almost always needed.

Your age, activity level, and general condition are also part of the decision. Older, less active adults are often at less risk of another dislocation. Surgery may not be needed for these patients because rehab has good results. On the other hand, young active adults who are capable of an aggressive rehab program may be able to strengthen the shoulder without invasive surgery.

You will probably have a better result all around if you understand your surgeon’s thinking in this decision. Don’t hesitate to ask for an explanation. If you don’t think rehab is valuable, you may be less likely to follow through as you should.

You are probably seeing the difference between an open repair (you) and an arthroscopic or closed repair (your friend). Until recently the open repair had better results for this problem. There were fewer cases of recurrent dislocation after the repair with the open method.

But newer techniques and a better suture system have changed those results. Now the arthroscopic repair has an equal rate of recurrent instability. Recurrent instability refers to repeated shoulder dislocations. The next step is to compare other outcomes from the two surgeries.

For example, do patients have the same pain levels after both kinds of surgery? Does one method give better function than another? Are patients more satisfied with the result with the open or closed method? The first study comparing these factors has been done.

Researchers report equal results when patients are matched for type of injury. They suggest that the decision is one of personal preference on the part of the surgeon.

You may have seen a dynamometer used to measure maximal forces in the shoulder. It’s a measure of the force of a contracting muscle. A pressure plate is held against the patient’s wrist while he or she presses against it as hard as possible. This type of muscle contraction is called isometric.

The gauge reads peak force in newtons. Some dynamometers also measure the time it takes to reach peak force and the total test time. As a manual muscle tester, it’s accurate, objective, and reliable.

Researchers in Australia have tested patients with rotator cuff tears using a dynamometer and compared the results with healthy adults without a rotator cuff tear. They found that the dynamometer is a useful tool when screening for rotator cuff tears. It is noninvasive, inexpensive, and easy to use.

Now muscle strength can be measured before and after surgery and before, during, and after rehab. It’s not 100 percent accurate so only during surgery is the diagnosis confirmed but dynamometer testing for rotator cuff tears could replace expensive imaging such as MRIs.

Hindsight is always 20-20 — meaning it’s easier to look back and see what might have been better than to look ahead and predict what’s best. In many cases there’s simply no way to tell what’s best for each patient.

Surgery to repair a rotator cuff tear has changed from a full, open-incision operation to all-arthroscopy with no incision. The mini-open repair is in between those two options with a small incision made during arthroscopic surgery.

Failure rates with recurrence of the rotator cuff tear are fairly equal between the mini-open repair and the all-arthroscopic procedure. Other factors may be at work here. Tendon quality, abnormal scarring, and postoperative rehab program may influence recurrence rates. Larger tears are more likely to tear again.

Postoperative stiffness is a common problem after the mini-open operation. Extra stretch is put on the deltoid shoulder muscle when the surgeon works through a small incision. There have also been reports of repair failure from a rehab program that’s too aggressive. For example, using weights with an overhead pulley too soon after surgery has been linked with a high rate of repair failure. Overloading the repair site can result in re-injury.