FAQ Category: Shoulder

A failed rotator cuff tendon repair is usually defined as one that has torn all the way through the tendon again. This is called a full-thickness defect. Your experience is not uncommon. Studies report some question about how much tendon healing is linked with pain relief. Patients with poor tendon healing can still get full pain relief. This means that the symptoms are not an accurate gauge of tendon healing.

The primary difference you are likely to notice is in the area of strength. A complete repair is needed before you can get back your full muscular strength. Strength also depends on muscle quality and how much fat has filled in and around the muscle fibers.

It’s also possible the rehab program can make a difference in outcomes but this remains an area of study at this time.

Cases of joint arthritis after a traumatic injury are very common. This is true for any joint, not just the shoulder. The type of operation you had is also linked with a higher rate of arthritis afterwards.

The Bristow procedure named after W. Rowley Bristow, MD was used most often back in the 1970s when shoulder repairs were done with an open incision. Today, arthroscopic surgery has replaced open procedures in many cases.

The Bristow procedure transferred the tip of the coracoid process to the front of the shoulder socket. The coracoid process is part of the scapula (shoulder blade) that juts forward toward the front of the shoulder.

The idea was to use this piece of bone to reinforce the shoulder socket. It kept the head of the humerus (upper arm) from popping out of the socket. Usually a piece of muscle was also attached like a sling to help as well.

The Bristow procedure is still used in Europe but has been replaced by other methods now in the U.S. There were concerns about restricted motion and arthritis leading to the development of other methods of surgical repair. The coracoid transfer is still used for some patients. Long-term results have been excellent bringing this method back to the attention of orthopedic surgeons for a second look.

There are many factors that affect the results of an injury of this kind. The severity of the injury, the type of operation done, the skill of the surgeon, and the healing powers of the young woman’s body all play into the final result. Good nutrition in a non-smoker is also important in wound healing.

There aren’t very many studies on this topic but there is one that may help answer your question. Back in the 1970s a group of U.S. Naval Academy midshipmen had surgery to repair an unstable anterior (forward) shoulder dislocation. At that time the operation was done with an open incision. The type of surgery done isn’t used much anymore because newer and better ways have been found to reinforce an unstable shoulder joint.

The results were very good. All patients graduated from the Academy. They had to pass a rigorous physical exam including running, swimming, pull-ups, sit-ups, and other tests. Only one of the patients had to change his career choice from special warfare to aviation.

Long-term results were good but not 100 percent. About 14 percent were given a disability rating when they left active duty. Some of those had recurrent dislocations that required another operation.

Today, 30 years later your daughter will have the benefit of new, improved surgical and rehab methods. The chances of a full recovery are very good.

Surgery to stabilize the shoulder after dislocation used to be saved for patients who had recurrent dislocations. It wasn’t routinely done after the first dislocation. Surgery has its complications and rehab worked for many people. This same guideline is still used by many surgeons. The change has come in patient selection.

Patients who are at high risk for another dislocation on the same side may be advised to have stabilization surgery after the first dislocation. Studies show that early repair makes a big difference in quality of life. This is especially true for younger patients (less than 30 years old).

Recurrence rates are as high as 75 percent in active individuals who try four weeks of immobilization followed by a rehab program. This compares to 11 percent in patients who are surgically repaired.

Recurrence rates have dropped and results have improved as surgical techniques have changed over the years. Now surgeons recognize the need to repair any damage to the soft tissues around the shoulder after dislocation.

For a young, active, athlete like your daughter the data suggests that early repair and rehab will put her back on the playing field sooner and with fewer problems compared to a wait-and-see rehab approach. You may want to get a third opinion to make sure there aren’t good reasons to choose one treatment approach over the other.

There are several things to consider here. First, how does the motion in your right shoulder compare to the left? You probably can’t expect to get more motion than you would have normally.

Second, how does your current motion compare to the motion you had before the surgery? Your surgeon may have taken measurements and can give you this information. Surgery to repair a dislocated shoulder doesn’t aim to restore full motion but you should be able to get 95 percent of the motion you had before surgery or compared to the left side.

Next, is the loss of motion due to pain, scar tissue, or some other factor? You may want to discuss this with your doctor. Depending on the cause of your motion restriction, a short course of physical therapy may be helpful. Again, make a follow-up appointment with your surgeon to find out what you can expect for full recovery and how to get there.

Dead arm syndrome starts with repetitive motion and forces on the posterior capsule of the shoulder. The posterior capsule is a band of fibrous tissue that interconnects with tendons of the rotator cuff of the shoulder. Four muscles and their tendons make up the rotator cuff. They cover the outside of the shoulder to hold, protect, and move the joint.

Overuse can lead to a build up of tissue around the posterior capsule called hypertrophy. The next step is tightness of the posterior capsule called posterior capsular contracture. This type of problem reduces the amount the shoulder can rotate inwardly — a motion needed by pitchers to throw the ball forward before releasing it.

Over time, with enough force, the player may develop a tear in the labrum. The labrum is a rim of cartilage around the shoulder socket to help hold the head of the humerus (upper arm) in the joint. This condition is called a superior labrum anterior posterior lesion. The final outcome in all these steps is the dead arm phenomenon.

The shoulder is unstable and dislocation may come next. Dead arm syndrome won’t go away on its own with rest — it must be treated. If there’s a SLAP lesion, then surgery is needed to repair the problem. If the injury is caught before a SLAP tear, then physical therapy with stretching and exercise can restore it and return the player to the field.

Shoulder problems are very common among baseball pitchers and other overhand throwing athletes. The pitching or throwing motion puts torsional overload on the fibers of the rotator cuff with actions repeated over and over.

Since the fibers of the tendons attach around the joint and to the bone, repetitive motion can also affect these areas. Shear force of the tendons can actually cause the tendon to tear or rupture. Sometimes a piece of the joint cartilage or bone comes off too.

These are the kinds of injuries pitchers try to avoid. Early screening during training is very helpful to identify any problems such as a loss of motion, joint tightness, or loss of flexibility. Sometimes too much motion can cause shoulder joint instability.

Stretching and strengthening are usually the first steps in a conservative plan of treatment. If these don’t work, then surgery may be needed. For example, if the tissue around the shoulder is too tight, one or more incisions may be made to release the joint capsule. Intensive physical therapy is needed afterwards to maintain the motion.

The acromioclavicular or AC joint is located along the front of the shoulder. It’s the point where the acromion meets the collarbone (clavicle). The acromion is a piece of bone that comes off of the shoulder blade and curves over the top of the shoulder joint.

Scar tissue, bone spurs, and other age-related changes can cause pain and loss of function at this joint. Cutting out the distal end of the clavicle where it meets the acromion is often a good way to relieve the pressure and reduce the pain.

Failure to get rid of the pain after clavicle resection occurs when the source of the problem is something besides the ACJ or when joint instability develops after surgery. Sometimes too much bone is removed also contributing to ACJ instability.

Instability is reported in about 10 percent of the cases when the surgeon uses the direct approach instead of the standard bursa method. Damage to the joint capsule and supporting ligamentous structures can cause this kind of problem.

Be sure you go back to your surgeon for follow-up. There may be other treatment options available to you. Re-evaluation at this time may help clear up the original cause of your symptoms.

You’ll need to see an orthopedic surgeon to find out for sure. Being able to point to the pain with one finger suggests a local problem in one of the soft tissue structures along the front of the shoulder. This could be a tendinitis or acromioclavicular (AC) joint problem. Shoulder pain can also be referred from one of many other structures including the neck, heart, chest, kidney, or stomach.

The doctor will take a history and examine you first before deciding if X-rays or other imaging studies would offer helpful information. Your symptoms especially when it hurts and how you move help the physician tell what’s wrong. He or she will also palpate (feel) different structures to see what’s hurting.

The AC joint (acromioclavicular) occurs where the outer end of the collarbone meets up with the curved acromion coming around from the shoulder blade. This is a common area of injury and instability with young people and degenerative changes in older folks.

Sometimes an injection of a local numbing agent is helpful. Lidocaine and a steroid mixed together and injected into the AC joint can rule out or verify the joint as the source of pain.

There are many clinical tests the doctor can use to find out what’s wrong. Early diagnosis and treatment may help prevent further problems later.

The ability to sublux (partial dislocation) or fully dislocate the shoulder joint is possible for people with loose ligaments, a condition known as ligamentous laxity. Your son may have been born this way or he may have developed this condition over time with repetitive trauma. Swimmers and baseball players or volleyball players are affected most often.

It’s best to avoid voluntarily popping the joint in and out. Over time the ligaments and other soft tissue structures holding the joint in place get stretched out. Pain can limit activities.

In rare cases, the individual may traumatically dislocate the shoulder. Surgery may be required if the joint capsule or the rim around the joint called the labrum are torn or ruptured.

Bankart or reverse Bankart injuries occur in the shoulder. They are usually the result of a traumatic injury leading to shoulder dislocation. About 95 percent of all shoulder dislocations occur in the forward (anterior) direction. In the case of the Bankart lesion, the anterior labrum tears during an anterior shoulder dislocation.

The labrum is a rim of extra cartilage around the shoulder socket. It helps deepen the fairly shallow shoulder socket to keep the head of the humerus inside the cup. With a reverse Bankart, the shoulder dislocates in a backward direction (posteriorly). The back (posterior) portion of the labrum is torn or ruptured. This type of injury is rare.

Your father has broken his upper arm bone called the humerus. Holstein-Lewis tells us the location of the break: in the lower third of the bone, sometimes at the juncture of middle and distal third of the bone. This type of fracture usually causes a spiral fracture that curves around the bone rather than going straight across.

Holstein-Lewis fractures are often treated with bracing rather than a cast to avoid elbow stiffness. Nerve injury can occur if bone fragments pierce the nerve. One in five patients have nerve injury that usually gets better with time and healing (3 to 4 months). Surgery may be needed if there is delayed healing of the bone or nerve.

The pectoralis (pec) major muscle is the large, fan-shaped muscle across the chest. The pectoralis minor muscle is a much smaller muscle underneath the pec major. The pec major attaches in many places. There are separate attachments along the breastbone, collarbone, and into the upper arm (humerus).

Depending on how the rupture occurs, different portions of the tendon may be injured. A partial rupture means that one or more sections have torn away from their attachments. A complete rupture usually refers to a severed tendon as it inserts into the humerus.

An MRI is usually needed to show the full extent of the injury. It will show whether the rupture is partial or complete and the amount of muscle retraction. In acute injuries MRI shows if there’s any bleeding or swelling in the area. In chronic injuries scarring and fibrosis can be seen.

For low-demand activities, a partial rupture can be treated conservatively. This means a rehab program but no surgery is needed. For someone like you who is a manual laborer, surgery to repair the tear may be the best option. A delay in treatment can result in weakness and loss of motion.

Pectoralis (pec) muscle rupture used to be a rare injury. Today it’s becoming more common with increased competitive sports events. Weight-lifting among middle-aged men is also bringing an increase in this injury. Bench pressing seems to put the greatest stress on the muscle when the arm is abducted and extended away from the body.

Studies show that surgery has the best results when the tendon is ruptured completely. Muscle belly tears or partial tendon tears may recover with more conservative care. Cosmetic results are usually good no matter what kind of treatment is applied.

There are however, occasional reports of poor cosmetic results with asymmetry or uneven muscle definition. If surgery is delayed for any reason, scar tissue may fill in the hole. The muscle retracts and atrophies causing weakness and an altered chest structure from one side to the other.

Given your interest in body building, it might be a good idea to get a follow-up visit with your surgeon. It’s possible a revision surgery for cosmetic reasons could help. Or perhaps a different rehab program designed for your particular goals would give you the results you’re looking for.

The radial nerve is the one most likely injured when there’s a fracture of the humeral shaft (upper arm bone). Damage can affect the motor and/or sensory function of the nerve.

With motor loss there is weakness of the wrist extensors. You will notice difficulty extending the wrist. Sensory loss is more likely to cause symptoms of numbness, tingling, or pain.

Most patients know by the end of 12 weeks if there has been some nerve damage. Most of the time a clinical exam by the doctor is all that’s needed to tell. The type of fracture is the first tip-off that there may be a problem. Nerve laceration is most common with spiral or comminuted (many small pieces of bone) fractures.

Special nerve tests can be done to confirm the changes. Surgery may be needed to find out what’s wrong and repair it.

You didn’t mention your age and we hate to bring it up but it’s a fact that shoulder dislocation with rotator cuff tears (RCTs) occur more often in people over 40 years of age. Active older adults are at greater risk for these types of injuries because of the changes in collagen tissue as we age.

In your case the shoulder dislocation happened first (and second) before the rotator cuff tear. In many patients it’s not clear if the rotator cuff tear caused the shoulder to dislocate or the other way around. Studies do show that repeated dislocations are a risk factor for RCTs.

Surgery to repair the damage is advised to avoid chronic shoulder instability.

Many shoulder dislocations occur at work or during recreational or sports activities. Most people give the same report the first time it happens. They didn’t have pain, popping, or any symptoms to suggest the shoulder wasn’t stable.

Once a shoulder has dislocated, it can happen again. Warning signs and symptoms of repeated dislocations called prodromal symptoms may not be present. Most of the symptoms of first or repeat shoulder dislocation such as pain, muscle spasm, and loss of motion occur after it’s already happened.

Some people can pop their own shoulder out of the socket. This is called voluntary dislocation. Patients are advised not to do this since the soft tissue around the shoulder can get stretched, putting the person at greater risk of chronic dislocation.

The more times a shoulder is dislocated, the greater chance there is for rotator cuff tears around the shoulder.

The specific dynamics of the first dislocation may not be fully understood. Repetitive motion is a likely factor. Was there a partial tear of the rotator cuff already present? Or do the rotator cuff tears seen with shoulder dislocations happen after the joint dislocates? Researchers are investigating these questions with the hope of preventing shoulder dislocation and the damage that can occur.

There is some evidence that small rotator cuff tears of a single tendon can heal on its own. Age may be helpful in terms of good blood supply but most younger adults are also very active. Increased activity is more likely a deterrent to healing in this case.

But the biggest determining factor is the size of the tear. Tears less than 100 mm2 (less than two and a half inches) may heal. MRIS may not be able to show a tissue defect but the new collagen tissue has reduced strength. There is always a risk of rerupture for the active, young adult.

For moderate to large sized rotator cuff tears, repair is advised. Even if it reruptures, the results are usually better than if no repair was done. And in the long run, repairing the rotator cuff seems to offer some protection to the joint from degenerative arthritic changes.

There’s only one study so far to look at the long-term effects of rotator cuff rerupture. Twenty patients treated at the University of Zurich in Switzerland were included. All had one or more tendon(s) repaired with an open incision.

Rerupture was shown on MRIs but not repaired a second time. At the end of three years the patients were re-examined. X-rays, MRIs, and clinical tests were done again. These same patients were followed for another three and a half years. The same tests were done again.

In two-thirds of the cases, small rotator cuff reruptures had healed. For the rest of the patients whose reruptures didn’t heal, the tears weren’t any worse. In all 20 patients, strength and function were better than before the first repair. Compared to patients who don’t have the original tear repaired surgically, all 20 patients had better results (even with a rerupture).

The shoulder is a ball and socket joint. Replacing just the top of the humeral head (ball) or just the socket (glenoid) is called a hemiarthroplasty. Most of the time only the humeral head is replaced in a hemiarthroplasty.

The benefits of hemiarthroplasty include less time in the operating room, less cost, and less blood loss. Smoothing and replacing the glenoid side increases the risk of problems. The glenoid implant is also more likely to pull loose.

Most patients get good results with humeral head replacement. They report pain relief and improved motion and strength. The overall positive outcome is improved function for daily activities.

Hemiarthroplasty is advised for younger, more active patients who have a good glenoid surface. Balanced muscle strength around the joint is also important. The only red flag about hemiarthroplasty is the result of recent long-term studies. It seems the good results deteriorate over time. Studies comparing partial to total shoulder joint replacement are looking to see if it wouldn’t be better in the long run to start with a total joint replacement.