FAQ Category: Shoulder

Osteoarthritis is the most common problem treated by joint replacement, including the shoulder joint. Patients get significant pain relief and improved function. The major contraindications for this operation are active infection in the joint or paralysis of the shoulder muscles.

Since you are a paraplegic with use of your arms, you may be a good candidate for this operation. Several factors must be considered. For example, younger patients may be better off having a partial joint replacement.

This is called a hemiarthroplasty. Usually the ball at the top of the humerus or upper arm is replaced. There are still problems replacing the socket (glenoid) side. There’s a greater chance that the glenoid implant will come loose.

The condition of your rotator cuff is important. The rotator cuff is made up of four major muscles and their tendons that envelope the shoulder joint. Proper soft tissue balance is important in the success of shoulder replacement.

An orthopedic surgeon is the best one to advise you on this decision. A careful physical exam and X-rays will guide the doctor in offering you the best treatment options. Depending on your age, overall health, and lifestyle you may want to think about a motorized scooter or electric wheelchair. Saving wear and tear on your joints is important but so is the activity and strengthening you get from pushing your own chair.

Repair of massive tears of the rotator cuff can be problematic. In some cases they are considered irreparable. Studies have been done trying different surgical methods of treatment for this problem. So far there hasn’t been a single type of surgery that works best.

For the most part the best approach seems to be cleaning up the damaged tendons. This is called debridement. Then the bone across the top of the shoulder (acromion) is removed. This is called an acromioplasty. If just the underside of the acromion is shaved, it’s called a subacromial decompression.

When any part of the rotator cuff is torn and can’t be repaired, an imbalance occurs at the shoulder. That’s why the rest of the rotator cuff can get impinged. Reducing or removing the acromion leaves room for the remaining tendons of the rotator cuff to slide and glide without getting pinched.

Other surgeries used to reconstruct massive rotator cuff tears include tendon transfers, fusion, and tendon grafting. No one method seems to have better results than the others.

There have been a couple of studies done on the use of allograft rotator cuff tendon repairs. An allograft refers to a tendon from a donor. Most often the Achilles, patellar, or quadriceps tendons are used for this operation.

One study reported this was an excellent way to repair massive rotator cuff tears (RCTs). The second study was not as successful with poor results overall. In a more recent study, researchers at the University of California – Los Angeles report on the results of 28 shoulders with massive RCTs. Everyone was treated using an allograft.

Pain improved. Range of motion and function were also better. But MRIs showed that the graft didn’t hold in place. Without the balance of all four tendons of the rotator cuff around the shoulder, the head of the humerus (upper arm bone) started drifting upward out of the socket.

The results of the allograft operation were not better than other methods of repair and it cost a lot more. There is also the possibility of graft infection and rejection.

With your history it’s best to discuss your options with one (or more) orthopedic surgeons. There are other ways to treat this problem with a better track record than tendon transplantation.

Reducing a dislocation of any joint means the joint is put back in place or ‘relocated.’ A closed reduction suggests the medical person who treated him was able to get it back in place without surgery.

Sometimes it’s just a matter of putting the patient in just the right position and the bone will slip back in place. For example, one way to relocate the collarbone (clavicle) to the sternum is to lie down on the back with the dislocated side on the edge of a table. A sandbag is put between the shoulders. The arm is brought out to the side and pulled out gently. The sound of a “pop” occurs when the clavicle goes back into place.

There are several other ways to relocate this joint. If that doesn’t work then surgery or open reduction may be needed. The clavicle is lifted up and put back in place. If it stays there without slipping down the incision is closed and the patient is immobilized in a special sling to hold it in place.

If the clavicle keeps slipping out of place then more extensive surgery may be needed. Your son should be advised not to do any lifting for the next six weeks until the joint is fully healed. Strenuous upper body exercises such as push-ups or pull-ups should also be avoided.

Any time new symptoms develop after a car accident, a medical exam is needed. There are many vital organs and structures behind the breast bone (sternum) that could be damaged from the impact with the steering wheel.

A shoulder injury can also affect the sternoclavicular joint (SCJ). The SCJ is located where the clavicle (collar bone) connects to the sternum. There could be a partial dislocation or subluxation of this joint.

Don’t wait to get her in to see a doctor. This may be an emergency and should be treated as such. Difficulty swallowing called dysphagia could indicate swelling of the esophagus or a more serious injury.

Shoulder fusion is not used as commonly as it once was. Shoulder replacement has replaced fusion in many cases. If you haven’t already talked to your surgeon about a total shoulder replacement, you may want to ask about this as an option before shoulder fusion.

Shoulder fusion or arthrodesis is called a salvage procedure. The arm is saved from amputation but full shoulder motion isn’t preserved. You may not have enough motion to swing a rope over your head or enough strength to wrestle a calf to the ground.

The fusion is done using metal plates and screws. The reconstruction plate is actually one normally used in the hip or pelvic area. It goes up along the outside of the upper arm and over the top of the shoulder along the bony ridge of the shoulder blade. Screws help compress the bones together to fuse the area. Sometimes bone grafts are used to fill in any spaces left open.

Your arm will be immobilized for at least eight to 10 weeks. Some doctors use a special abduction pillow. Others put the arm in a full cast from wrist to shoulder. Once there is evidence of fusion on X-ray, rehab exercises can begin.

Modern fusion methods have improved the results quite a bit. Nonunion is still a problem for about 10 percent of the patients. The bone simply doesn’t fuse completely. Most nonunions are painful. Another operation may be needed to use bone graft to get a solid fusion.

Getting the right position can be a problem. The shoulder must be fused in a position that allows the patient some motion. Not enough flexion may keep the patient from reaching the face to wash or brush teeth. There needs to be the right combination of flexion, rotation, and abduction (moving the arm away from the body).

Sometimes there are problems where the metal plates and screws on the inside rub against bone or soft tissue. The fixation devices can even poke through the skin. If the fusion is solid then part or all of the hardware can be removed.

The last problem is fracture. Without motion the bones around the shoulder start to lose density or mass. This weakens the bone so that even minor trauma can cause a fracture.

All in all shoulder fusion called arthrodesis works well for many patients. It stabilizes the arm and reduces painful symptoms. There’s still enough motion to allow for daily activities of care.

The empty can test refers to a position of the arm used to identify problems with the supraspinatus muscle. The supraspinatus is one of the four muscles/tendons that make up the shoulder rotator cuff.

The test was first described in the early 1980s by two very well-known orthopedic surgeons (Drs. Jobe and Moynes). The arm is raised out to the side with the elbow straight and the thumb pointing down towards the ground as if you were emptying out a can of soda pop.

The shoulder is fully rotated inward (internal rotation) during this test. Any weakness to resistance while in this position suggests a tear of the supraspinatus tendon.

The rotator cuff is a group of four muscles and tendons that slip over the shoulder like an envelope. One or more of the tendons can develop a tear or tendonitis. It isn’t always easy to identify which one(s) are involved.

Shoulder pain patterns aren’t specific for rotator cuff tears (RCTs). For example pain can occur in the front, side, or back of the shoulder with a RCT. Since there aren’t a lot of pain nerve endings in the rotator cuff itself, doctors think most of the pain comes from the bursa getting pinched.

The doctor can apply specific tests for each tendon to help narrow down the problem area. MRI or arthroscopic exam is really needed to show what is wrong and the extent of the damage. This information will help the doctor plan the best treatment approach.

X-rays aren’t used to diagnose problems with soft tissues like tendonitis or a torn rotator cuff. MRIs and arthroscopic exams are better choices. In the case of a cuff tendonitis there are two important signs that guide the doctor’s exam.

The first is a positive painful arc test. As the patient lifts the arm out to the side and up over the head, the pain is reproduced during the middle of the movement. This usually occurs somewhere between 60 and 120 degrees of motion.

Injecting a local numbing agent into the subacromial space is also a helpful test. Pain on movement goes away when this test is positive. It indicates that the tendon is getting pinched under the acromion as the arm is raised. The acromion is a curved bone that comes around from the shoulder blade over the top of the shoulder. One of the rotator cuff tendons (the supraspinatus) passes under this bone.

Other helpful tests include palpation and strength testing. Pressing on the painful tendon reproduces painful symptoms. Specific strength tests for each tendon may be weak pointing more to a rotator cuff tear than to tendonitis.

A short course of physical therapy can also help with the diagnosis. Exercises to improve your posture may help take pressure off the tendon and allow it to heal.

Athletes involved in overhead throwing sports often have shoulder problems. These range from tendonitis to rotator cuff tears to dislocations. SLAP injuries (superior-inferior-labral anterior posterior lesions) of the cartilage are especially problematic.

The labrum is a rim of cartilage around part of the shoulder socket. A SLAP injury means the labrum has pulled away from the bone. It can be rated one to four to show how severe the tear is.

Diagnosis of shoulder problems in athletes is best made by an orthopedic surgeon. A history and exam are the first two steps. Special exam tests can be done to help sort out which soft tissues are involved. MRI may be helpful. The only way to know for sure what’s wrong is an arthroscopic exam.

The surgeon inserts a thin needle with a tiny TV camera on the end into the joint. The tool can be rotated around to give the surgeon a good look at the joint, ligaments, and other soft tissues. The arthroscopic exam often confirms and gives details of what the MRI shows.

Talk to your coach about your symptoms. The coaching staff may be able to help you identify what’s wrong. As with any acute injury, rest and ice are the place to start. If the symptoms don’t get better or go away, then a medical referral is advised.

Injuries to the labrum, the cartilage rim around the shoulder, are complex and difficult to treat. Improper treatment or rehab can result in an unstable shoulder. Often there are other soft tissue injuries that occur at the same time causing even more complications.

Most labral tears are sports-related injuries. Athletes (and military recruits) often have a purpose-driven approach to activity and exercise. Usually this attitude is in their best interest. After surgery, a different set of values is more helpful.

For example following the surgeon’s directions and being compliant with treatment is crucial to the success (or failure) of treatment. Soft tissue healing can’t be rushed. In normal, healthy adults, it takes six to eight weeks for the tissues to knit back together.

That’s a minimum, not a maximum time frame. If the surgeon used bioabsorbable sutures to make the repair it takes time for the body to repair the damage and absorb or dissolve the anchors holding everything in place.

Going back to PT (physical training), especially if it involved any push-ups, pull-ups, or weight lifting before the tensile strength of the ligaments and tendons are ready is a common way to cause failure of the fixation.

The best thing you can do for yourself after this revision surgery is to follow the doctor’s orders. Consider what he or she says and tells you to do no different than your drill sergeant’s commands. You’ll be on a medical profile so there’s no shame in wearing the sling and avoiding activities you’ve been told to avoid until the right time.

When in doubt, ask! Don’t ask your fellow cadets or drill sergeant. Ask your doctor and only your doctor what you can and can’t do, and when you can and can’t do it.

Bioabsorbable means the body can break down the device. It dissolves and is absorbed by the body. The blood stream will carry it to the kidneys where some of it will be sent out of the body through the urine. Particles that can’t be gotten rid of will go to the liver, the body’s toxic waste site.

The tack helps reattach soft tissues to the bone. They are made of a synthetic (manmade) copolymer that doesn’t set up an inflammatory response by the nearby tissue. They work well for ligaments, tendons, and bones. Tacks or anchors come in different sizes and shapes depending on how and where they are used.

There may not be any restrictions. Your surgeon will advise you according to what is done in the operating room. Most often patients are limited only by their pain. They are encouraged to use the arm with as much motion as soon as possible.

The reason for this is because with this type of surgery there are no stitches or sutures to be careful of. The healing tissue isn’t likely to pull apart. No tendon has been sewn back to the bone.

Debridement is just a cleaning up process. Any fragments of torn tissue are carefully removed. Rough patches are shaved and smoothed. In an acromioplasty, part or all of the bone that comes across the top of the shoulder is taken out. Movement is going to be the best rehab.

You probably won’t want to lie on that side. And when you lie down on the other side, it might be helpful to have a pillow under the arm that was operated on. This will help support the healing soft tissues. The physical therapist will probably instruct you in some range of motion and gentle strengthening exercises to get you started.

You didn’t mention your age, your activity level, or any other health problems you may have. For example the rotator cuff does tend to degenerate as we age — and sometimes without us even knowing it! This is because our activity level is starting to slow down too. We aren’t doing those one-arm push-ups anymore that would signal a problem.

Arthritis often catches up with us and any new ache or pain is attributed to that. Many people get along with partial range of motion and strength just fine — again, for the same reasons mentioned here. We do less as we get older so we don’t notice a big difference.

It sounds like you had partial rotator cuff tears if you had no symptoms (or very few). With few overhead or contact sports activities, you could very well have partial tears and not know it.

There are some long-term effects of throwing in the shoulders of throwing athletes. The glenohumeral (shoulder) joint comes under high joint forces, speed, and stress during this activity.

Extreme positions of motion may actually alter the shape of the joint capsule and surrounding ligaments. Joint stability may even be compromised. Right now all we have are theories. Evidence to prove any of these changes occurs is lacking. Even the idea that the soft tissues “stretch out” after long-term throwing remains unproven.

In a recent study of elite baseball pitchers, physical therapists from the University of Florda offer some insight. They measured the joint motion and stiffness of 34 professional baseball pitchers. They found the same amount of motion on both sides (throwing versus nonthrowing shoulders). What they noticed was that the pitching arm had more external rotation. The nonthrowing arm had more internal rotation.

The front portion (anterior capsule) was stiff in both arms. This stiffness gave the joint greater stability. There was less risk of injury. The risk of arthritis in the adult years with overhead pitching in young children isn’t known yet. More long-term studies are needed.

Overuse injuries are a worry for any throwing athlete. Long-term effects of throwing include changes in the stabilizing structures around the shoulder joint. This puts the athlete at increased risk of injury.

Stiffness of the soft tissues around the joint is needed to protect the shoulder. Stiffness restrains the joint and helps prevent subluxation or dislocation. A lax joint can allow the head of the humerus to slip out of the joint socket.

The repetitive motion of a baseball pitcher does change the way the joint moves, especially the amount of external rotation that is present. A recent study at the University of Florida showed that this altered rotational pattern doesn’t affect the joint’s passive restraining mechanism. That’s good news!

If you do have a loss of the natural protective joint stiffness at the end range of motion, you may need a specific exercise program. A physical therapist can help you with this. Motion will be tested (quantity and quality). Then a specific program of exercises can be suggested. The goal of muscle strengthening is to increase joint stiffness and reduce the risk of injury.

Your surgeon is the best one to advise you on this matter. Treatment for anchors that have moved or were put in the wrong place depends on several factors. The first is usually based on the patient’s symptoms. Someone with pain and loss of motion will be treated differently from a patient who has no symptoms.

If the implant is securely fastened, it may not be easy to remove or replace it. If it’s sticking up, the surgeon may be able to push it back down. And if the patient isn’t having any symptoms but the surgeon detects shoulder instability, a second anchor or tack may be added in the right place. The original suture is left in place.

Synovitis or an inflammation of the synovium occurs about four to six percent of the time. The synovium is a lining inside the joint with fluid that lubricates the joint. The inflammatory response is common when the body sees the sutures as a foreign invader. As the suture starts to break down, this reaction is triggered.

Synovitis occurs most often when sutures or tacks are placed inside the joint (as opposed to on the outside of the articular surface). The reaction occurs about two to four months after the operation. This is about the time the suture material starts to disintegrate.

Studies show that some materials are more likely to cause synovitis than others. The reason for this is unknown. It may be the design, type of material used, or amount of surface exposed. Given how popular these devices have become, we may expect to see this problem occur more often in the future.

Your surgeon will really have to examine your shoulder to know for sure what’s going on. There may be a problem if the torn soft tissue was reattached using tacks or suture anchors. Sometimes these devices push through the cartilage and rub against the bone.

Sometimes knots tied in the wire don’t slide or glide like they are supposed to. Anchors, tacks, screws, and other implants used to reattach soft tissue to bone can come loose or even break. A piece of the device (or even the whole device) can move or migrate inside the joint.

X-rays are often used as the first imaging study. If the device is radiolucent, it may not be seen. In these cases, MRIs are done. Don’t wait to call your surgeon or make a follow-up appointment. Early detection and treatment can save you from worse complications and problems later.