FAQ Category: Shoulder

There are actually two ways to tear the rotator cuff. Trauma is the most common in the young, athletic population. Aging is more common in the over 50 crowd. Aging comes with its own wear and tear process in the shoulder.

The rotator cuff is a group of four tendons surrounding the shoulder. Over time and with use, it’s possible to wear a hole in the rotator cuff. Many people aren’t even aware it’s happening. It a lot like wearing a hole in the seat of your pants.

Weakness and then pain start to get our attention. It’s not until the person has trouble reaching behind to unfasten a bra or put on a coat that the problem is recognized.

The shoulder is a very complicated joint. In fact, the shoulder complex is really made up of four different joints or moving parts. And with lots of muscle bulk around it, access to the affected area can be difficult, if not impossible. Not only that but pain patterns often overlap. In other words the patient’s description of his or her pain can be caused by more than one condition.

Many of the clinical tests doctors do only confirm the problem is in the shoulder. They don’t tell the doctor exactly what’s wrong. New information is coming out all the time about the shoulder and changing the way doctors conduct their exams.

X-rays are still the first imaging test ordered. There are two different views that help the doctor see inside the joint. An accurate diagnosis is really the key to choosing the best treatment. Be patient and bear with the process. Although it’s come a long way, orthopedic medicine still isn’t always an exact science.

Finding out what’s wrong with a patient’s shoulder can be a difficult task even for the best orthopedic surgeon. The shoulder joint is actually a group of four different joints with many layers of soft tissue.

Besides rotator cuff tears, arthritis, impingement, bone spurs, and tumors can cause a stiff shoulder. Your history (how and when the symptoms came on) can help the physician sort out one problem from another. For example with a rotator cuff problem the pain occurs with motions as the arm is raised or lowered. With capsular stiffness pain doesn’t occur until the patient reaches the limit of joint motion called the end range.

There are various clinical tests a doctor can perform to help sort out the cause of a shoulder problem. Imaging studies such as X-rays, CT scans, and MRIs may be needed.

Sometimes the only way to know for sure is to perform an arthroscopic exam. The doctor inserts a long, thin needle into the joint. A tiny TV camera on the end of the tool allows the surgeon to view on a TV screen what’s going on inside the joint. A less invasive test is the use of lidocaine (a local anesthetic) injected into the joint. Pain relief occurs when there’s a rotator cuff problem but not with a stiff shoulder.

Both of these tests are used to look for shoulder instability. In the load and shift test, your daughter would be sitting up straight. The doctor places one hand over the top of the shoulder to stabilize the scapula (shoulder blade). The other hand grasps the top of the humerus (upper arm bone) where the bone inserts into the shoulder socket.

The humerus is shifted forward and back. The doctor looks and feels for the amount of shifting in each direction. This test helps the examiner tell how loose or lax the joint is. Too much or not enough motion in one direction is diagnostic of shoulder instability.

The joint may not be dislocated but the ligaments and capsule around the shoulder may be stretched from the injury. In such cases the shoulder shifts farther in one direction compared to the other. For someone who has loose ligaments in general, the amount of shift will be equal from one direction to the other.

The crank test is also known as an “apprehension” test. It also tests for instability problems, usually caused by trauma. The patient is lying on her back with the arm out to the side and the elbow bent. The hand is moved back like a crank toward the ear on the same side.

A positive test is a look of alarm on the patient’s face. The patient will not want the arm to be cranked back any further. The patient says it feels like the arm is going to pop out (dislocate). There may be a painful click in the shoulder during the movement. A positive crank test suggests there may be a tear of the labrum in the shoulder. That’s the rim of cartilage around the edge of the socket that helps hold the head of the humerus in the socket.

You may want to discuss the test results and treatment suggested if you haven’t already done so.

Shoulder dislocations can be complex problems. If the soft tissues around the shoulder aren’t torn or damaged during the injury, the body may be able to heal itself. Usually this takes at least six weeks. Some strengthening exercises may be needed to protect the joint from further injury. This is especially true if the joint is being stressed or overloaded during sports activities.

If the ligaments around the joint are stretched, bleeding, or torn, then a person is at increased risk for another dislocation. An orthopedic surgeon can examine and test the joint during an office visit and advise patients. The only way to know for sure the status of the joint and soft tissues around it is an arthroscopic exam (surgery).

Many athletes do, in fact, dislocate a shoulder and return to sports with no further problems.

We don’t really know how much force can be applied to normal tendons much less healing soft tissues. Animal and cadaver studies have given surgeons a general idea. The amount of acceptable force will increase over time as the tissues interface with the bone.

You’re best off to follow your surgeon’s advice carefully. The healing tissue is very weak and can’t hold together with stress or pull. Even the simplest of movements can put a greater load on the surgical site than it can handle.

Most surgeons give their patients specific guidelines to follow. There are some general guidelines for everyone having the surgery you had. There are some just for you based on your age, the condition of your soft tissues and bones, and the type of surgery done. Be sure and ask if you don’t know what are the limits in your case. You wouldn’t want to undo what the surgeon just spent hours (and your money) fixing.

Each surgical repair is different based on a few factors. First is the size of the tear and the method used to repair it. Second is the timing. You mentioned being in the early weeks of recovery. The amount of load the repair can handle increases as the tissue heals. In the first six weeks the load limits are much less than after six to eight weeks.

For example the load on the repair is much less with forward flexion of the arm compared to other shoulder movements. Passive motion (someone else moves the arm) versus active movement (you move the arm) has different load limits.

Your surgeon should have given you some idea of the limits both in terms of motion and lifting. Sometimes patients don’t realize the paperwork they take home with them has this information in it. Read everything given to you. Contact your surgeon directly if you don’t find what you are looking for.

It sure does matter. Even under the best circumstances up to half of all rotator cuff repairs tear again. During the first six weeks, the muscle isn’t really reattached to the bone. It’s just held in place by tiny sutures. It takes awhile for the tendon and bone to knit back together.

Too much load or too much strain can pull the stitches right through the tendon. Surgeons have a pretty good idea of how much their surgical repair can handle. It’s best to follow their instructions very carefully. Patients should ask before doing more than the surgeon advised.

The rotator cuff is a group of four tendons and muscles that surround the shoulder joint. One of those tendons is the supraspinatus. It sounds like that’s the one you had repaired.

The rotator cuff isn’t a two-dimensional structure. It has depth, height, and width. The place where the supraspinatus tendon inserts into the bone is the footprint. It’s usually a rectangular shape.

The surgeon lifts up the torn tendon to see where it was attached. The size of the footprint where it attached to the bone is measured carefully. Then the surgeon decides what type of suture will work best for the size and shape of the tear. When a tear occurs, it’s usually not a simple straight line. There aren’t two ends that can be picked up and sewn back together. The tear often forms a triangular-shaped hole.

The surgeon tries to match the original “footprint” as much as possible when making the rotator cuff repair. This may require a single or double row of stitches. The goal is to restore as much of the surface area as possible.

Doctors often say it would be better to break a bone than tear a tendon. Bone heals fairly consistently in four to six weeks. Minor soft tissue injuries such as sprains and strains take six to eight weeks. But restoring tendon to bone is another matter.

Studies show it usually takes 12 weeks for a tendon to bone interface strong enough to resist the pull of resistance and load of everyday movements. During this time the soft tissue goes through three separate phases of healing.

In the first six to eight weeks, blood and inflammatory cells fill in the gap made by the tear. Then blood vessels form to help remove debris. Finally collagen cells start to form in the area. For the next four to six weeks, tendon fibers form, then fibrocartilage. In the final step of this process the tendon-bone interface must calcify or harden.

The healing rate varies from patient to patient. It depends on your natural healing rate, your overall health and nutrition, and the type of surgery done to repair the injury.

The last thing you want is for the srepair to tear. Be patient with your body as it is healing as fast as it can. In fact 12 weeks is really a minimum of time. Many studies show final healing can take six to nine months.

After a rotator cuff repair, the arm is immobilized to allow the tear to heal. It takes time for the tendon to really “graft” itself back to the bone. Right now it’s being held in place by a button or sutures. Too much motion or the wrong kind of movement can disrupt the repair.

Several studies have shown that the body forms a layer of tissue between the bone and the tendon. This interface is made up of fibers and blood vessels. The bone will gradually fill into this interface. This is a very delicate time in the healing process. The fibrovascular tissue can be ripped away by unexpected or extreme motion.

The length of your enforced “quiet time” depends on several things. First the surgeon assesses how severe was the tear. Then the type of surgery done can make a difference. Most surgeons give their patients an exercise program to start early on.

Don’t hesitate to call your doctor or the doctor’s nurse and ask some questions about your situation. They usually give the patient some written materials to follow in those early days after surgery.

There are lots of problems with operations trying to repair the AC (acromioclavicular) joint. In fact more than 60 different ways to surgically repair the AC joint have been tried.

Wires and screws don’t seem to hold. They break or move causing problems. Sutures to hold the joint together don’t seem strong enough. Many times the joint starts to move apart again.

Surgery isn’t an option unless the person doesn’t recover with conservative care or the injury is so severe an operation is the only way to treat it.

If your son follows his doctor’s instructions he should heal in two to six weeks. Rehab should be completed before resuming football to prevent re-injury.

Talk to the orthopedic surgeon who did your surgery. It could be that the type of repair done can’t restore normal motion and function. This is often the case with AC repairs. If screws, wires, or sutures were used the hardware may give you lots of stability but not as much mobility.

The doctor will be able to assess your joint and possibly take X-rays to find out what’s wrong. It’s possible nothing else can be done. Perhaps a second surgery is needed to modify the repair.

You may be referring to the Grutter and Petersen article in The American Journal of Sports Medicine on using the flexor carpi radialis (FCR) tendon graft. They developed this method of AC repair that doesn’t use any wires or screws.

They say the tendon graft restores the joint to its normal position and function. They used the FCR tendon graft to replace three of the ligaments holding the AC joint together.

If this is the study you saw, it’s important to note they used cadavers, not live patients. The results were encouraging since cadavers don’t have the “live” and dynamic muscles around the joint to assist with motion and stability. The models used were all from older adults, too.

Most likely this technique will be studied on live subjects before it’s adopted as a standard operation for AC repair.

The surgeon’s job is to reattach the torn tendon but needs some way to hold it in place while it heals. This can be done in a number of different ways and is called tendon fixation. For a rotator cuff repair, the sutures may be placed at the tip or end of the bone or tied over a wider bone bridge.

Sometimes the surgeon uses what’s called an anchor suture. This is a stitch that connects the end of the tendon to the bone. They can also use a button anchor. The suture goes through the button to give greater strength to the repair. These are used especially when the bone is weak from osteoporosis.

A third option is called a transosseous suture. A tunnel is drilled through the bone from one side to the other. The suture is threaded through the canal. A recent study at Columbia University showed that this method gives a much tighter “fixation” and is less likely to fail.

Don’t hesitate to ask your surgeon to show you a drawing or picture of the operation planned. The more you understand about what’s being done the better able you may be to follow the planned rehab and avoid movements and positions that might compromise the healing tissue.

Researchers think so. The newest way to do rotator cuff repairs is called a mini-open technique. A special tool called an arthroscope is used to let the doctor work
inside the joint without making a large incision. Puncture holes to insert the scope and a small incision are used.

This method has only been around for 10 years. The results have been very good so far. Most studies report 85 percent (or more) of the patients have good to excellent results. The outcomes are measured using pain, activity, and strength. Even old tears like yours
can have a good result with today’s newer methods of repair.

Tonsils, appendix, wisdom teeth, and rotator cuff. Baby boomers may think these are the required operations in their lifetime. Better health care has reduced the first three operations. Improved technology has probably increased the use of rotator cuff repair surgery.

Living longer, more active lives puts us at increased risk for rotator cuff problems. It has become a much more common problem than ever before. The rotator cuff is made up of four muscles and their tendons as they surround the shoulder.

Problems in this area occur for several reasons. First, there isn’t a huge blood supply to the area normally. As we age, the tissues may get even less. Second, the soft tissue
structures are easily pinched by the nearby bones and soft tissues from sagging posture. Weakness as we age adds to the problem. Overuse and repetitive use also increase the risk of injury.

You aren’t destined to have a rotator cuff injury. In fact a series of simple exercises to strengthen the rotator cuff are available from any orthopedic doctor or physical therapist.

Some patients can get along fine with just the decompression part of the operation. A piece of the bone that’s pinching the tendon is removed. The tendon doesn’t grow back or
repair itself, but if you aren’t engaging in activities or sports, you may not need this.

Decompression by itself often relieves the pain and patients are happy with just that. But if you are someone who is younger or more active (or wants to be more active), repairing the tendon is a must.

With the new arthroscopic method of doing the operation, it’s fairly simple for the doctor to relieve the pressure and repair the tear. Healing time is about the same and you end up with a stronger repair. This leaves you open for engaging in activities you
may have given up because of the shoulder pain.

Laser light and radiofrequency (RF) electric current are both used to heat capsular tissue in the shoulder after chronic dislocations. The procedure helps tighten up loose tissue around the joint. Patients must have dislocated more than once. Conservative
treatment with rehab is always tried first for at least three months.

The treatment is called thermal shrinkage or thermal capsulorrhaphy. It’s
currently being used for patients with an unstable shoulder from trauma and joints that dislocate in more than one direction. It’s also used when tissue inside the joint gets pinched.

A recent study from a shoulder and elbow clinic suggests it works best with traumatic shoulder dislocations. A shoulder that dislocates in all directions has the poorest
results. Of course, anyone with fragile tissue in poor condition can’t have this kind of heat applied.

You may be talking about thermal shrinkage of capsular tissue that surrounds the shoulder joint. The capsule gets stretched out when the shoulder dislocates. More than one dislocation makes the problem worse.

Thermal shrinkage uses a heat source to raise the temperature of the tissue. In the process of heating and cooling down, the capsule tightens up. Research shows there’s an ideal temperature the tissue must reach during this procedure. Doctors are careful to keep within the “safe” range.

They also use a “striping” technique. The heat probe is passed up and down over the loose tissue. Some areas are left untreated between areas of shrinkage. The tissue is only
heated up once. Studies show passing over the tissue more than once can cause injury to the capsule.

Doctors are also careful not to leave the probe in one spot too long. Some tissue can’t be treated with this method. Thin, torn, or poor quality tissue won’t hold up under the
high heat. No one really knows yet how much tissue shrinkage gives the best result. More studies are underway.