FAQ Category: Shoulder

You may be pleased to know that many “seniors” are taking aging by the horns and redefining it. Perhaps you’ve heard the expression “60 is the new 40” (referring to age in years). Well, if that’s true then 80 is the new 60 and so on. The Baby Boomers (adults born between 1946 and 1964) have also voted to eliminate the word “elderly” from our vocabulary and substitute “older adult” instead.

Whatever we choose to call today’s modern grandparents, it is clear that they are outliving many of their body parts, including and especially joints. Hip, knee, and shoulder joint replacements are on the rise in this age group. And many older adults are outliving their joint replacements!

In the case of massive rotator cuff tears leading to severe degenerative changes of the shoulder joint, orthopedic surgeons have teamed up with other researchers, engineers, and component parts manufacturers to rethink the mechanics of the shoulder joint and design an artificial shoulder that works in such cases.

The solution was to reverse the socket and the ball, placing the ball portion of the shoulder where the socket used to be and the socket where the ball or humeral head used to be. This new design led to a much more stable shoulder joint that could function without a rotator cuff. The artificial joint itself provided more stability by creating a deeper socket that prevented the ball from sliding up and down as the shoulder was raised. The large deltoid muscle that covers the shoulder could be used to more effectively lift the arm, providing better function of the shoulder. The final goal is to have a shoulder that functions better, is less painful, and can last for years without loosening.

As with all major operations, complications (including death) are possible. Some studies report that patients receiving reverse shoulder group have higher rates of complications (e.g., dislocations, infections, ongoing pain, loosening of the socket) compared with total shoulder replacement or hemiarthroplasty (only replacing half the joint).

Rsearch results support the use of reverse shoulder arthroplasty primarily for older patients with a degenerative shoulder joint and humeral head collapse from a massive rotator cuff tear. In fact, it has been suggested that the “use of the reverse shoulder arthroplasty should continue to be restricted to elderly patients.”

Regardless of what you call yourself or how you refer to your age group, an orthopedic evaluation is the place to start. There may be simpler nonoperative measures that can be taken to assist you. Or you may be a good candidate for some type of shoulder replacement. For sure, there is no reason for you to suffer debilitating pain and loss of function for the next 20 years!

Before prescribing the best treatment for your shoulder, it’s always important to know you have the correct diagnosis. For example, the terms frozen shoulder and adhesive capsulitis are often used interchangeably. The two terms describe the same painful, stiff condition of the shoulder no matter what causes it. A more accurate way to look at this is to refer to true adhesive capsulitis (affecting the joint capsule) as a primary adhesive capsulitis.

As the name suggests, primary adhesive capsulitis affects the fibrous ligaments that surround the shoulder forming the capsule. The condition referred to as a frozen shoulder usually doesn’t involve the capsule. It may be better to refer to frozen shoulder as a secondary adhesive capsulitis.

Secondary adhesive capsulitis (or true frozen shoulder) might have some joint capsule changes but the shoulder stiffness is really coming from something outside the joint. Some of the conditions associated with secondary adhesive capsulitis include rotator cuff tears, biceps tendinitis, and arthritis. In either condition, the normally loose parts of the joint capsule stick together. This seriously limits the shoulder’s ability to move, and causes the shoulder to freeze.

Exercises may help keep the fluidity of the joint and aid in maintaining (or restoring) motion. But which exercises, how to apply them, and other specific physical therapy techniques that might help will depend on the underlying cause(s) of your shoulder problems.

This is where a physical therapist can be most helpful in examining the entire shoulder complex and identifying the specific movement pattern impairment you have. From there, a specific home exercise program can be developed along with a few sessions of direct treatment. If you have not been evaluated by a physical therapist for this problem, now may be a good time to make an appointment. Consult with your physician first in order to ensure the best way to coordinate treatments (steroid injections and physical therapy).

You raise a very good question and one that many people may be facing as the number of adults who are obese increases in the coming years. There are some special considerations when someone with a body mass index (BMI) of 50 thinks about having joint replacement surgery.

For example, many people (children/teens and adults) who have a BMI greater than 30 also have other health concerns. Diabetes is the number one health risk factor. Diabetes increases the risk of poor wound healing and infection.

Traditional anatomic total shoulder replacements have been shown to aid in reducing pain and improving motion and function in very obese patients. But when compared with adults who are not obese (and who also receive an anatomic total shoulder replacement), results are definitely not as good. The obese patient is more likely to have problems and complications and less likely to be happy with the results.

The “normal” or anatomic shoulder replacement was designed to copy our real shoulder. The glenoid component (the socket) was designed to replace our anatomic shoulder socket with a thin, shallow plastic cup. The humeral head component was designed to replace the ball of the humerus with a metal ball that sits on top of the glenoid.

A different type of implant has been developed for use with older adults who need a shoulder replacement but who have a severe tear of the rotator cuff tendons. The four muscles and their tendons that make up the rotator cuff fit around the shoulder joint and help hold the joint stable yet provide full range-of-motion at the same time. This alternate replacement device is called a reverse total shoulder arthroplasty (RTSA).

Without an intact rotator cuff, the implant often loosens and/or the shoulder dislocates. This can be prevented by reversing the socket and the ball, placing the ball portion of the shoulder where the socket used to be and the socket where the ball or humeral head used to be. This new design provides a much more stable shoulder joint that can function without a rotator cuff. How well does it work with people who have an intact rotator cuff but have a different problem: they are obese.

To find out, the reverse total shoulder arthroplasty (RTSA) was used in three separate groups and results compared in a recent study. The three groups included 17 obese patients, 36 patients who are overweight, and 23 patients in the normal weight category. Patients ranged in age from 51 to 88 years old.

They found that obese patients were able to regain significant amounts of lost motion but they also had significantly more complications than the other two groups. The obese patients lost more blood during the procedure, but surgical time and length of hospital stay were the same among all three groups.

Complications were greater in the obese group for several reasons. Surgical difficulties occur just due to the amount of adipose tissue (fat) that must be cut through to get to the shoulder joint. Fatty tissues tend to have less blood flow to them (they are said to be poorly vascularized). This lack of blood flow can delay or impair healing.

Many more patients in the obese group also had diabetes, which we already know is a risk factor in delayed wound healing. And the infection rate of 18 per cent in the obese group was clearly much higher than for the nonobese group who had no (zero per cent) infections.

Although obesity is NOT a contraindication to reverse total shoulder replacement, patients should be aware of the high complication rate, especially for the risk of infection. Of course, you can also expect the same improvements in motion and reductions in pain obtained by nonobese patients. Time will tell if other changes (positive or negative) will occur in the long-term results.

Your primary care physician working in conjunction with your orthopedic surgeon will evaluate your case and advise you as to the best treatment approach to your shoulder problem. So before crossing yourself off the treatment list, seek counsel from these experts and find out what are all of your options. And good luck!

As you have pointed out, patients contemplating shoulder replacement surgery who happen to be significantly overweight may have some special needs. The use of tobacco in any form adds even more risk. The presence of vascular (blood flow) problems often present in obese adults and anyone who smokes can increase your risk of complications during and after surgery. Poor wound healing and infection are common problems but life-threatening blood clots, heart attack, stroke, and even death have also been reported.

Traditional anatomic total shoulder replacements can be used to aid in reducing pain and improving motion and function in overweight and obese patients. But when compared with adults who are not overweight or obese (and who also receive an anatomic total shoulder replacement), results are definitely not as good. The obese patient is more likely to have problems and complications and less likely to be happy with the results.

A different type of implant has been developed that is being considered for use with obese adults who need a shoulder replacement. This alternate replacement device is called a reverse total shoulder arthroplasty (RTSA). This implant reverses the socket and the ball, placing the ball portion of the shoulder where the socket used to be and the socket where the ball or humeral head used to be.

This new design provides a much more stable shoulder joint and its use is NOT contraindicated for obese adults. But according to the authors of a recent study investigating the results of the reverse shoulder replacement, patients should be warned of the high complication rate, especially for the risk of infection. Of course, they can also expect the same improvements in motion and reductions in pain obtained by nonobese patients. Time will tell if other changes (positive or negative) will occur in the long-term results.

As you have been told, adults with very large tears of the rotator cuff (four tendons/muscles surrounding the shoulder) can get pain relief and improved function after surgical repair — even if the tendon doesn’t heal. These are the results of a small study of 15 to 18 patients who were followed over a two to 10 year period of time.

Results were reported two years after the arthroscopic repair in the first study by the same authors of this second study (with the same group of patients). Outcomes were re-measured 10 years after the primary (first) surgery using ultrasound studies and patient self-report of pain, motion, and function. That’s when the surgeons discovered two things.

First, the results were the same at the 10-year post-operative time as compared with results two years after the surgery. That means the patients were able to maintain outcomes without further decline. And second, a failed healing in 17 of the 18 patients didn’t keep them from improving and holding that improvement steady over the years.

X-rays and ultrasound studies done on 11 of the original 18 patients confirmed the continued presence of rotator cuff tears. In a couple of patients, the tear was worse. There was no change in four shoulders and four patients actually had a decrease in the size of the tear. In all 11 cases, the head of the humerus had migrated (moved) up out of the natural resting place where it should be in the shoulder socket.

The bottom-line is that despite evidence of worsening of the soft tissues and shoulder joint, the majority of patients still had improvements with the surgery. Although the unhealed repair allows for continued function, the shoulder was not protected from further degenerative changes.

Other studies have shown that with severe rotator cuff tears, the damaged area fills in with fatty tissue. It’s not clear yet what effect this fatty atrophy will have in the long-run but researchers will continue to study these patients to find out. Osteoarthritic degeneration and function in unhealed shoulder cuff tendons will be the focus of other future studies as well.

Experts advise that patients with severe or “massive” tears of the rotator cuff tendon should be informed that surgery may fail to create a healing response. But the pain relief offered and improved motion and function may make it worth having the procedure anyway. It sounds like your surgeon is up-to-date with this information and providing it to patients appropriately.

According to this study, improvements seem to last for up to a decade (10 years) even when there is evidence of ongoing degeneration of the soft tissues. In older adults who are not in need of full strength and motion, surgical repair of a torn rotator cuff may still be beneficial because healing is not needed for a successful result.

Snapping scapula syndrome is as the name suggests: when the arm moves, some portion of the scapula drags against the rib cage causing a snapping sound and sensation. Pain is often (though not always) a main feature associated with this problem. Patients present with a range of severity from mildly irritating to extreme debilitation. The people affected most often are usually young athletes involved in activities requiring repetitive overhead motion.

As you have probably experienced yourself, without a properly working scapula (shoulder blade), smooth and coordinated motion and function of the arm is compromised. Disorders of the scapula are rare and a thorough understanding of the anatomic features of this structure is needed to treat them successfully.

An understanding of the knowledge we have about this problem is important because surgery doesn’t always “fix” the problem. That’s why conservative care is recommended first. This approach may include medications and change in activity type/level to reduce inflammation. If these measures don’t help, then one to three steroid injections may be tried.

Physical therapy to address posture and weakness or imbalance in muscle function is a key feature of the nonoperative approach to snapping scapula syndrome. Patients are advised to be patient as the rehabilitation process can take up to six months to be effective. Only when there are tumors or “masses” should surgery be considered sooner.

When six months (or more) of conservative care fails to change the clinical picture, then surgery to remove a portion of the bone and/or inflamed bursae may be advised. The exact rehab protocol will depend on the type of surgery done (open versus arthroscopic, what procedure was used, what tissues were removed).

Open surgery requires a longer period of immobilization in a sling afterwards (e.g., four weeks for open surgery instead of one week after arthroscopic surgery). The reason for this is because more muscle tissue is disrupted with open surgery. A longer time of rest and protection is needed to allow for muscular healing.

Only passive shoulder motion is allowed in the first eight weeks after open surgery. Passive motion is quickly progressed to active motion and then strengthening exercises for patients who have arthroscopic surgery. These patients are advanced according to their own tolerance level for pain and discomfort. After open surgery, active motion begins at eight weeks post-op and strengthening begins at 12 weeks post-op.

Depending on your occupation and/or activity level, you may continue on with physical therapy to prepare you for return to specific work, sports, or recreational activities. Keep in mind that results of surgical treatment for this condition are not always as expected or hoped for. Studies published with patient outcomes report incomplete relief from painful symptoms and lower than expected function are possible.

You may have a problem that involves the scapula (shoulder blade). Without a properly functioning scapula, smooth and coordinated motion and function of the arm is compromised. Problems affecting the scapula that can disrupt the motion and rhythm of arm movement include bursitis, snapping scapula, and tumors (benign or malignant) of the bone or nearby soft tissues.

Snapping scapula syndrome is the most common problem among this group of scapular disorders. As the name suggests, when the arm moves, some portion of the scapula drags against the rib cage causing a snapping sound and sensation. Pain is often (though not always) a main feature associated with this problem. Patients present with a range of severity from mildly irritating to extreme disability. The people affected most often are usually young athletes who (like yourself) are involved in activities requiring repetitive overhead motion.

An understanding of the knowledge we have about this problem is important because surgery doesn’t always “fix” the problem. That’s why conservative care is recommended first. This approach may include medications and change in activity type/level to reduce inflammation. If these measures don’t help, then one to three steroid injections may be tried.

Physical therapy to address posture and weakness or imbalance in muscle function is a key feature of the nonoperative approach to snapping scapula syndrome. Patients are advised to be patient as the rehabilitation process can take up to six months to be effective. Only when there are tumors or “masses” should surgery be considered sooner. When six months (or more) of conservative care fails to change the clinical picture, then surgery to remove a portion of the bone and/or inflamed bursae may be advised.

The first step is really to get a proper diagnosis. See your student health care provider and describe your symptoms. With a thorough history and physical examination, your health care provider will be able to determine whether imaging studies are needed and order them.

Sometimes a plain X-ray is all that is needed. They may reveal bone spurs or other bony masses. When appropriate, CT scans or MRI may be requested. A final diagnosis may require arthroscopic examination but this is not typically needed. Treatment will depend on the underlying cause of the problem. In most cases, the first step is physical therapy. The therapist will help you correct any alignment or postural problems contributing to the symptoms. Stretching and strengthening may be important as well. Expect a recovery time between six weeks and six months.

Surgeons from the Steadman Philippon Research Institute in Colorado recently wrote about their experiences using of an all-arthroscopic Bony Bankart Bridge (BBB) surgical technique for chronic shoulder instability. It was a fairly small study with only 15 patients. This is a fairly uncommon injury and the all-arthroscopic procedure is just starting to replace an open incision technique. But the information offered may be helpful to you.

A chronically unstable shoulder means the shoulder continues to dislocate over and over. Pain, fear of movement that might cause another dislocation, and loss of function for daily activities can really affect your lifestyle and quality of life. With each dislocation can come further damage to the soft tissues and especially the bony rim around the shoulder socket.

Some people report up to 10 or more repeat dislocations. These microtraumas cause the bony rim around the shoulder socket to break away taking with it the attached soft tissues. Studies have shown that a loss of 20 per cent (or more) of the bony rim significantly increases contact pressure (bone on bone). This type of bone loss also reduces resistance to dislocation. And with this type of bone deficiency, there is a high rate of failure after surgical repair of the soft tissues.

The Bony Bankart Bridge (BBB) addresses the bone loss by reattaching the bone fragment back into its “donor bed” (original place). A special bridging technique using push-lock knotless suture anchors reconstructs the shoulder and restores stability. There is no hardware where the two bony edges meet (where healing takes place). The surgeon also repairs any soft tissue damage to the capsule, labrum, and glenohumeral ligament. Care is taken to avoid tilting the bony piece, which could lead to over- or under-correcting the problem.

The greatest significance of this technique is that it was done completely by arthroscopic techniques. In other words, no open or large incisions were made to give the surgeon access to the area. All-arthroscopic procedures are becoming more common now even for difficult-to-treat problems like this one. The goal of this treatment is to restore the surface area of the shoulder socket and prevent any more dislocations.

The rehab protocol after surgery may vary somewhat from one surgeon to another. What you will likely experience is a short period immobilized in a sling (one to three weeks). The length of time in the sling and the speed at which you are advanced in the rehab program depend on three things: 1) fracture severity and location, 2) presence of other soft tissue injuries (joint capsule, labrum, ligaments), and 3) exact techniques used in the surgical procedure.

Passive range of motion (the physical therapist moves your arm) is started early on (in the first week). The therapist will gradually progress you to active assisted motion, then full motion, and then onto strengthening exercises. Typically, strength training doesn’t begin until the tissues have established good healing (usually six to eight weeks after surgery at the earliest).

Three to four months after the procedure, you will be able to return fully to your everyday activities. If you want to participate in physical activities, sports, or recreational/leisure activities, then it must be noncontact until six months after surgery. Your surgeon will let you know when it is safe to engage in full contact (or throwing) sports if that is of interest to you.

The procedure you are referring to is most likely the Bony Bankart Bridge. As you described, it is a technique used to restore a fractured glenoid (shoulder socket). The Bony Bankart Bridge (BBB) addresses the bone loss by reattaching the bone fragment back into its “donor bed” (original place).

A special bridging technique using push-lock knotless suture anchors reconstructs the shoulder and restores stability. There is no hardware where the two bony edges meet (where healing takes place). The surgeon also repairs any soft tissue damage to the capsule, labrum, and glenohumeral ligament. Care is taken to avoid tilting the bony piece, which could lead to over- or under-correcting the problem.

The greatest significance of this technique is that it was done completely by arthroscopic techniques. In other words, no open or large incisions were made to give the surgeon access to the area. All-arthroscopic procedures are becoming more common now even for difficult-to-treat problems like this one. The goal of this treatment is to restore the surface area of the shoulder socket and prevent any more dislocations.

It is important to address the problem of a chronic shoulder instability. Chronic shoulder instability means the shoulder continues to dislocate over and over. Pain, fear of movement that might cause another dislocation, and loss of function for daily activities can be very bothersome. With each dislocation can come further damage to the soft tissues and especially the bony rim around the shoulder socket. These microtraumas cause the bony rim around the shoulder socket to break away taking with it the attached soft tissues.

Studies have shown that a loss of 20 per cent (or more) of the bony rim significantly increases contact pressure (bone on bone). This type of bone loss also reduces resistance to dislocation. And with this type of bone deficiency, there is a high rate of failure after surgical repair of the soft tissues.

The type of injury you have is not that common and the all-arthroscopic surgical technique is fairly new. Newer, more advanced arthroscopic techniques have been developed that allow for this type of reconstruction of bone defects. And according to a recent study, this new all-arthroscopic repair for a mild-to-moderate Bankart lesion can restore shoulder stability.

Patients of all ages (up to and including 70-year-olds), experienced significant pain relief and return to normal (or near normal) function. The Bony Bankart Bridge technique may help avoid the high failure rates normally associated with this type of bony reconstruction procedure when they are done with an open incision.

According to a recent study from Washington University in St. Louis, adults with very large tears of the rotator cuff (the four tendons/muscles surrounding the shoulder) can get pain relief and improved function after surgical repair — even if the tendon doesn’t heal. It was a small but still significant study of 18 patients who were followed over a two to 10 year period of time.

Results reported two years after the arthroscopic repair were re-measured 10 years after the primary (first) surgery. Like your surgeon, the lead surgeon in the study used ultrasound and X-rays to see what was going on in the shoulder. Patients also gave a self-report of pain, motion, and function. That’s when the surgeons discovered two things.

First, the results were the same at the 10-year post-operative time as compared with results two years after the surgery. That means the patients were able to maintain outcomes without further decline. And second, a failed healing in 17 of the 18 patients didn’t keep them from improving and holding that improvement steady over the years.

X-rays and ultrasound studies done on 11 of the original 18 patients confirmed the continued presence of rotator cuff tears. In a couple of patients, the tear was worse. There was no change in four shoulders and four patients actually had a decrease in the size of the tear. In all 11 cases, the head of the humerus had migrated (moved) up out of the natural resting place where it should be in the shoulder socket.

The bottom-line is that despite evidence of worsening of the soft tissues and shoulder joint, the majority of patients still had improvements with the surgery. Other studies have shown that with severe rotator cuff tears, the damaged area fills in with fatty tissue. It’s not clear yet why improvements are maintained despite degenerative changes in the shoulder after repair of rotator cuff tears. But the pain relief offered and improved motion and function may make it worth having the procedure anyway.

You are not alone in asking this question! In a recent study, researchers from Rush University Medical Center in Chicago, Illinois reviewed the literature from 1948 to 2011 looking for any information, studies, and evidence about the use of shoulder injections. They did not limit their search to articles on just steroid injections but also included hyaluronic acid injections (another form of injection treatment) for shoulder disorders.

We won’t hold you in suspense about the results. They found very few studies and the level of evidence was very weak. In fact, it turns out that current clinical recommendations are all based on expert opinion and consensus (agreement among physicians). Consensus is also based on expert opinion but with experience and case series added in to assist in coming to agreement.

A closer look at the two different injection approaches (steroids versus hyaluronic acid) revealed little scientific evidence to support steroid injections. Steroid injections seem to work better and more consistently for people with adhesive capsulitis compared with shoulder osteoarthritis. Hyaluronic acid injected into the joint may be more effective for both frozen shoulders and arthritis but some high-quality, well-designed studies are needed to provide evidence of this.

Experts agree the benefits of these kinds of injections must be weighed against the potential adverse side effects. With any injection, there’s the pain of the injection itself — both during and afterwards. Most of the time, this is temporary and only lasts a short time. Joint infection can occur when bacteria is introduced into the joint by the needle pushing through the skin. Anyone with infectious arthritis, a joint replacement implant, or fracture is not a candidate for injection therapy.

With steroid injections, some people have a flare-up reaction that can last several days. Sometimes the protective fat around the joint is lost. It takes the body up to six months to replace or restore this fat. With hyaluronic acid injections, pain and swelling in the joint may get worse instead of better at first. Some people even respond with an acute systemic inflammatory response. It looks like they are developing gout or a blood infection but it’s just a reaction to the injection.

The authors of that review concluded it’s not likely that physicians will stop using steroid (or hyaluronic acid) injections for shoulder problems. But they are doing so on the basis of very limited evidence. It’s mostly opinion and conjecture and that is not a strong enough recommendation in today’s evidence-based practice.

Up to one-third of the adult population in America suffers from shoulder disorders on any given day. So, it’s a problem that affects many people every day. A conservative approach is usually always recommended first. Physical therapy, antiinflammatory medications, acupuncture, and/or any of the other alternative approaches (e.g., massage, Reiki, BodyTalk, physiologic quieting) are recommended. These may be tried individually or in combination until the right mix with the best results is found for each patient.

When shoulder pain from arthritis becomes unbearable and nothing else will touch it, surgeons may recommend steroid injections. But in today’s evidence-based medicine, the question comes up: what’s the evidence that injections directly into the shoulder joint (intra-articular) really reduce shoulder pain and stiffness associated with arthritis or adhesive capsulitis (frozen shoulder)?

According to the latest research, there are very few studies to support the use of steroid injections for shoulder arthritis. And the level of evidence that is available is very weak. Current clinical recommendations are based on expert opinion and consensus (agreement among physicians). Consensus is also based on expert opinion but with experience and case series added in to assist in coming to agreement.

There are studies that show physical therapy alone provides better pain relief, increased shoulder motion, and improved function compared with steroid injection (for patients with shoulder osteoarthritis). People with adhesive capsulitis (frozen shoulder) have slightly different results and seem to do better with physical therapy when it is combined with both steroid and hyaluronic acid injections.

When comparing different treatment approaches for painful, limiting shoulder arthritis, it is important to weigh the benefits against the potential adverse side effects. Physical therapy does take longer but may have more lasting value. In addition to pain relief, the therapist will address loss of strength, motion, and function while paying attention to other important factors such as posture, osteoporosis, and falls and fracture prevention.

Steroid injection may provide pain relief in the first 24 hours but with any injection, there’s the pain of the injection itself — both during and afterwards. Most of the time, this is temporary and only lasts a short time. Joint infection can occur when bacteria is introduced into the joint by the needle pushing through the skin. Anyone with infectious arthritis, a joint replacement implant, or fracture is not a candidate for injection therapy.

With steroid injections, some people have a flare-up reaction that can last several days. Sometimes the protective fat around the joint is lost. It takes the body up to six months to replace or restore this fat. And studies clearly show that steroid injection provides short-term pain relief but not long-term change.

There are two separate schools of thought regarding treatment for adhesive capsulitis. Some experts suggest a home-based approach because eventually the problem corrects itself. Patients use pain relievers, moist heat, and simple exercises to keep the joint moving. Others recommend direct treatment to make sure patients regain normal motion and function.

Most experts agree that severe painful limitations of motion should be treated by a physical therapist. For patients with persistent pain, pain-relieving medications and steroid injections are commonly used in addition to physical therapy. But steroid injections have some disadvantages and some patients either don’t want them or can’t tolerate them. That’s when hyaluronic injections may be used instead.

Hyaluronic acid is a normal part of the matrix that makes up cartilage. It has two distinct properties that make it so important for smooth joint motion. It is both viscous (slippery) and elastic. The viscosity allows the tissue to release and spread out energy. The elasticity allows for temporary energy storage. Together, these two properties protect the joint, help provide joint gliding action (especially during slow movement), and act as a shock absorber during faster movements.

Some experts think hyaluronic acid (HA) injected into the shoulder has some additional benefits. They suggest that the HA reduces inflammation of the synovium (lubricating fluid inside the joint). It also has a direct effect on the pressure inside the joint to separate the joint capsule where it is stuck together. Hyaluronic acid may be protective of the joint cartilage and prevent the formation of adhesions that keep the capsule from the smooth gliding action needed for normal shoulder motion.

The question naturally arises — which works better: steroid or hyaluronic acid injections? In your case, you are also wondering about trying prolotherapy as well. Prolotherapy involves injecting a group of substances into the joint that will stimulate an inflammatory reaction. The idea is to restart the body’s natural healing process that got interrupted, which may be why the joint froze up in the first place.

We don’t know of any studies comparing steroid injection to prolotherapy (or comparing either of those treatments to hyaluronic acid). However, the first study comparing steroid injection to hyaluronic acid injection has been published. The authors of the study divided 90 patients with adhesive capsulitis into two groups. The first group received a series of three steroid injections (spread out over six weeks’ time) into the shoulder.

The second group was injected with hyaluronic acid with the same frequency (one injection every two weeks for a total of three injections over six weeks’ time). Ultrasound (instead of the usual fluoroscopy) was used to guide the needle into the joint. The main advantage of ultrasound over fluoroscopy is that it doesn’t expose the patient to unnecessary radiation. That is important when using a series of injections with the potential for repeated radiation exposure.

Results were measured using pain intensity, shoulder joint motion, and function. Everyone in both groups was evaluated using these measures before treatment and again two weeks and six weeks after treatment. They didn’t find much difference in outcomes between the two treatment techniques.

Everyone in both groups had less pain, better motion, and improved function. These improvements were observed at the two week follow-up and maintained through the six-week check-up. The only difference was greater passive external shoulder rotation with the hyaluronic acid injections. This might have occurred because the pressure from the hyaluronic acid opened up the joint space, which is needed to increase external rotation.

The authors concluded by saying that hyaluronic acid injections delivered with careful placement using ultrasound may be just as effective as steroid injections. In fact, there may be some added advantages. The patients receiving hyaluronic injection via ultrasound are not exposed to radiation. They are not affected by the potential negative consequences of steroids (e.g., thinning and weakening of the soft tissues, skin color change). They even get some extra rotational motion.

For patients who cannot tolerate steroid injections (or who don’t want them), hyaluronic acid injection may be a good alternative treatment approach. Likewise, patients with other problems that affect the soft tissues such as diabetes, hyaluronic acid injections may be a better choice.

If you have already started with steroid injections, your surgeon may advise you to finish the third injection before considering a different treatment approach. The effect of one or more hyaluronic acid injections following the two steroid injections you have already had are unknown.

Many adults (mostly women) between the ages of 40 and 60 years of age develop adhesive capsulitis (also known as “frozen shoulder”). This condition causes shoulder pain and stiffness when the normally loose parts of the joint capsule stick together. As you have probably found out, this seriously limits the shoulder’s ability to move, and causes the shoulder to “freeze.”

There are two separate schools of thought regarding treatment for adhesive capsulitis. Some experts suggest a home-based approach because eventually the problem corrects itself. Patients use pain relievers, moist heat, and simple exercises to keep the joint moving. Others recommend direct treatment to make sure patients regain normal motion and function.

Most experts agree that severe painful limitations of motion should be treated by a physical therapist. For patients with persistent pain, pain-relieving medications and steroid injections are commonly used in addition to physical therapy. But steroid injections have some disadvantages and some patients either don’t want them or can’t tolerate them. That’s when hyaluronic injections may be used instead.

Hyaluronic acid is a normal part of the matrix that makes up cartilage. It has two distinct properties that make it so important for smooth joint motion. It is both viscous (slippery) and elastic. The viscosity allows the tissue to release and spread out energy. The elasticity allows for temporary energy storage. Together, these two properties protect the joint, help provide joint gliding action (especially during slow movement), and act as a shock absorber during faster movements.

Some experts think hyaluronic acid (HA) injected into the shoulder has some additional benefits. They suggest that the HA reduces inflammation of the synovium (lubricating fluid inside the joint). It also has a direct effect on the pressure inside the joint to separate the joint capsule where it is stuck together. Hyaluronic acid may be protective of the joint cartilage and prevent the formation of adhesions that keep the capsule from the smooth gliding action needed for normal shoulder motion.

The question naturally arises — which works better: steroid or hyaluronic acid injections? Studies are being done to find out, so we don’t have a definitive answer on this yet. What we know so far is that hyaluronic acid injections are safe and effective for many people with knee osteoarthritis. Its use with shoulder problems like adhesive capsulitis is fairly new.

Results of treatment with hyaluronic acid in studies done so far are fairly positive using pain intensity, shoulder joint motion, and function as markers of success/failure. Studies comparing hyaluronic acid and steroid injections also report that everyone in both groups report less pain, better motion, and improved function.

One study comparing the two showed patients receiving three hyaluronic injections spaced out over a six week period of time had greater passive external shoulder rotation at the end of treatment. This might have occurred because the pressure from the hyaluronic acid opened up the joint space, which is needed to increase external rotation.

For patients who cannot tolerate steroid injections (or who don’t want them), hyaluronic acid injection may be a good alternative treatment approach. Likewise, patients with other problems that affect the soft tissues such as diabetes, hyaluronic acid injections may be a better choice.

Patients are often sent to physical therapy for strengthening when the shoulder joint is unstable. But physical therapists don’t prescribe the same exercise program for everyone. The therapist uses clinical skill, expertise, experience, and evidence-based information to decide which mode (type) of exercise to use. The same decision-making process is involved in determining a starting point for frequency, duration, and intensity of the exercises.

There are many variables for the therapist to consider. For example, does the patient have anterior instability (shoulder moves forward in and even out of the socket). Or is there posterior (backward) instability. Sometimes patients have multidirectional instability (the shoulder is unstable in more than one direction). Each one of these situations calls for an individual rehab program.

Then there is the scapula (shoulder blade) to consider. How well does it move? Is it moving in a coordinated rhythm with the shoulder? Scapular control is an important part of glenohumeral (shoulder joint) stability. Muscles must be evaluated for weakness, shortening, length-tension, and ability to generate as well as withstand forces needed for arm movement.

The therapist will also address proprioception (joint sense of position) with a physical therapy program. Restoring these aspects of scapular and glenohumeral motion is vital. This concept is especially important for the athlete who depends on his or her arm for accuracy and strength in motion and function (e.g., think about the need for a baseball pitcher to deliver the ball exactly in the strike zone across the home plate).

The plan of care is designed by the physical therapist for each specific patient. Progressively moving each person (particularly athletes) back toward full function for his or her daily activities and sports participation is often the direction therapy goes. This type of conditioning is called functional progression.

Nonoperative care under the direction of a physical therapist can save time, money, and avoid or delay surgery for many individuals. If your surgeon advised you to try this type of conservative care, it’s likely there is a good chance for functional recovery for you. Give it your best and see what happens! Let us know.

When rotator cuff repairs were first done using the mini-open technique back in 1993, surgeons didn’t really know how the results would turn out years down the road. Now with the data from a new Australian study, we have some 15-to 20-year outcomes to judge this technique by.

Seventy-nine (79) patients with shoulder pain, weakness, and impingement from a supraspinatus tendon tear were enrolled between 1993 and 1996. All had a tendon repair (stitching it back to the bone) and a subacromial decompression procedure by the same surgeon.

Subacromial decompression refers to shaving away some of the bone along the acromion to take pressure off the rotator cuff. The acromion is the curved piece of bone that comes from the scapula (shoulder blade) across the top of the shoulder. A mini-open (small incision) approach using an arthroscope was used to perform the surgeries.

Results were assessed using a special patient self-survey called the UCLA score. This simple but reliable tool measures patient satisfaction with the results after rotator cuff surgery based on function, active range of motion, strength, and pain. Everyone in the study completed the survey several times: first two years after surgery, then seven years later, and one final time (between 15 and 20 years).

Slightly more than two-thirds (69 per cent) felt they had good-to-excellent results. If only overall patient satisfaction was used as a measure (i.e., no one was dissatisfied), then 84 per cent thought the results were acceptable. Some patients did experience deterioration over time of the benefits they received and three had to have a reoperation. This is to be expected with an aging adult group.

The authors concluded that the mini-open rotator cuff repair technique does provide satisfactory long-term functional results for the majority of patients who have a reparable supraspinatus tendon tear.

The fact that some of their patients were older and less active might have given better results compared with younger patients having this surgery. This is one of the first (and few) studies reporting on long-term outcomes (durability) for this procedure. Having hit the 20 year mark, we expect to see more results published over the next five years.

Sounds like you may have had a tendon repair (stitching it back to the bone) and a subacromial decompression procedure. Subacromial decompression refers to shaving away some of the bone along the acromion to take pressure off the rotator cuff. The acromion is the curved piece of bone that comes from the scapula (shoulder blade) across the top of the shoulder. A mini-open (small incision) approach using an arthroscope was used to perform the surgeries.

Results of this procedure are not always the same for everyone. Age at the time of the injury and surgery as well as general health can make a difference. It’s a known fact that cigarette smoking and diabetes are linked with slow or delayed healing (and sometimes failure to heal).

But for the most part, patients followed in short- to long-term studies have good-to-excellent results. Outcomes are usually measured by pain level, shoulder motion, and shoulder function. Overall patient satisfaction is another way to measure success.

Worker’s compensation claims are often reviewed with an eye toward differences in patient outcomes when compared with patients who are not Worker’s Comp. And, in fact, there are often some measurable (and sometimes questionable) differences.

It is true that some people assume individuals receiving Worker’s Compensation won’t get better until the claim is settled. But a recent study of long-term results for rotator cuff tear repair with decompression showed that many patients continued to improve over time — during and after the claim process.

Sometimes patients retire as a result of the injury and become less active (putting less stress on the repair). That factor alone could account for why these individuals get better after the claims process is completed.

As the old saying goes, “There’s no silver bullet.” In other words, there’s no easy answer to complex problems. And treatment for the shoulder (glenohumeral) joint is no exception. In fact, the entire shoulder complex involves the humerus (upper arm bone), clavicle (collar bone), and scapula (shoulder blade). The scapula contains the glenoid fossa (shoulder socket) and the acromion (curved bone that goes across the top of the shoulder joint).

Together, these components along with all the soft tissues must move in a smooth, coordinated, rhythmical fashion just to raise your arm up and down. That goes for all the other motions your arm makes possible: e.g., scratching the middle of your back, pitching a ball forward, reaching into a back pocket, and so on).

Patients are often sent to physical therapy for strengthening when the shoulder joint is unstable. But physical therapists don’t prescribe the same exercise program for everyone. That’s because there are so many variables to consider.

For example, rehab is different depending on whether the patient has anterior instability (shoulder moves forward in and even out of the socket) versus posterior (backward) instability. Sometimes patients have multidirectional instability (unstable in more than one direction). Each one of these situations calls for an individual rehab program.

Then there is the scapula (shoulder blade) to consider. How well does it move? Is it moving in a coordinated rhythm with the shoulder? Scapular control is an important part of glenohumeral (shoulder joint) stability. Muscles must be retrained if they are weak, short, or have an altered length-tension ratio. They must be able to generate as well as withstand forces needed for arm movement.

And the therapist mustn’t forget addressing proprioception (joint sense of position) with a physical therapy program. Restoring these aspects of scapular and glenohumeral motion is vital. This concept is especially important for the athlete who depends on his or her arm for accuracy and strength in motion and function (e.g., think about the need for a baseball pitcher to deliver the ball exactly in the strike zone across the home plate).

Finally, the plan of care is designed by the physical therapist for each specific patient. The therapist uses clinical skill, expertise, experience, and evidence-based information to decide which mode (type) of exercise to use. The same decision-making process is involved in determining a starting point for frequency, duration, and intensity of the exercises.

More research is needed to verify optimal treatment for shoulder instability whether it’s an anterior, posterior, or multidirectional instability. With all the factors, variables, and considerations the therapist must consider, it’s no wonder exercise programs are not easy or simple and one program does not “fit all.”

Studies are beginning to show that early on after rotator cuff tendon repair, the tendon retracts or pulls away from the bone. A recent study from the well-known Cleveland Clinic reported all rotator cuff repairs pulled away from where they were sutured (stitched in place). It was a fairly small study but repeated findings from other studies.

Special marker beads were placed in the repaired tendons of 14 patients. The surgeons used serial (repeated at six weeks, 12-weeks, 26-weeks, and one year) low-dose CT scans to check the position of the anchor beads. Since the beads were inside the tendon, this was a clear representation of the tendon position. Movement of the beads away from the bone signaled tendon retraction.

The surgeons noticed that this retraction did not always mean the tendon would tear. Only about one-third of the group developed an actual recurrent (second) tear in the damaged rotator cuff tendon. So your surgeon may not be concerned because the original tear was small, the amount of retraction now is minimal, the tendon repair looks good, or all three.

Patients who have significant tendon retraction are also the ones most likely to develop a tendon defect. Defect is defined as a full-thickness, fluid-filled gap in the tendon (as seen on CT scan). Surgeons refer to tendon retraction without defect as a failure with continuity. Retraction and defect do not seem to occur at the same time but rather, retraction develops first and that leads to recurrent tendon tear for some patients.

Older patients with larger defects to begin with are more likely to develop retraction leading to tendon tear. Both of these factors suggest poor tendon quality at the time of surgery as an important risk factor. Your surgeon may also be taking into consideration your age as another reason not to be too concerned (that is, if you are younger).

They found that patients who developed a tendon retraction that led to a tendon defect did lose shoulder/arm function but not strength of the scapular (shoulder blade) muscles. Tendon retraction alone (remember: failure with continuity) did not result in loss of function.

So once again, taking all these variables into consideration, your surgeon may not see you at risk for further change in the final repair. But now that you have returned home and have questions, concerns, or doubts, don’t hesitate to call your surgeon for a follow-up conversation to find out more about why he or she is not overly concerned.

Your questions actually mirror the results of a recent study from the well-known Cleveland Clinic. Perhaps their findings might help you evaluate your own situation and bring about a helpful conversation with your surgeon.

In this study of 14 patients who had a rotator cuff repair, surgeons placed special marker beads in the repaired tendons. Then they used serial low-dose CT scans (repeated at six weeks, 12-weeks, 26-weeks, and one year) to check the position of the anchor beads. Since the beads were inside the tendon, this was a clear representation of the tendon position. Movement of the beads away from the bone signaled tendon retraction (pulling away from the bone).

The surgeons noticed that this retraction did not always mean the tendon would tear. Only about one-third of the group developed an actual recurrent (second) tear in the damaged rotator cuff tendon.

Tendon retraction occurred early after surgery (in the first six to 12 weeks). Those patients who had the most tendon retraction were also the ones who developed a tendon defect. Defect was defined as a full-thickness, fluid-filled gap in the tendon (as seen on CT scan). The authors refer to tendon retraction without defect as a failure with continuity. Retraction and defect did not occur at the same time but rather, retraction developed first that led to the recurrent tendon tear.

Questions that come up from these findings were the same questions you are asking: 1) Why does this happen? 2) How does this affect the patient’s function? and 3) What can be done about it? The answer to the first question (why) isn’t completely clear.

A couple of clues were uncovered in this study. First, older adults were more likely to experience this tendon retraction/recurrent tear. Tendons that pull through the sutures and repairs that elongate or lengthen in the newly forming tissue during the healing process result in tendon retraction and/or defect.

And second, patients with larger defects to begin with were more likely to develop retraction leading to tendon tear. Both of these factors suggest poor tendon quality at the time of surgery as an important risk factor. These risk factors and findings naturally affect function (question number two) and speculation as to how to prevent it from happening (question number three).

Exactly how to prevent the problem of retraction/recurrence remains unclear. Perhaps reattaching the torn tendon to a different place on the bone might help. There may be other changes in the surgical technique that could help improve the quality of repair. This would have to be studied more closely by comparing results of different suture placement and repair techniques. More study is also needed to understand the mechanisms by which tendon retraction occurs in the first place.

The fact that age is a risk factor suggests that biologic characteristics of the damaged tendon are as important as the type of surgical repair. Small tears can be repaired since function is not affected by tendon retraction but medium-to-large tears should be reconstructed. Patient selection for each type of surgery becomes important as well.

And finally, the clear understanding that the problem develops early on leads to the conclusion that activity in the early days and weeks after surgery must be monitored closely. Too much activity, motion, and force on the healing tissue may contribute to tendon retraction and must be prevented. The fact that 80 per cent of all retractions occurred in the first 12 weeks highlights this as a key time period for protection of the healing tissue in all patients.

Patients should be clearly instructed to follow all of the surgeon’s post-operative guidelines carefully and not deviate from the program. Clearly, too much activity, too soon can lead to problems. If, as you describe yourself, there are tendencies toward being obsessive-compulsive, this will aid you in following directions and protecting the healing tissue.