FAQ Category: Shoulder

Not always. Soft tissue injuries are much harder to identify than a simple broken bone, which shows up on X-ray. The shoulder complex is made up of more than just the basic shoulder joint. There are tendons, ligaments, and cartilage that can be damaged in an
accident like yours.

The acromioclavicular (AC) joint is often injured. This is where the collarbone (clavicle) joins with the acromion, a bony projection off the shoulder blade. There are several good tests for AC injury, but a recent study showed other shoulder tests can be
positive when the problem is in the AC joint.

Since doctors rely on clinical tests to decide treatment, we may have to endure some extra prodding and pulling. Successful treatment is based on finding the exact problem. The initial discomfort is important in the final outcome.

The term shoulder separation refers to an injury of the acromioclavicular (AC) joint. This is where the collar bone meets the shoulder blade (scapula) above the
shoulder joint.

Usually what happens is the collarbone is pulled up while the acromion, a bony projection
on the scapula, is forced downward. The capsule of the AC joint is torn. If the ligaments around the joint are not torn, the AC joint is subluxed (partial dislocation). If the supporting structures are torn, the joint is dislocated.

A shoulder separation occurs when you tear the ligaments that hold your collarbone (clavicle) to the joint where it meets the shoulder blade. Your collarbone may move out of its normal place and push up the skin on the top of your shoulder. Other common terms
for shoulder separation is AC separation or AC sprain.

Shoulder separations, or sprains, are graded I, II, or III, depending on how far the
collarbone is separated from the shoulder. A grade I sprain has tenderness but no actual
separation. A grade II sprain has slight separation of the clavicle from the shoulder, and grade III has a greater separation. With a grade III separation, the patient may have a bump caused by the separated joint. The bump may be seen or felt at the tip of the
shoulder.

The Apprehension Test is used to look for instability in the shoulder. The test is performed on patients who have injured or even dislocated the shoulder. The test is done by moving the patient’s arm out to the side and rotating the arm (and shoulder) outward
into external rotation. This is the position you would use to throw a ball.

An apprehension test is positive if the patient looks alarmed or concerned. The patient may ask the doctor or therapist to stop the test. Many patients say it feels like the shoulder is going to dislocate again. In fact, if the test is done too quickly the shoulder can dislocate.

Your doctor can best advise you on this matter. A recent report on five cases of this type suggests early treatment is best. A second operation to revise the first procedure can remove and reposition the screw before further damage is done.

Waiting too long resulted in a poor outcome for the five men in this study. The tip of the screw scraped the joint cartilage causing destructive damage. After a second operation, all five men reported pain and were unhappy with the results. The revision surgery wasn’t done for a full year after the first operation.

The researchers suggest immediate revision in cases of this type.

You may be describing what happens when a screw used to anchor down the torn cartilage comes loose. Screws can break, come loose, and/or move in the shoulder joint. Sometimes the screw isn’t placed in the best position. The tip of the screw may not be deep enough.
It must go beneath the cartilage into the first layer of bone.

The result can be severe damage to the joint itself. It’s best to let your doctor know about your symptoms as soon as possible. Early treatment to correct the problem can prevent severe destruction to the surface of the joint.

It can. Older MRIs don’t always measure the tissue as accurately as the newer MRIs. For example, a rotator cuff tear may be reported by an older machine as a range from two to four cm. The doctor needs a single, accurate measurement to get ready for the operation.

The measuring tool in newer MRIs can give the width and length of a rotator cuff tear. It can also tell the doctor how far the tendon has pulled back into the tissue. This kind of information can be very helpful before an operation.

Look for a facility with MRIs that are less than five years old. Newer is better.

Patients are offered better ways to get tested as technology continues to advance. The open MRI is an example of this. It’s the best option for patients who are claustrophobic or too large for the regular closed MRI. Open MRI is also good for children because now the parents can stay in the room with them.

Open MRI works pretty much the same as the traditional MRI test. The big difference is the shape of the machine. In a closed MRI the patient lies in a narrow, tube-shaped structure. With open MRI the patient lies on an imaging table with more space around the body. In fact three sides of the body are surrounded by open space.

The patient can see and talk to family, friends, or support staff. Regular and open MRI are both painless. Open MRI is less noisy. You can look at a picture of both kinds of MRI
at the Johns Hopkins Bayview Medical Center by going to:
http://www.jhbmc.jhu.edu/Imaging/openmri1.html.

Not all parts of the body can be viewed with open MRI. You’ll have to check with your doctor to see if this method will work for you.

Good question. First let’s look at why you had shoulder pain from the bleeding ulcer. Blood in the abdominal cavity can put pressure on the diaphragm. The diaphragm is a large muscle across the top of the abdominal cavity. It’s involved in breathing.

Since the diaphragm and the shoulder both have the same nerves, messages from either place go into the spinal cord and get sent to the brain. The nervous system can only tell what nerves delivered the message. It doesn’t have any way to tell if the nerve at the shoulder or at the diaphragm picked up the message. So it takes a guess and sends the message back out to one or the other.

In your case, it guessed wrong and you got shoulder pain. When the shoulder hurts, the muscles tighten up. This reduces blood flow to the area, which can cause the pain to get worse. Ultrasound is a form of heat. Any form of heat can relax the muscles and bring blood to the area. The blood washes away the build up of toxins and waste from the tense muscle tissue.

This is why the US worked at first. As the bleeding into your gut continued the pain got worse and the real problem was found.

You’ve asked a question researchers have been asking for the last few years. Many studies show little or no benefit from non-steroidal anti-inflammatory drugs and steroid injections. The role of physical therapy is just now coming under closer study.

A group of doctors in Turkey reviewed the use of ultrasound (US) with soft tissue disorders of the shoulder. They divided patients into two groups. One group got US, a form of deep heat. The other group had a “sham” US (the machine was used but never turned on). Both groups also received hot packs, electrical stimulation, and exercise.

There was no difference in results between the two groups. Results were measured in terms of pain levels, motion, and function. Other studies are needed to compare US with exercise or electrical stimulation alone to know for sure what works and what doesn’t.

There may be a muscle imbalance. Too much activation of the upper trapezius muscle may be the problem. The trapezius is a large muscle in three parts. The upper part is across the top of the shoulders and contracts to shrug the shoulders.

Most muscles work in coordination or in opposition with others. They either work together at the same time or one contracts while the other is relaxed. To keep the shoulder from rising up when using the arm overhead, the upper trapezius and the serratus anterior muscle (SA) work together. The SA is attached to the scapula (shoulder blade) and at the other end to the upper eight or nine ribs.

You can have this tested by a physical therapist. The therapist will be able to give you some exercises to bring these muscles under better and more normal control.

It can be. Besides the place where the bones meet to form the shoulder joint, there are ligaments, tendons, and cartilage that could be injured. Sometimes the rim around the socket side of the joint gets torn. This is called a labral tear. They are very hard to diagnose accurately.

Above the shoulder is the acromioclavicular (AC) joint where the collarbone (clavicle) meets the acromion from the shoulder blade. The coracoacromial ligament passes from the acromion to the coracoid process and crosses in front of the shoulder joint. Injury to this ligament can also seem like a true shoulder problem.

Each part of the soft tissue structures has one or more tests that are positive when an injury occurs. A physical exam helps narrow down the choices. This can save money when it comes time to decide if imaging studies are needed and which one(s) is best.

A recent study of tests for the AC joint report two tests are 99 percent accurate for AC injury when positive. These are the Paxinos test (pressing the acromion and clavicle together) and a bone scan. More studies will help us narrow down testing choices and streamline future exams.

The true shoulder joint is where the head of the upper arm bone (humerus) inserts into a shallow cup in the shoulder blade. The cup is called the glenoid cavity. It’s a ball and socket joint.

ust above the true shoulder joint is a bony projection coming around from the back of the shoulder blade. This piece of bone is called the acromion. The end of the acromion meets the collarbone to form a shelf over the shoulder.

Pain from any of the structures around or above the shoulder joint can cause pain that seems like it’s coming from the joint. A careful exam by your doctor can pinpoint the exact cause. This is helpful information so the right problem is treated.

CRPS stands for complex regional pain syndrome. It’s a group of symptoms with no real known cause. It usually occurs after surgery or trauma. Women are affected more often than men. Children can get CRPS, but it occurs more often in adults. Symptoms occur in the arm or leg that’s been injured or operated on.

The patient often has pain that can be very severe. Changes occur in the skin. It can become dry and flaky or smooth and shiny. Sometimes the patient loses the hair on the arm or leg that’s affected. Other times hair grows more on the involved limb.

There are ways to treat this problem, though symptoms come back in about half of all patients. Ask your mother’s doctor about treatment options. Physical therapy and medications are usually tried first. Surgery may be needed if these don’t work.

A special type of computed tomography (CT), called CT osteo-absorptio-metry
(CTOAM) measures the density (thickness) of bone. These measurements can be used to map the distribution of density in various layers of bone. When linked with a special computer program, CTOAM can give the doctor a 3-dimensional view of the joint.

These density measures show where the joint carries the load. Researchers are looking for baseline measures for different age groups. It can be used to follow-up patients after surgery. It can also show early changes in bone density before there are any clinical
signs.

Shoulder instability refers to a range of disorders. Instability can occur when soft tissues like ligaments, capsule, and tendons are damaged around the shoulder joint. The result may be a partial dislocation. This means the head of the humerus (upper arm bone) comes out of the socket but can go back in by itself. This is called a
subluxation.

The other end of the spectrum occurs when the shoulder completely dislocates and must be put back in or reduced under anesthesia. Most shoulder instabilities are caused by
trauma. If the damaged tissue doesn’t heal properly, the shoulder can dislocate many more times.

The treatment for chronic shoulder instability is usually surgery to repair the damage. This operation is done as an outpatient. The doctor puts a tiny lighted telescope and small instruments into the shoulder joint. Small anchors with suture attached are inserted right into the socket of the shoulder. The torn ligaments are reattached to the
socket. Complete healing takes about four to six months.

Recent technology has allowed us to take pictures of various joints and form a 3-D view of them. As a result we now know that some shoulder sockets are tear-shaped. Others are oval.

At first there was some question that the shape might be linked to injury or instability. Scientists thought stress, load, and bone density might be related to the shape. However, a recent study comparing unstable joints to normal, healthy joints disproved this idea.

There was a shift in where the surfaces of the shoulder joint made contact. This change was linked to type of trauma (major or minor), not the shape of the socket.

Your post-operative care is prescribed by your surgeon and depends on the kind of surgery you had. The type of injury, size of the tear, and method used to reattach the tendon
direct what positions and motions you can use. You don’t want to do anything that will disrupt the repair, especially during the early weeks of tissue repair.

It’s true the shoulder can scar down and get “stuck” or “frozen” if you don’t move it. The abduction pillow you are using along with the physical therapist’s range of motion
exercises should keep you from developing problems.

Many researchers advise following a program just as you’ve described. This will protect the repair from repeated loads it can’t handle. With the help of your therapist, you’ll be able to make up any lost motion quickly once you pass this early rehab phase.

The tendons attach to the bone and must be reattached after injury in order to give you back shoulder motion and strength. Some of the newer ways of repairing rotator cuff tears
involve drilling holes through the bone. Then the doctor threads the sutures through the tunnel to the other side. This gives the repair strength and the shoulder stability.

The sutures may not hold if the bone is soft or brittle from osteoporosis. In cases of bone problems, they can use special anchors that look like buttons to help hold the stitches in place.

Most doctors will support a conservative approach for small or partial tears of the rotator cuff. If you’re not an athlete with a need for a strong, mobile shoulder, a rehab program can work quite well.

The decision to operate is often based on the type and size of rotator cuff tear. Medium to large tears usually require surgery to repair them. The longer the patient waits, the greater the chances for problems after the operation.

A recent study from Austria showed that chronic, untreated tears of the long biceps tendon have poorer results than other types of tears. The study also showed a longer wait time before the repair took place makes a difference. A longer wait time is directly linked to results.

You did the right thing by following your doctor’s advice and getting the care you needed.

The shoulder has the most motion of any joint in the body. To have that much mobility, the joint gives up a lot of stability. That means the head of the humerus (upper arm bone) pivots off the shoulder socket more than snapping in tightly.

In order to do this without dislocating the joint capsule, ligaments, and muscles hold it firmly in place. There’s a special group of muscles that surround the shoulder called the rotator cuff. They hold the humeral head in place while allowing arm motion in all directions.

The skeleton you saw was likely very normal. But to see the bones without the soft tissues can be misleading.