FAQ Category: Shoulder

As the old saying goes, “If it’s not broke, don’t fix it.” Joint replacements don’t last forever. Just removing the damaged part and replacing it can cause problems. The muscles around the joint must be cut and a certain amount of bone removed.

Many doctors would agree when only half the joint is a problem then a
hemiarthroplasty is the way to go. This operation only replaces the part of the joint that is damaged. This is usually the head of the humerus or ball portion that fits into the socket. Any part of the joint that is still in good health should be saved.

Research shows there are some ways to tell if a partial shoulder replacement (called hemiarthroplasty) will be successful. First, age and sex don’t seem to make any difference. The condition of the healthy joint and surrounding muscles is much more
important.

If you have a smooth socket and healthy rotator cuff your chances of a good result improve greatly. If you’ve never had surgery on that shoulder before, you’re more likely to have a successful operation.

Almost all patients report pain relief and increased comfort and function after hemiarthroplasty. The operation has been around long enough now that the results are better and better all the time.

Talk with your doctor about your concerns. Ask if there’s any reason why you can’t delay or postpone the operation until you’re absolutely ready to do it.

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.

The overhead athlete faces some unique challenges. The core muscles around the shoulder are called the rotator cuff. The rotator cuff must be strong enough to move the arm forward at high speeds without letting the shoulder coming out of the socket.

Two muscles are especially important during the overhead throw. These are the infraspinatus and teres minor, two muscles that rotate the shoulder outwardly.

Problems can occur if the joint is naturally loose or even too tight. Athletic conditioning programs often include exercises to strengthen these muscles. The idea is to: (1) increase muscle strength, (2) prevent injury, and (3) enhance performance.

Teams with high rates of injury may not be focused on exercises for all three goals.

Frozen shoulder or adhesive capsulitis is a term used for a shoulder that doesn’t move freely like it should. Often there is a history of injury, surgery, or other reason why the patient stopped moving the arm and shoulder.

Frozen shoulder is not uncommon after being in the intensive care unit. Patients are connected to machines and often unable to move. Patients getting a heart pacemaker or heart bypass are told not to lift the arms over head for up to six weeks after the operation.

When no movement occurs in a joint, tiny fibers link the joint capsule to the bone. This keeps the joint from moving freely. The condition is a form of scar tissue called fibrosis and leads to a frozen shoulder. Since it’s all soft tissue, there are no changes in the bone and nothing shows up on the X-ray.

A frozen shoulder does refer to a shoulder joint that is painful and restricted in motion. Often the patient can’t lift the arm up past the nose much less reach overhead. There are many causes of frozen shoulder. The most common are diabetes, trauma, or
surgery. Sometimes it happens with no known cause.

A resistant frozen shoulder means it doesn’t get better with treatment. Often the patient has tried drugs, physical therapy, and exercises at home. The shoulder is still painful and stuck. Range of motion can be mildly to severely limited.

In cases like these, surgery is often the next step. The doctor performs an operation called a shoulder manipulation. Under anesthesia, the patient is relaxed and the arm is moved through its full range of motion. In some cases the doctor may use an arthroscope to look inside the joint and cut loose any fibers or scar tissue holding the joint down.

A frozen shoulder can be resistant to manipulation, too. That’s why the patient must follow a rehab program after the operation. Stretching and motion will help keep the motion gained during the manipulation.

No one has ever measured adults to see what is the normal hand-behind-back range of motion. Therapists working with patients of all sizes, shapes, and ages report this motion varies quite a bit from person to person and even from right to left in the same person. This is what you’ve noticed in yourself.

Some of the factors that could make a difference might be age, previous shoulder or arm injury, and strength. It’s possible that the muscles and soft tissues of your dominant arm are tighter. This can occur from using it more. Less flexibility means the hand can’t reach up quite as far on one side.

A difference from one side to the other may not be a problem if you’re not having shoulder pain and if you can reach behind while dressing or bathing. This may be a good exercise to include three or four times each week to regain lost motion and keep your flexibility. It’s easy to injure the shoulder in this position, so move slowly and gently. Don’t force the arm up the back by pushing on it.

Whereas 80 percent of adults have back pain that goes away, a much higher number have shoulder pain that doesn’t go away. The shoulder is more likely than any other joint to have chronic pain. Pain can last anywhere from six to 18 months or longer.

Most people seem to learn to live with it and don’t seek medical help. Or they see their doctor one time and don’t go back when it doesn’t get better.

Yet studies show that early treatment can make a difference. The shorter the symptoms last, the better chances are for a good outcome. The cause of the problem can make a difference, too. Someone with shoulder pain from a minor injury is more likely to have a good result than someone with major trauma.

Maybe it’s time your neighbor went to see the doctor again (or for the first time). Perhaps having someone like yourself to go with him or her would make a difference. Suggest the idea and see if you can get the ball rolling.

It may seem like older patients are less likely to have a good result with treatment for this type of problem. Degenerative changes in the joint are common. Bone spurs, tendon tears, uneven cartilage are only a few things that can add to the problem.

Studies show many older adults with major changes in the shoulder joint don’t have any pain or loss of function. Symptom-free rotator cuff tears have been shown in half of all adults over the age of 60.

A new study from Australia showed that more than half of all older adults with shoulder pain responded well to conservative treatment. These good results were still present six months after the treatment ended.

Give therapy a try and see what kind of results your mother gets in the first month. Look for a gradual improvement of symptoms and increased function. If there’s no improvement, then the doctor may need to take a second look.

The basic steps to this operation are the same from patient to patient. There may be some small differences based on what the doctor finds during the procedure.

First you will be anesthetized or put to sleep (some patients have a nerve block and remain awake but feel no pain). The doctor will gently mobilize the shoulder joint. This means while lying on your back, your arm will be lifted and rotated inwardly. This shows
the doctor how the back (posterior) half of the joint capsule is moving (or not moving if it’s stuck or bound down).

Then the arm is gently moved out to the side away from the body. This motion is called abduction. Next the arm is rotated outward. This is done first with the elbow bent and then with the elbow straight with the arm down at the side. This gives the doctor
information about the front (anterior) half of the joint capsule.

In the final step, the doctor uses a special tool (arthroscope) to look inside the joint for any areas of scar tissue, inflammation, or tears in the capsule. The scar tissue will
be released and any rough spots shaved smooth. The doctor may cut and remove the joint capsule from the front and the back. Any other damage will be repaired and space made for all structures to move freely.

Most patients are seen in physical therapy right away. Rehab often continues after discharge from the hospital. A home program is essential.

Thermal capsulorrhaphy is a heat treatment to the shoulder capsule to shrink the soft tissue. It’s used most often for patients with shoulder instability after injury or chronic dislocations. A probe is placed inside the joint and heats the tissue up using radiofrequency energy.

The treatment may be losing favor. After 10 years of study, it looks like the long-term results aren’t as good as expected. Studies show some patients end up with damage to the joint. The capsule around the joint can be completely destroyed instead of heated up to the point of shrinking and tightening up the capsule.

This type of damage is hard to repair. The tissue can’t even hold together with stitches. Damage to the axillary nerve, which supplies the deltoid muscle in the arm, can also occur. Scientists are now turning their attention to other ways to treat shoulder instability.

Studies using thermal energy to heat the shoulder capsule were first done on animals. There were no obvious problems seen afterwards in relaxation of the tissue. Studies were done next on cadavers (human bodies preserved after death for study) and finally, on live humans. Loss of joint motion hasn’t been reported.

If anything there are some concerns that shrinkage alters the elasticity of the tissue. Under too much load there’s a risk of stretching out the tissues. In this case, the shoulder can become unstable again with too much motion.

Your best bet for a good result is to follow your doctor’s directions and report any problems early on.

It’s not uncommon, but it’s also not “normal.” The muscles often respond with protective splinting and guarding after surgery or immobilization. Sometimes the muscles develop trigger points. These are irritable spots in the muscles that can set off pain and spasm.

Even though it seems like movement makes it worse, sometimes movement is just what you need. Gentle, slow, repetitive motions can often “re-set” the nervous system and help the muscles relax. You may need some outside help as well. Massage therapy is one option. Physical therapy can offer electrical stimulation, movement therapy, and trigger point release.

In most states you can go to a massage therapist or physical therapist without seeing your doctor first. After surgery of any kind, it’s always a good idea to ask your doctor’s opinion. It’s best not to do anything that will affect the results of the operation.

There are many versions of one brace used most often for this problem. The most common names are the Sully brace, SAWA max shoulder brace, and the Wyre brace. Sometimes these are referred to as shoulder stabilizers.

Most of these braces are similar. They all fit like a vest, with a single short sleeve on the involved shoulder. Motion is limited with straps. The brace holds the shoulder girdle and limits arm motion on the affected side. You adjust it to limit or restrict motions. Some are made of soft material (neoprene) with elastic straps held by velcro.
Others are cotton canvas.

Any of these braces can help hold the shoulder joint in place. They assists or restrict movement according to the needs of athlete. The athlete can wear the support while participating in sports. It allows natural movement of the muscles and joints. The Sully brace is suggested for athletes who throw overhead. The Wyre brace is used for nonoverhead throwing athletes in contact sports.

You really need a medical opinion on this. The main problem with putting off treatment is the concern about redislocating the shoulder. There is a high recurrence rate (80 percent) in younger patients (up to age 30).

Many doctors advise early treatment to prevent further injury and damage to the joint. But a new study from the University of Minnesota showed that 90 percent of the athletes could complete their season with nonoperative treatment. The athletes went to physical
therapy and used a variety of shoulder braces, depending on their sport.

More than half of the injured athletes ended up having surgery during the off-season. There were no reports of injury that affected their ability to play or the surgery later.

Return to play depends on several things. Was this the first time you dislocated the shoulder? Or is this a recurrence of a previous dislocation? There is a high redislocation rate reported for young adults. Did you have an MRI to show how much and what kind of soft tissue structures (if any) were damaged?

There has been a recent study to see how quickly young athletes can return to their sport without having surgery. Shoulder instability in 30 athletes was treated with early movement, physical therapy, and bracing. Ninety percent of the athletes were able to return to their former position and play fully without surgery. The average time off the field was 10 days. The range was from zero to 30.

More than half the players finished the season and then had the surgery. The study showed no long-term problems from following this delayed treatment schedule.

The best way to treat a shoulder injury is to find out exactly what’s wrong. Shoulder injuries can cause tears of the tendons, ligaments, and capsule. Damage to the cartilage rim around the socket (labrum) is also possible.

There are different tests for each structure. Sometimes “stressing” the shoulder with a particular movement or position causes extreme pain or apprehension. This gives the
doctor a lot of information about what’s going on inside the joint. In the hands of a good clinician, you’re “safe” with these tests. In other words, the skilled tester won’t let the injury get worse.

The only way to confirm the exact cause is to do an arthroscopic exam. This is a simple operation but still a surgical procedure. There are always risks and possible problems when under anesthesia. Tests of motion, strength, and joint integrity before the arthroscopy help guide the doctor. The injury can be found quickly and likely repaired at the same time.

Not necessarily. If your wife doesn’t reinjure herself during these early weeks, she may actually get some nice healing at the injury site. The shoulder may not be able to heal itself completely and surgery may still be the best option.

During the waiting time ask your doctor about some simple exercises to keep the shoulder joint mobile. Codman’s, or pendulum, exercises can be done three to four times per day followed by ice.

Let pain be your guide. Movements that cause severe pain should be avoided. Your wife should be aware of her breathing and avoid holding her breath when moving the shoulder. Breathing and relaxation while moving through the pendulum exercises can help prevent unnecessary scar tissue from forming while waiting for the MRI.

The acromion is a piece of bone that’s part of the shoulder blade. It curves above the shoulder joint and attaches to the collar bone. A tendon from the rotator cuff called the supraspinatus goes under the acromion and attaches to the shoulder joint. When the acromion pinches against the tendon, it causes a painful condition called shoulder
impingement.

Acromioplasty is the removal of a piece of acromion process and may be done as part of a repair of the rotator cuff. It takes the pressure off the supraspinatus tendon and relieves the pain. You can see an easy to understand picture of this at:
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Many people of all ages have rotator cuff repair surgery with good results. They report decreased pain. If they had a clicking sound or sensation before the operation, this is often gone afterwards.

The Mayo Clinic just released the results of a long-term study of rotator cuff repairs in patients younger than 50. The results were a bit disappointing. More than half the
patients had a “poor” result, meaning they still had pain and no increase in motion. Many of the patients who did have improved pain still reported loss of shoulder motion and strength. About 25 percent of the patients ended up having a second operation later.

The reason for these poor results is unclear. More studies of this kind are needed to compare patients from clinic to clinic. Ask your doctor what kind of results he or she has seen in your area. Ask what you might be able to expect for both short- and long-term results.