FAQ Category: Shoulder

Subacromial impingement syndrome (SIS) is actually a fairly common cause of shoulder pain and dysfunction. Symptoms occur when the shoulder is elevated, a position often used in golf and other sports activities.

Despite the many people affected by SIS the cause is still unclear. Doctors think the supraspinatus tendon of the rotator cuff gets pinched between the shoulder and the acromion when the arm is raised overhead. The acromion is part of the shoulder blade that curves around over the top of the shoulder joint.

What causes the impingement? It could be from changes in head, neck, and upper back posture. A forward head position pulls the shoulders forward in a slouched position. The shoulder blades move forward and up. Muscles get out of balance and soft tissues get pinched and irritated.

You may have a shoulder impingement. This is when the rotator cuff tendon(s) get caught between the top of the shoulder and the bottom of the acromion. The acromion is a bone above the shoulder joint that curves over part of the rotator cuff. The rotator cuff is made up of four muscles and their tendons that surround the shoulder joint.

There are special tests that can be done to find out what is the exact problem. A doctor or physical therapist will move your arm and shoulder through a series of motions. Each test helps identify which soft tissue structures are involved. If the rotator cuff is involved the specific muscle can be identified.

If impingement isn’t the cause of your symptoms, you may have a torn capsule or other structural problem. An MRI may be ordered to confirm the exam findings.

Joint replacements have been around long enough now to study patient results for a long time. Some studies show outcomes up to 10 or 15 years later. And it’s true that researchers have noticed a link between number of operations done and results.

The surgeons who do the most number of same operations have the best results. There are fewer problems after the surgery and even fewer deaths. Surgeons and hospitals with low-volumes have longer hospital stays for patients compared to middle- or high-volume centers.

There are a few other factors to consider. For example, how do patients’ pain levels compare from low-volume to high-volume centers? What is their function like after the operation? Are they more or less independent based on how often the surgeon does the procedure?

Likewise, what are their activities of daily living (ADLs) like? Can they return to their previous levels (and better)? What is the quality of life like for patients treated by low-, medium-, and high-volume surgeons and hospitals.

There is more than meets the eye on second look at this issue. We should get a “bigger picture” view as more studies are done on this topic.

Rotator cuff tears are often repaired using some kind of anchor or suturing system. The fixation devices are called suture anchors. They work like rivets to reattach the tendon to the bone. These anchors can be made of bone, metal, or plastic.

Problems differ depending on the type of anchor material used. For example, some anchors (like the bone buttons) require a hole predrilled before insertion. This extra step makes for a longer operation. Sometimes the surgeon has trouble making and then finding and using the hole.

Anchors made of bone are usually absorbed by the surrounding bone and don’t have to be removed. Plastic anchors may also “dissolve” or get absorbed by the bone. Some metal anchors are held in place by threads or barbs. These do not resorb and can cause problems if they move or come loose.

Other problems can include breakage of the anchors, anchor pullout, infection, or rerupture of the tendon. Infection and poor wound healing are problems in a small number of cases. Usually, these patients have diabetes or some other healthy issues or they are tobacco users.

Suture anchors are devices used to reattach and secure a torn tendon in the shoulder. They function like tiny rivets. The anchors can be made of metal, plastic, or bone. Bone anchors come in several shapes. The original anchors were made in the shape of a button. These were fastened to the bone with stitches through two holes in the button.

A new suture anchor is now ready for use. Made of bone, it is shaped like an arrow with a sharp point at the top. The sharp tip goes right into the bone without drilling a hole first. Testing shows these new suture anchors stay in place, can handle repeated loads,
and gradually become part of the bone.

Whenever checking on prices be sure to compare apples to apples and oranges to oranges. For example, some operating room prices include all supplies and the anesthesia while others cost these out separately.

Your basic operating charges include the operating room, supplies, anesthesia, the surgeon’s fee, and the anesthesiologist’s fee. There may be a pathology fee if tissue is removed from the body. And don’t forget the hospital room, supplies, and all expenses for an overnight (or longer) hospital stay.

A separate issue is how costs are decided in the state of New York. These are based on the wage index for the region. Salaries for certain hospital employees are used in the decision. Other costs such as real estate, building maintenance, utilities, and supplies are also figured in.

Finally, costs often go down the more operations are done. A high-volume hospital often has lower prices. A hospital with fewer operations to share overall facility costs will have to charge more to cover their expenses.

It sounds like you are talking about a special type of suture used to reattach a torn tendon in the shoulder. It’s made of bone and is pushed through the tendon into the bone.

Studies were done on this type of anchor to find out how strong it was. First it was tested out on cadavers (human bodies saved after death for scientific study). Scientists could find out how much load it can take by putting more and more force against the anchor until it did break.

When the bone was too thick for the anchor to go in, an awl was used to make a tiny pilot hole. Then a surgical hammer or mallet was used to drive the anchor into the bone. During testing there were no problems with breakage.

The shoulder is a very complex joint with muscles, tendons, ligaments, bursae, and fibrous cartilage helping to hold it together and give it smooth motion. Four muscles and their tendons called the rotator cuff surround the shoulder joint like an envelope. These are covered by a fibrous connective tissue called the capsule.

The head of the humerus (upper arm bone) and the shoulder socket are enclosed by the capsule. Normally the capsule is large and loose. When injury or immobility damages the capsule a frozen shoulder can develop. This means the shoulder doesn’t move smoothly in the socket. It gets stuck or frozen in place. The medical term for this is adhesive capsulitis.

With a frozen shoulder a typical pattern of movement restriction starts. This is known as the capsular pattern of the shoulder. The greatest loss of motion is in outward or external rotation of the shoulder. Moving the arm away from the body is also limited. This is called shoulder abduction. In a severe capsular pattern inward or internal shoulder motion is also stuck.

Shoulder pain is a common problem especially as we get older. The way the shoulder is examined isn’t the same from doctor to doctor or therapist to therapist. It’s not uncommon to get a different diagnosis from each specialist who sees a patient.

The shoulder joint itself is very complex. The way it works often causes more than one soft tissue structure to get pinched or pulled. This makes it hard to find out the actual cause of the problem.

Experience and training go a long way in making a correct diagnosis of shoulder pain. Besides musculoskeletal problems, shoulder pain can be caused by cancer, infection, or problems in other parts of the body. For example, a kidney infection or ruptured spleen can cause shoulder pain.

Researchers are trying to find a reliable way to test the shoulder. One model being studied is the selective tissue test (STT) first developed by an orthopedic surgeon (James Cyriax, MD). Many doctors and therapists use this skillfully and successfully to
make a shoulder pain diagnosis.

There aren’t too many studies just on the duration of pain relief with steroid injections into the joints. Results range from one week as in your case up to 13 weeks.

It’s clear that steroid injections work better than placebo injections with saline solution. And studies show that some steroids work better than others. Long-term pain relief may require a higher dose of the steroid.

In some cases steroid injections are used to control pain and reduce rehab time after arthroscopic surgery. In a patient with recurring bursitis there may be other factors such as posture and overuse to be addressed. The injection may help calm the joint enough to work on improving alignment and motion. Combining physical therapy with steroid injection may be one way to improve overall results.

Friedrich’s disease is a rare condition affecting the collarbone (clavicle) where it attaches to the breastbone (sternum). The patient reports pain or discomfort,
swelling, and crackling or popping of the joint called crepitus. There may even be a loss of arm motion on that side.

The cause of this disease remains unknown. For some reason there is a loss of blood supply to the area. The bone starts to die and decay. This process is called osteonecrosis. The bone becomes fragmented with normal, healthy bone surrounding small islands of necrotic (dying) bone.

Most often the problem solves itself and treatment isn’t needed. Sometimes the end of the bone must be removed surgically before healing can occur.

The joint you’re describing is called the sternoclavicular joint (SCJ). It is the site of several problems that occur with aging. Many systemic conditions can cause SCJ pain and swelling. Imaging studies are needed to sort these all out.

Most doctors start with plain X-rays. This gives a two-dimension view of the bones and joints in the area. Any bone spurs, fractures, or arthritic changes will show up on X-ray. CT scans may be needed to show changes in the bone or bone destruction. CT scans show small changes not seen with X-rays or bone scans. MRIs provide more detail when there’s inflammation or a tumor or other kind of mass.

The doctor may order some lab work if there’s any sign of infection or inflammation. With disorders of the SCJ, it can be very hard to tell exactly what the problem is. All of these studies are needed to determine the underlying problem.

Not too rare. The most common problem affecting this joint (called the sternoclavicular joint or SCJ) is osteoarthritis. Degenerative changes from aging make this a disease of the older adult.

Studies show more than half of all adults age 60 or older have moderate to severe arthritic changes in the SCJ. Part of this may be due to the fact that the SCJ is the only place where the bones attach the arms to the main skeleton. Anyone with a history of manual labor or overuse of the arms is at risk for this condition.

Some have painful symptoms, while others do not. Treatment is only needed when pain and loss of motion occur. Surgery is rarely needed. Most patients do well with rest, antiinflammatory drugs, or local steroid injection.

The belly-press test is used to test one of the four muscles of the rotator cuff in the shoulder. The muscle being tested is the subscapularis. While in the standing position the patient puts a hand on the stomach and pushes as hard as possible.

The effect is an isometric contraction with the shoulder in a position of internal rotation. At the same time the patient moves the elbow forward, which puts the shoulder in even more rotation. The test is positive for a tear in the subscapularis muscle if the patient can’t press against the belly while rotating the shoulder.

The lift-off test is another test used to look for subscapularis weakness from a tear or other injury. The patient puts one arm behind the lower back and tries to push the arm away from the body. The test is more accurate when the hand is in the low back rather than buttock area.

Rotator cuff tears are much more common in older adults because of age-related changes. However, overuse or trauma in sports can put anyone at risk for injury.

Although rotator cuff tears are uncommon in teenagers more and more cases are being reported. In fact many new injuries are occurring in children and adolescents because of increased participation in sports. Athletics has become more competitive with year-round training and play. These factors add to the reasons why even athletes in good shape can get injured.

The subscapularis tendon is one of four tendons of muscles that surround the shoulder. Your son may have injured his shoulder sometime in the past.

Anytime tissue is damaged, the body responds to this injury with an inflammatory response. This sometimes ends with calcification of the damaged tissue. Tiny calcium deposits develop. The resulting calcification is usually only seen with a microscope. Sometimes it’s large enough to be seen on X-ray. This is more common in children whose bones are not fully mature. The body makes a big effort to repair itself with the result being an over response of calcium formation.

There are other causes of tendon calcification. Infection, tumor, and autoimmune disorders are the most common. Ask your doctor about this finding. It’s likely the result of an old injury but could also be the start of a newly developing condition.

The peel-back sign refers to what is seen using an arthroscope to diagnose a SLAP lesion of the shoulder. A SLAP lesion is a tear of the riangular-shaped piece of cartilage on the rim of the shoulder socket. The rim is called the labrum.

The biceps muscle is divided into two main parts. The long head of the biceps tendon comes up the arm from the elbow and over the top of the head of the humerus. It attaches just above the labrum and helps hold the labrum in place. This is called the biceps
anchor.

This area is at risk from injuries related to overuse and traumatic injury. If the labrum is torn but the biceps anchor isn’t, then repetitive overhead throwing puts force on the labrum through the biceps. The added load can keep the injury from healing.

The peel-back mechanism is a likely cause of one type of SLAP lesion. As the shoulder is rotated outward (like a pitcher reaching back to throw the ball), the base of the biceps twists. An increased load goes to the labrum.

The actual peel-back sign can only be seen visibly during the arthroscopic exam. The arm is placed into 70-90° of abduction (away from the body) and then turned outward or externally rotated more and more. During this motion, the base of the biceps twists.

A torsional load is transmitted to the superior labrum. If there’s a tear in the back half of the labrum, this twisting of the biceps actually peels back the labrum. Surgery is needed to stitch the labrum back in place. The patient can’t externally rotate the arm for three weeks while the labrum heals.

A SLAP (superior labral anterior posterior) shoulder injury is not the same as a rotator cuff tear. Both affect the shoulder. Different parts are injured. In the rotator cuff tear, one of four tendons around the shoulder is torn.

The SLAP lesion is a tear of the fibrous rim along the upper portion of the glenoid cavity (shoulder socket). The upper (superior) part of the labrum anchors one of the two tendons of the biceps muscle.

A SLAP injury occurs if the arm is bent inward at the shoulder enough times or with enough force. The upper arm (humerus) acts as a lever and tears the biceps tendon and labrum cartilage from the glenoid cavity. The tear occurs in a front-to-back (anterior-posterior) direction. That’s why it’s called a superior labrum anterior-posterior tear. In simpler terms it’s an upper rim front-to-back injury.

The SLAP lesion can occur as a result of overuse or trauma. It’s most common among overhead throwing athletes. When the force of injury is great enough the rotator cuff can be torn along with the labrum.

Maybe not. A type II SLAP tear of the labrum in the shoulder means the fibrous rim has pulled away from the bone along with a piece of the biceps tendon where it attaches to the labrum. The joint is unstable without the biceps anchor.

The joint can become loose or lax and further injury can occur. Chronic instability leads to tears of the rotator cuff. The rotator cuff is a group of four muscles and tendons that surround the shoulder joint and keep it in the socket.

Take the advice of your doctor. If surgery is advised you can start a rehab program as early as one week after the operation. The program of motion and exercise will gradually progress the first four weeks. Strengthening can be added in most cases after four weeks.

Sport-specific exercises can be prescribed four months after the surgery. If all goes well, by six months, you’ll be back on the playing field as good as new.

In some cases nerve damage at the time of the original injury may be the cause of the frozen shoulder.

There may be a separate problem going on altogether. For example, neck arthritis with nerve impingement can cause shoulder pain and weakness. Loss of motion leading to a “stuck” or “frozen” shoulder can occur.

Many rotator cuff tears occur gradually. Often there’s been a history of shoulder problems. Painful motion, night pain, and gradual weakness in the arm may result in wasting of some of the muscles. Given these conditions, a frozen shoulder can occur. This is especially true if the patient hasn’t had a good rehab program after the repair.

Physical therapy to restore motion and function is the first step. If your symptoms aren’t improved in six to eight weeks, then a second shoulder surgery may be needed.