FAQ Category: Shoulder

Cuff tear size is graded as small, medium, or large based on the diameter of the tear. Small is less than one centimeter. Medium refers to a tear that’s one to three centimeters wide. Large means the tear is three to five centimeters.

The term massive is reserved for tears larger than five centimeters. That’s about an inch and a quarter. It may not seem like much but in the area of the shoulder, a massive tear is significant.

Fortunately, today’s surgery seems to be successful regardless of tear size. With large or massive tears, there can be some extra complications. The shape of the tear makes a difference. Large or massive U-shaped tears require extra steps to repair.

Sometimes a piece of bone or cartilage breaks off and remains attached to the end of the tendon. Special surgery may be needed to repair all the damage present.

You may be referring to the Simple Shoulder Test or SST developed at the University of Washington. It’s a series of Yes/No questions asked each patient.

One group of questions is about pain. A second group of questions asks about mobility. Strength and function are also evaluated. A normal shoulder would have a ‘yes’ answer to all 12 questions.

Here’s a sample of the questions:

The Bernoulli equation comes from Newton’s laws of motion. It deals with flowing fluids and says that when a gas such as air flows, its pressure drops. For fluid in the joint the Bernoulli effect means the pressure is lower in a moving fluid than in a fluid that’s still.

In the shoulder during arthroscopic surgery, fluid is pushed through the tube of the scope into the joint. This technique helps with several things. First, it clears the joint of any blood obstructing the surgeon’s view. Second it pushes the joint open and gives the surgeon more room to work.

Finally lower pressure means less damage in the joint. Each hole that is made in the joint capsule to allow the scope to enter the joint leaves an opening. Fluid can leak out of the joint into the nearby tissues. Keeping fluid flowing through the joint reduces pressure, and keeps the fluid from escaping.

You aren’t the first one to have scale shock after shoulder arthroscopy. Most folks notice between a two and 20-pound weight gain. The average weight gain is about 10 pounds.

A recent study from the University of Texas tracked weight change in patients before and after this surgery. They found the main cause was the fluid pushed into the joint to help separate the joint surfaces. It gives the surgeon a little more room to work in.

The more damage there is to the joint or the longer the surgery takes to finish, the more fluid is pushed into the area. This is the key factor causing the weight gain. Doctors have been advised to shorten the surgical time whenever possible.

Swelling of the neck, nerve problems, and even death of skin tissue can occur after arthroscopic surgery. Evidently the surgeon pushes fluid into the joint during the operation. This helps keep the joint open. It also washes away any blood that might keep the surgeon from seeing what he or she is doing.

The longer the surgery takes, the more fluid is forced into the joint. This increases the chances of problems occurring. Surgeons are encouraged to shorten the operating time as much as possible to reduce the amount of fluid put into the joint.

Ask your doctor to go over the pros and cons of each option. Even if this was explained one time, ask for another explanation. This is important since you’re still undecided. As a general rule the rate of complications with either method is less as the anesthesiologist’s experience increases.

In other words, whichever method the anesthesiologist uses most often usually has the lowest rate of problems later. Once you decide which option is best for you, ask your surgeon to recommend an anesthesiologist with good results using that method.

Regional blocks can fail but the surgeon can always switch you over to general anesthesia. The opposite isn’t true. The success of a regional block depends on the skill of the anesthesiologist. With good results you should have a shorter operation, less pain afterwards, and less nausea and vomiting.

With a general anesthesia the patient is asleep and therefore doesn’t move. With a regional block, you are awake but you are given drugs to sedate or relax you. Movement is possible, but isn’t very likely.

Many shoulder surgeries are done now with the patient in a position seated as if in a beach chair. This supports your entire body without putting pressure on one side more than the other. The arm being operated on is placed in a special arm holder. Your body may be gently strapped in place to avoid slipping to one side or the other. A face mask may be used to hold your head in the middle.

Sometimes doctors will use a light general anesthesia along with the block. Talk to your doctor about your choices, especially if you are concerned about having just the regional block.

The nerve that goes to those two fingers is called the ulnar nerve. It runs down from the neck and shoulder through the elbow then to the wrist and fingers. Near the elbow, the nerve is close to the skin. Numbness and tingling can occur if it gets bumped, stretched, or pushed too hard or for too long.

This may have happened during the surgery because of the position of your arm. Pressure on the elbow for a long time could be the cause. This doesn’t happen often. We do know it usually goes away by itself.

Most patients report the symptoms go away anywhere from two weeks after the surgery to six months later. The average time it takes is nine weeks.

Report these symptoms to your doctor (if you haven’t already done so). He or she may suggest a wait-and-see approach for now.

That’s a fair assessment. Most recurrence of shoulder instability occurs in the first six months in shoulders that have multidirectional instability. That means the joint capsule has been damaged or stretched out in the front and in the back. If nothing’s happened by the end of two years the joint is probably healed, strong, and stable.

Of course, a traumatic injury or accident could cause another dislocation. Any joint that’s subjected to loads greater than it can handle can dislocate. Your risk for recurrence of the problem increases if you play contact sports like rugby, football, or soccer. A bad fall or car accident are two other common ways to reinjure a repaired shoulder.

Six to eight weeks is the standard length of time it takes the average soft tissue to heal fully. Range of motion and strength gradually return from that point on up to 12 weeks after surgery.

Returning to full-time work may take a bit longer depending on the type of work you do. Most patients return to full employment around the end of three months. Joining in sports activities is usually next around four or five months. By six months you should notice you’ve made a full recovery.

Studies show that shoulder dislocation after repair occurs anywhere from 12 to 24 percent of the time. There are different reasons for this. Sometimes it depends on the type of surgery done to repair the problem.

For example, an open incision allows the surgeon to repair the tear in the cartilage and tighten up the joint capsule at the same time. Arthroscopic surgery may only include repair of the damaged soft tissue while leaving the capsular laxity alone.

Another factor in repeat dislocations after surgery is the patient. It’s important to follow the surgeon’s instructions. A shoulder sling may be needed for up to four weeks. Exercises must be done daily. Doing too much too soon is a common way to undo the benefits of the surgery.

You’ve asked a good question. Sometimes researchers can pinpoint one or two factors that clearly make a difference. Special math formulas are used to analyze the data. Statistical analysis helps sort out some of these things.

In other cases, it’s not always clear how the results were affected by surgery versus something else like rehab. If the study doesn’t evaluate other factors there may be no way of knowing.

Many researchers report the limitations they see in their own studies. They may point out areas that weren’t studied or weaknesses in the way the study was done. You may have hit on one of the key differences from study to study.

It may be best to let your surgeon decide. X-rays, MRIs, or CT scan results may give him or her all the information needed to plan the best method. Some surgeons start with an arthroscopic approach and switch to an open incision method if the damage is too great to repair arthroscopically.

There aren’t too many studies comparing the results of patients with both kinds of surgery. There are many factors to consider. Patients may all have shoulder surgery but the type of damage and kind of repair needed can vary greatly. Even with the same problem, surgeons may use different methods of repair.

The measures of success may vary too. Comparing the results of one study to another isn’t always possible. Some doctors may use range of motion and muscle strength as the final sign of success. Others may depend on patient reports of pain and function.

If you have confidence in your surgeon give him or her the go-ahead to use his or her best judgment in deciding the best approach for you. Keep the lines of communication open in case there are important decisions that are yours to make alone.

You’ve just been introduced to the ongoing debate about shoulder repairs. Some surgeons use an open incision. Others use an arthroscope, which eliminates cutting the patient open. There are usually two or three small puncture holes where the arthroscope enters through the skin into the joint.

Some surgeons declare the open method the best and say it has “stood the test of time.” Others are more willing to try arthroscopy and compare the two techniques.

Studies show there is a steep learning curve with arthroscopy. This means the surgeon learns how to use this method and improves quickly with each case. There is great variation in ways to do arthroscopic shoulder repair compared with open methods.

This fact alone makes it difficult to compare the techniques. Most researchers use the final results to compare the two methods. You can always ask your surgeon what his results are with the open method and compare this to another surgeon who uses arthroscopy.

Right now both ways are perfectly acceptable with good results.

Depend on your doctor’s final word to guide you. Doctors rarely rely on imaging studies without knowing the patient’s history and doing an exam. Many clinical tests can be done to find the exact tendon that’s involved.

A misdiagnosed torn rotator cuff usually goes the other way. In other words, there’s a tear but the image shows a normal tendon. It would be rare (but possible) to have a normal tendon diagnosed as torn. This could occur when there is what’s called an artifact, a blip in the picture. Artifacts come from extra electronic signals. Another possible reason for a wrong diagnosis is that the radiologist looking at the image can misread it.

One benefit to in-office ultrasound testing for orthopedic surgeons is the doctor’s knowledge of the patient. The patient doesn’t have to depend on the results read by a radiologist who has never seen the patient.

The surgeon has the advantage when looking at the image of knowing how the patient presented. The test can be done at the time of the exam, saving the patient from having to make another appointment on another day.

Damage to a tendon of the rotator cuff is usually called a rotator cuff tear. Minor fraying of the tendon but no other change in the tendon is counted as part of the “normal” aging process. But frayed pieces with a loss of tendon fibers is a partial-thickness tear.

Full-thickness tear means the tendon is severed all the way through. There is usually a gap seen on MRI or CT scan to show this. Sometimes a tendon will look normal on imaging studies. There are also times when a tear looks partial but is really full. The only way to know for sure is by doing arthroscopic or open surgery. At that time the diagnosis is confirmed with 100 percent accuracy.

Even a doctor might not recognize the results of an ultrasound (US) of soft tissue structures without some training. Most have years of training and experience to accurately diagnose problems.

An ultrasound of the shoulder can show, first of all, if there is a torn tendon. It can show which tendon is damaged and if the tear is partial or through the full thickness of the tendon. Anyone trained to read US images can also tell the size of the tear and which direction it’s going (up and down or sideways).

Sometimes with a full-thickness tear the tendon pulls away from the bone. This is called retraction. Small amounts of retraction are difficult to see with in an US image. Retraction more than one centimeter shows up more clearly.

There are several standard clinical tests for shoulder impingement. Your doctor probably conducted one or more of these tests on you to find the cause of the problem. Most of the time these tests are accurate enough that MRI, CT scans, or other imaging studies aren’t needed.

The most definitive test is done by injecting a local anesthestic (like lidocaine) into the subacromial space. This is a space below the acromion, a curved piece of bone that comes over the shoulder blade, forming the highest point of the shoulder. The deltoid and trapezius muscles attach to the acromion.

Pain relief with testing after injection is a positive sign of impingement.

Shoulder impingement is a common problem, especially as we age. The protective pad called the bursa gets thin and even disappears in many adults. Without the proper space between the head of the humerus (upper arm bone) and the acromion (highest point of the shoulder), the shoulder tendons can get pinched as the arm is raised up.

Some patients don’t get better after treatment for impingement because the rotator cuff is torn as well. Your surgeon will be able to check the rest of the shoulder when the decompression is done.

Subacromial decompression removes some of the bone to make room for the soft tissues. It’s a very successful surgery for most people.

Acupuncture schools exist around the world. You don’t have to be a medical doctor to study acupuncture. There is an International Acupunture Association of Physical Therapists. Physical therapists in other countries like China, Canada, and Sweden can do acupuncture.

In Sweden PTs gained the right to do acupuncture in 1984 when the practice was approved by the Swedish National Board of Health and Welfare. Special training is required and only registered medical professionals can learn acupuncture.

In the United States physical therapists are regulated by the practice act of the state in which the therapist is conducting business. If the practice act doesn’t mention acupuncture, then they can do it by exclusion. Most, if not all, states do not permit a physical therapist to do acupuncture at this time.

PTs in the United States can stimulate acupuncture points with electrical stimulation, ultrasound, or direct pressure. This technique is called acupressure.