FAQ Category: Shoulder

The mechanics and design of the reverse shoulder replacement are the exact opposite of a traditional shoulder replacement. In the reverse implant, the ball portion of the shoulder is placed where the socket use to be and the socket is where the ball or humeral head occurs naturally in the normal shoulder joint. This new design has made it possible to create a much more stable shoulder joint that can function without a rotator cuff.

The loss of the support and function of the rotator cuff muscle is the key ingredient here. Without this important muscle group, patients with severe rheumatoid arthritis do not do well with the traditional shoulder replacement. But concerns about bone loss and a lack of information on how patients with rheumatoid arthritis would do with this type of implant have kept surgeons from using the reverse shoulder replacement.

There has been one study (from the Mayo Clinics in Arizona and Minnesota) that showed encouraging results for patients with severe shoulder destruction from rheumatoid arthritis and rotator cuff tears. They successfully replaced the shoulder joints of 19 patients with a reverse shoulder replacement. Early results (after three years) were good but there were some complications.

Compared with preoperative measurements, the postoperative results were excellent for 12 of the 19 patients. Five others had satisfactory results. Only two had an unsatisfactory outcome. There were a few complications but most were not directly related to the surgery. Falls leading to bone fractures were the biggest postoperative problem but these were not directly related to (or caused by) the shoulder replacement surgery. No one in the study needed revision surgery.

The Mayo surgeons concluded that patients with severe shoulder joint destruction from rheumatoid (inflammatory) arthritis have some new options with this procedure. The main indication for the use of reverse shoulder replacements has always been severe rotator cuff damage. It looks like a reverse prosthesis can also successfully reduce pain and significantly improve function previously affected by limited motion.

The authors say they will continue using this procedure with their patients when appropriate. That last word is very important — patient selection is done carefully with the goal of the best results with the fewest complications. As with all major surgical procedures, complications can occur.

Some of the most common complications following reverse artificial shoulder replacement are infection, fracture, dislocation, loosening, and nerve or blood vessel injury. For more information on the specific surgical complications that can arise, see our patient handout: A Patient’s Guide to Reverse Arthroplasty.

A recent study from the Mayo Clinics (Arizona and Minnesota clinics) showed encouraging results for patients with rheumatoid arthritis, severe shoulder destruction, and rotator cuff tears. They successfully replaced the shoulder joints of 19 patients with a reverse shoulder replacement. Early results (after three years) were good but there were some complications.

The mechanics and design of the reverse shoulder replacement are the exact opposite of a traditional shoulder replacement. In the reverse implant, the ball portion of the shoulder is placed where the socket use to be and the socket is where the ball or humeral head occurs naturally in the normal shoulder joint. This new design has made it possible to create a much more stable shoulder joint that can function without a rotator cuff.

The loss of the support and function of the rotator cuff muscle is the key ingredient here. Without this important muscle group, patients with severe rheumatoid arthritis do not do well with the traditional shoulder replacement. But concerns about bone loss and a lack of information on how patients with rheumatoid arthritis would do with this type of implant have kept surgeons from using the reverse shoulder replacement.

That’s why this study is so important. For the first time, we have some early results that support this type of treatment for patients with rheumatoid arthritis affecting the shoulder(s). Results of the reverse procedure were measured using pain levels, shoulder motion, and function of the arm that depended on use of the shoulder. X-rays were used to show position and condition of the implant.

Compared with preoperative measurements, the postoperative results were good to excellent for most of the patients. There were a few complications but most were not directly related to the surgery.

The conclusion of the study was that patients like yourself with severe shoulder joint destruction from rheumatoid (inflammatory) arthritis are not without some options. According to the early results of this Mayo clinic study, the use of reverse shoulder arthroplasty can be beneficial in cases of RA and rotator cuff tears.

The main indication for the use of reverse shoulder replacements has always been severe rotator cuff damage. It looks like a reverse prosthesis can also successfully reduce pain and significantly improve function previously affected by limited motion.

The authors say they will continue using this procedure with their patients when appropriate. You can certainly bring this up to your surgeon and see if you might be a good candidate. Not all surgeons perform this procedure so you may have to be referred to a clinic where reverse shoulder replacements are being done.

Symptoms that suggest a rotator cuff tendinopathy include pain with arm motion overhead, pain at night, and a positive impingement sign (pain during a particular arc of shoulder motion). A common treatment for this problem is a steroid injection into the acromial bursa. The antiinflammatory properties of the steroid medication are designed to reduce swelling and thereby decrease the size of the bursa. An inflamed bursa can be painful but can also take up space in the shoulder causing impingement (pinching) of the rotator cuff tendons.

In a recent study from the University of California, one surgeon found that injecting the shoulder from the front and side (anterior and lateral routes) gave better results than injecting from the back (posterior). This was especially true for women. It turns out that the posterior route was the least accurate when injecting the subacromial bursa in females.

One possible reason for this difference between men and women may be the downward-sloping angle of the acromion. Age did not seem to be a contributing factor. In this study, 75 shoulders were injected in 35 men and 40 women from 24 to 76 years of age. So there was a broad range of ages to compare. The main difference was really gender (male versus female).

When patients fail to get pain relief from a steroid injection for rotator cuff syndrome, it may not be because the injection failed. It could be the injection never reached its intended destination if the surgeon failed to accurately inject the bursa. Pain relief with successful steroid injection is expected to occur within the first hour after injection. A second reason pain relief may not occur is an incorrect diagnosis (the problem may not be a rotator cuff tendinopathy).

Injection of a steroid (antiinflammatory) and a numbing agent into the subacromial bursa is a fairly common treatment for rotator cuff problems. An inflamed bursa (a fluid-filled sac between the muscle and bone) can cause pain when the arm is raised (forward or to the side) past 90 degrees. The rotator cuff tendon gets pinched between the bursa and the bone. Bringing the bursa back down to its normal size can help eliminate painful symptoms.

But the injection may fail for two main reasons. One, the problem wasn’t a rotator cuff tendinopathy — there may be something else causing the painful symptoms. This would require further testing and study. And two, failure to accurately inject the bursa can mean painful symptoms persist.

Studies show that accuracy of injection can range anywhere from 29 to 87 per cent. Accuracy is much improved when the surgeon uses ultrasound or fluoroscopy (a special type of X-ray) to guide needle placement and injection. Without these tools, accuracy can be very diminished.

And in a more recent study from the Sports Medicine Center at UC-Davis, it was discovered that accuracy of injection can also be affected by which direction the surgeon uses to give the injection. Injections to the subacromial bursa can be given from the anterior (front), lateral (side), or posterior (back).

In that study, one orthopedic surgeon injected 75 shoulders using these three pathways. There were three groups of patients and each group received one of the three types of injection. Patients were randomly assigned to the group they were in. The fluid injected included the steroid medication, a numbing agent, and a dye. The dye was part of the injection so that X-rays taken would show the accuracy of the injection (i.e., did the fluid actually end up inside the bursa?).

This surgeon found that injecting the shoulder from the front and side (anterior and lateral routes) gave better results than injecting from the back (posterior). This was especially true for women. It turns out that the posterior route was the least accurate when injecting the subacromial bursa in females.

Treatment ranges from conservative (nonoperative) care with doing nothing, physical therapy, or steroid injections to surgery to release the adhesions. Surgery can be done with a simple manipulation (shoulder is moved through full motion while patient is anesthetized), arthroscopic capsular release, or open incision release.

A recent study of long-term outcomes after arthroscopic capsular release may have some helpful insights for you. A single surgeon from the Orthopaedic Research Institute in Australia followed a group of patients through surgery and the follow-up recovery time (including up to five years later). This was the first study to report such results more than two years after the first arthroscopic procedure.

The surgeon performed a complete 360-degree release of the capsule (all the way around the shoulder joint). Then a gentle manipulation was performed by moving the arm through its full range-of-motion. The surgeon injected the joint with a numbing agent combined with a steroid (antiinflammatory) medication.

The goal of the injection therapy was post-operative pain relief. Everyone treated with this approach went home on the day of surgery without a sling and with instructions from the physical therapist for the proper exercises to perform.

Results were measured by comparing before and after surgery range-of-motion, pain intensity, activities and function. The ability to reach behind the head and back was measured. Ability to lie on the painful side and sleep at night were also reported and recorded. Current level of sports participation was rated from “none” to hobby, club, or professional play.

All the patients reported immediate pain relief during activity and at night while sleeping. There was at least a 50 per cent improvement in range of motion early on. Functional skills like reaching overhead or behind the back improved steadily from postoperative week 6 through the end of the first year. By the end of the first year, the affected shoulder had motion equal to that of the unaffected shoulder. And there were no complications (e.g., infection, worse symptoms, nerve damage, joint instability).

The author concluded that arthroscopic capsular release for idiopathic adhesive capsulitis is an acceptable, safe, and effective treatment technique. The good-to-excellent results in the short-term were maintained into equally good long-term results. These results compare favorably to the 50 per cent of patients treated nonoperatively who still had pain or stiffness five to seven years later.

“Frozen shoulder” sometimes referred to as adhesive capsulitis occurs in up to two per cent of the general adult population. When it develops without warning or known cause, it is referred to as idiopathic. Accidents and injuries with tears of the rotator cuff and/or labrum (rim of fibrous cartilage around the shoulder socket) are possible known causes of this condition.

Women seem to develop this problem more often than men. In both groups (men and women), adhesive capsulitis tends to occur between the ages of 35 and 65 years. Again, the reason for this remains unknown. Typical symptoms are pain and stiffness limiting motion, especially overhead arm movements. Reaching behind the back is also restricted.

Arthroscopic examination inside the joint shows a thickened joint capsule, the connective tissue that surrounds the joint and helps hold it in the socket. Histologic examination (looking at the tissue under a microscope) show a tightly packed group of collagen fibers. Collagen is the basic building block of all soft tissue.

What happens in this condition over time is referred to as the natural history. There seem to be some well-defined and expected phases to this problem. First comes the painful stiffness and limited shoulder motion. Gradually the joint loosens up again. And eventually, most (if not all) motion is restored.

Studies show that it is possible to leave the shoulder alone (called benign neglect) and it will go through these phases successfully. Other studies suggest that conservative (nonoperative) care of any kind (benign neglect, steroid injection, physical therapy) results in improvements but not a complete restoration.

In up to half of all patients treated without surgery, mild pain, stiffness, and some loss of function are still reported five to seven years after the initial attack. Surgery to release the capsule and manipulate (move) the shoulder through its full motion seems to have the best results without complications and with full recovery of pain free motion.

Platelet-rich plasma (PRP) refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself. It is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries. Platelet-rich plasma is the same as “blood injection therapy.”

Platelet-rich fibrin matrix (PRFM) is a variation of platelet-rich plasma. The fibrin matrix processes the patient’s plasma in a way that helps keep blood-clotting platelets in the matrix while also slowly releasing cytokines to aid in healing.

Cytokines are signaling molecules used in cellular communication. They are part of the immune system response to injury. They help set up a new blood supply to the area and attract stem cells to the area to help form new tendon.

Surgeons are experimenting a bit with this approach to tendon healing. They are trying to find the best way to use platelet-rich plasma therapy. Tinkering with the “recipe” so-to-speak is one way to improve results. It was hoped that by providing a healing product like PRFM, rotator cuff healing could be accelerated or speeded up. So far, that hasn’t been the case.

In a recent study from the Sports Medicine and Shoulder Service at the Hospital for Special Surgery in New York City, the surgeons found that PRFM seemed to inhibit healing. There were more treatment failures in the PRFM group compared with the control group. Although PRFM did not improve rotator cuff tendon healing and was even linked with lower healing rates, further study is needed to understand what happened before either abandoning the technique or using it on other patients.

Surgeons from the Sports Medicine and Shoulder Service at the Hospital for Special Surgery in New York City did report that using this healing method for rotator cuff tears, may have an inhibitory effect on healing.

But let’s back up a bit and fill you in on what this all means. In the past 10 years, surgeons have started using platelet-rich plasma (PRP) (also known as blood injection therapy) for a wide range of musculoskeletal problems.

Platelet-rich plasma (PRP) refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself. It is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries. This is probably what you’ve been reading about.

In this study, the surgeons used a special platelet-rich fibrin matrix (PRFM) they made themselves in the operating room. It was a slight variation from the original platelet-rich plasma (PRP) product first used. The fibrin matrix processes the patient’s plasma in a way that helps keep blood-clotting platelets in the matrix while also slowly releasing cytokines to aid in healing.

Cytokines are signaling molecules used in cellular communication. They are part of the immune system response to injury. They help set up a new blood supply to the area and attract stem cells to the area to help form new tendon. By painting this substance at the tendon-bone interface, the researchers hoped to speed up rotator cuff healing.

Instead, what they found with ultrasound studies and by measuring patients’ motion, strength, and function was that the group who did NOT receive the PRFM got better results. The two groups (with and without the PRFM) had similar outcomes in terms of grip strength and pain after surgery. But the PRFM group had a significantly higher number of tendon defects. This finding indicated the PRFM might have a negative effect on tendon healing.

The original hypothesis in conducting this study was that PRFM would speed up or accelerate rotator cuff tendon healing. It did not. In fact, it seemed to inhibit healing. There were more treatment failures in the PRFM group compared with the control group. Of course, the natural question is, “Why didn’t it work?”

The authors propose three possibilities: 1) the study was fairly small (39 patients in one group, 40 in the other), 2) the study only looked at tendon results with ultrasound 12 weeks out; it is possible that further tendon healing took place much later, and 3) the method used to make the matrix could be improved. They took the patients’ plasma and used it without analyzing exactly how many of each kind of cells (e.g., platelets, growth factors, cytokines, white blood cells) were present.

Although PRFM did not improve rotator cuff tendon healing and was even linked with lower healing rates, further study is needed to understand what happened before either abandoning the technique or using it on other patients. The type of blood injection product your surgeon is planning to use may not be the same as the one used in this study. Therefore, it would be wise to talk with your surgeon first before changing your plans to use platelet-rich plasma with your surgery.

You might be thinking of hyaluronic acid, a substance that is present in the fluid structure outside, around, and between cells. It is a thick substance that is a normal part of the matrix that makes up cartilage.. It’s found in the synovial fluid that lines and lubricates the joints. It is also the protective coating around each cartilage cell.

Hyaluronic acid has the ability to suck up and water needed to cushion joints from the shear stresses and compression they are subjected to. It seems to have many roles. Besides remaining elastic under high shear forces, it also makes it possible for the joint to withstand the heat that develops within the joint even with low shear stress.

Hyaluronic acid can store mechanical energy for release later when needed. It bathes the cartilage cells with fluid and keeps them nourished. It even has antiinflammatory properties to reduce joint inflammation and an ability to reduce pain — or at least the perception of pain.

There was a recent study in Taiwan comparing the use of physical therapy (PT) alone with PT plus hyaluronic acid. Patients were randomly placed in one of two groups: group one received the HA injections along with physical therapy. Group two only went to physical therapy and did NOT get the injections.

Neither one was more effective than the other in reducing pain, improving motion, or restoring function. The results were equal between the two groups. If this is the case, then the added expense of the injections may not be needed for this condition.

There were some shortcomings in this study though. So before the recommendation to drop the use of hyaluronic acid for shoulder adhesive capsulitis is made, more research is needed to settle some of the questions left unanswered in this study. For example, they did not compare patients receiving injection only to these other two groups.

Fluoroscopy or ultrasound was not used to guide the injections, so it’s possible more accurate injection technique might make a difference. And different stages of adhesive capsulitis may respond differently to treatment making hyaluronic acid a time-specific treatment. And finally, long term results (six months to several years later) should be investigated.

It sounds like you might have a condition known as adhesive capsulitis — a problem of chronic inflammation of the shoulder joint capsule. The shoulder capsule is a covering of connective tissue interconnected with shoulder ligaments and tendons. They all help hold the head of the humerus (upper arm bone) in the shoulder socket.

The inflammatory process causes the capsule to thicken and tighten to the point that the extra fold of capsular tissue needed for full motion overhead gets stuck to itself. There is a loss of normal synovial fluid in the joint.

When this happens, the shoulder can no longer slide and glide smoothly through its full range-of-motion. The capsule loses its ability to stretch. The result is the shoulder gets stuck and becomes stiff and painful. In chronic cases, inflammation is gone but it was the first step that got the process started. Treatment is still directed at the joint capsule.

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. 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 use of hyaluronic acid injections into the shoulder has been quite successful for the knee and has just recently been tried with shoulder problems. Studies are beginning to be published with results using this treatment for arthritis, shoulder pain, and adhesive capsulitis. Ask your doctor about the use of this treatment tool for your problem. You may be a perfect candidate or there may be some reasons why a different approach would be better for you.

Core training (strengthening the muscles of the belly and trunk) has become quite popular but for good reason. The more we learn about the influence of the center stabilizing areas of the body, the more we realize how important core strength is to movement of the arms and legs.

The core includes: the abdominal muscles (in particular the transverse abdominis), the deep muscles of the spine (multifidus), and the hip flexors (iliopsoas muscle).

Looking at the body as a whole, the core is made up of the lumbar spine, the pelvis, and the hip joints. This area is also called the lumbopelvic-hip complex. Any of the structures that cause or prevent motion in these areas is part of the “core.” There is also evidence to show that the scapula (your shoulder blade) plays an important role in the kinetic chain (connection between the core and the extremities).

For example, when using the arm overhead, there is an entire sequence of actions needed. First, there is a ground reaction force as the foot and leg push against the ground. This force moves through the legs to the knees and hips and then into the trunk. The legs and trunk produce about half of the energy and force needed for this motion.

The trunk and scapula (wing bone) then work together to funnel this force to the shoulder, arm, and hand. This allows the smaller muscles of the arm and hand to position the hand to control the movement. Each activity has its own kinetic chain and energy. You cannot move the arm without core control so your exercise physiologist is right on with this approach!

The scapula (more often referred to as your “wing bone” or shoulder blade) is a key reason why your shoulder and arm normally move and glide smoothly and easily. Not only does the scapula give the shoulder muscles a base of operation, it also acts as a moving platform for the shoulder ball-and-socket joint to function properly.

In short, the scapula is a silent partner with the shoulder in moving the arm in any and all directions. Any injury that affects the shoulder is going to also affect the scapula. This connection may not be apparent at first but over time, a condition known as scapular dyskinesia develops. Dyskinesia just means the body part isn’t moving in the normal rhythm or sequence.

With a shoulder injury, you may not feel anything directly wrong with the scapula at first. But over time (as you have noticed), there is a snapping or grinding sensation as the scapula moves over the ribs. This is one indication that the scapula is no longer moving as it should. Another sign of a scapular problem is what’s called scapular winging. As you move the arm up overhead or forward, the scapula may pop out away from the body. Reaching behind the back with the hand on the affected side will also result in excessive “winging”.

The cause of scapular dyskinesia is usually mechanical such as muscle stiffness or shortening, bone fractures, alterations in shoulder joint motion, joint instability, or muscle (strength or timing) imbalances. Three-dimensional (3-D) motion pictures of patients with scapular dyskinesia show that the altered position of the scapula affects all aspects of upper quadrant movement.

Treatment depends on a thorough and careful evaluation process to detect all areas of involvement. With this information, a physician, physical therapist, or athletic trainer can move to the next step of determining the best treatment approach for this problem. Of course, addressing fractures, rotator cuff tears or degeneration and the impingement that comes from rotator cuff disease, and labral tears is the first step. But for complete recovery, it will be important to restore normal alignment and movement of the scapula as well.

Rotator cuff tears are actually very common — perhaps one of the most common injuries to the shoulder. From what we know about this problem, there can be multiple factors that contribute to the lesion. As your family has just discovered, not all rotator cuff tears are the result of a traumatic or sports injury.

Sometimes simple anatomy answers the “why me” question. There can be just enough curve in the bone, a dip in the alignment of the tendon, a hooked or sloped acromion (the bone that comes across the top of the shoulder) to create an impingement or pinching of the rotator cuff. After many months and sometimes even years, that impingement can result in a tear of the tissues.

Microtrauma from repetitive overuse is another possible variable contributing to a tendon tear. Degenerative changes associated with the aging process can (and do!) result in rotator cuff tears. And anyone who smokes (or uses tobacco) or who has diabetes is at increased risk for rotator cuff tears (or any soft tissue injuries).

Each individual has his or her own unique risk factors. The only way to know for sure is to consult with the surgeon who is evaluating the case. Questions about past history, past and current activity level, age, and general health can sometimes help. Imaging studies from X-rays, CT scans, and MRIs add additional information to answer the question of why this injury developed.

Surgeons are grappling with the question of whether to use single-row sutures to repair a torn rotator cuff or if the results might be better with a double-row? Some studies have shown that a double row of sutures provides greater stability and biomechanical strength. But similar studies to prove the clinical value (e.g., fewer complications, better shoulder function) are lacking.

Both single-row and double-row suture technique can be done arthroscopically without a wide open incision. Arthroscopic surgery is less invasive and involves less cutting into the soft tissues such as muscles and tendons. The benefit in the end is less scarring, less pain, fewer injuries to important soft tissues such as muscles.

Double-row sutures brings more of the tendon in contact with the bone. The hope is that more fibers will be recruited in the healing process. This might result in a more stable repair. Double-row sutures also means less stress and force are applied to each individual suture. There is also the potential for less gapping in the soft tissues where they should be smooth and closely reattached to the bone.

A recent study from Boston University School of Medicine took a closer look at the question of which approach is better (single versus double-row sutures). The surgeons there conducted a systematic review, which means they searched all previously published articles on this topic to see if there was any consensus or agreement from the studies done so far. They found seven suitable studies to include in their analysis.

Although they found a trend toward more failures in the single-row group, it wasn’t significant enough to say single-row sutures is an inferior repair method compared with double-row sutures. The retear rate, number of complications, and functional outcomes were not statistically different between the two suture repair techniques. There was a trend toward a higher retear rate among the single-row group. But again, this difference did not reach statistical significance. The mechanically superior double-row fixation simply does not improve the final results.

The authors concluded that further study of this topic is needed. They suggested that perhaps rotator cuff tear site, size, and quality make a difference and should be included in the analysis.

SLAP stands for superior labral anterior posterior and refers to a tear of the labrum located around the rim of the acetabulum (shoulder socket). The labrum is a ring of fibrous cartilage around the shoulder socket. It helps support and hold the round head of the humerus (upper arm bone) in the shallow socket.

The superior labrum is located along the top of the socket. It is attached loosely by elastic connective tissue. A force or load through the shoulder that is greater than the tensile strength of the thick connective tissue can cause tearing of the structures.

There are four types of SLAP lesions. The groups are based on severity and help determine treatment. Type 1 occurs most often in older adults. Fraying and thinning of the labrum is most common with this type of SLAP lesion. If surgery is called for, the surgeon will shave off any fragments and smooth the remaining edges of the labrum.

The other types describe the extent of injury. For example, in a type 2 SLAP injury, the biceps anchor where the labrum attached is detached. There may be some frayed edges of the labrum as well.

Type 3 is a bucket-handle shaped tear in the labrum but the biceps anchor is not disturbed. Type 4 has a similar bucket-handle shape that extends all the way into the biceps tendon. Sometimes people have more than one type of tear at a time. Surgery is often needed to repair the more severe injuries.

Studies show that more and more of these SLAP procedures are being done. Men have this surgery three times more often than women. And folks over 40 are more likely to have surgery now than in the past.
Why are there more older adults having this surgery? It may be because newer repair techniques (e.g., with suture anchors) makes this procedure more successful in that age group than ever before.

But other studies have clearly shown that tenotomy (tendon is cut) or tenodesis (stitching tendon back to the bone) procedures have better results than SLAP repairs in patients over 40. These findings may be what one of the surgeons you saw was referring to when he or she suggested that age makes a difference.

SLAP stands for superior labral anterior posterior and refers to a tear of the labrum located around the rim of the acetabulum (shoulder socket). The labrum is a ring of fibrous cartilage around the shoulder socket. It helps support and hold the round head of the humerus (upper arm bone) in the shallow socket.

The superior labrum is located along the top of the socket. It is attached loosely by elastic connective tissue. A force or load through the shoulder that is greater than the tensile strength of the thick connective tissue can cause tearing of the structures.

The type of treatment applied may depend on a number of different variables such as age of the patient, activity level, severity of the injury, and length of time since the injury first occurred. There is still much debate and controversy among experts regarding the best treatment for this problem. Conservative (nonoperative) care may be appropriate but we have yet to identify who is the best candidate for surgery and who should see a physical therapist first.

One point of disagreement is whether the surgery should be done arthroscopically or with an open incision. Types of procedures to choose from include debridement, tenodesis, or tenotomy. Debridement refers to removing any frayed tissues and smoothing down the area as much as possible. Tenodesis is the stitching of the tendon back to the bone. In a tenotomy the tendon is cut.

The decision about what to do should be made together with the patient, family, and surgeon. All patient characteristics and personal factors should be taken into consideration before accepting any invasive procedures.

Normally, arthroscopic repair of the rotator cuff is a very reliable technique. Most patients (more than 90 per cent) swear by it and would do it again if they had to make the decision over. But in the remaining few (six to eight per cent), the repaired tendon fails to heal. Or in some cases, the patient reinjures the arm before healing takes place. These cases are called failed rotator cuff syndrome.

The result is as you described yourself: you don’t get the expected results. And instead of pain relief, increased shoulder motion, and restored function, there is persistent pain and/or weakness. Some of the reasons patients fail to heal include age (65 years old and older), the tear was very large in size, significant muscle atrophy (wasting), and tendon retraction (tendon pulls way back from the bone).

A few other factors that hinder healing after rotator cuff tear repair include smoking, diabetes, unwillingness to engage in the rehab program, and failure to follow the physician’s or physical therapist’s guidelines during recovery.

Treatment for failed rotator cuff syndrome varies depending on the reason(s) why the surgery wasn’t successful in the first place. A three-month trial of physical therapy aided by a home exercise program may be all that’s needed. But if this measure fails to restore motion and strength, then revision surgery is a possibility.

Talk with your surgeon a bit more and find out what he or she thinks might be the reason or reasons for the failed surgery. Sometimes it’s not a simple ‘this’ or ‘that’ reason. It could be multifactorial (many reasons combined together). If there is a known factor or factors, you might feel more at ease with this disappointing outcome. And the next step in treatment will depend on the reasons for failure.

Sometimes patients don’t get the expected results after arthroscopic rotator cuff repair. Instead of pain relief, increased shoulder motion, and restored function, they experience persistent pain and/or weakness. There are usually good reasons why this happens.

For example, older adults (65 years old and older) are at risk for failure to heal due to poor nutrition, poor general health, or the presence of other compromising conditions such as heart disease, diabetes, or smoking. If the tear was very large in size, there was significant muscle atrophy (wasting), or a lot of tendon retraction (tendon pulls way back from the bone), the risk of failure goes up dramatically.

A few other factors that hinder healing after rotator cuff tear repair include an unwillingness on the part of the patient to engage in the rehab program. Failure to follow the physician’s or physical therapist’s guidelines during recovery can also be some patient’s downfall.

Treatment for failed rotator cuff syndrome varies depending on the reason(s) why the surgery wasn’t successful in the first place. It doesn’t have to be another surgery. A six to 12 week trial of physical therapy aided by a home exercise program may be all that’s needed. But if this measure fails to restore motion and strength, then revision surgery is one possibility.

Revision surgery begins with release of any soft tissue restrictions (scarring, adhesions). If possible, the retracted tendon is brought back to the bone where it was originally attached (a place on the bone called the footprint).

If there isn’t enough “give” in the tendon, then it is pulled as close as possible and sutured (stitched) to nearby soft tissue. The surgeon must maintain a balance between tendon tension and tendon mobility. Creating a balanced shoulder is important (meaning the muscles all around the joint pull equally, evenly, and in a coordinated fashion to create movement.

In young, active patients with massive tears, it may not be possible to repair the rotator cuff. In those cases, a tendon transfer can be used to restore motion and function. The tendon harvested for use depends on the location and severity of the rotator cuff tear. For example, with damage to the supraspinatus and subscapularis (front of the shoulder), the tendon to the pectoralis major muscle is used. If the cuff is damaged more toward the back of the shoulder, then the latissimus dorsi tendon is harvested.

Very large tears with poor tendon healing in older adults may just require a shoulder replacement instead of a revision procedure. There are several options to choose from: a hemiarthroplasty, reverse total shoulder arthroplasty, or traditional total shoulder replacement. The hemiarthroplasty is a partial replacement (only half of the shoulder is replaced). A reverse replacement places the round head needed for motion where the shoulder socket used to be and the shoulder socket where the round head of the humerus (upper arm) is normally located.

So you see there are reasons for the failure that may or may not be overcome. Treatment to improve symptoms is still possible so don’t give up just yet. Give yourself some time to explore all your options and find a pathway that best suits you in this situtation. And good luck!

eople who can dislocate their shoulders by will or on command often have abnormally loose shoulder ligaments or shoulder capsule. The shoulder capsule is a watertight sac that surrounds the joint. It is formed by a group of ligaments that connect the humerus to the glenoid. These ligaments are the main source of stability for the shoulder. They help hold the shoulder in place and keep it from dislocating.

Sometimes this type of shoulder instability is the result of trauma, injury, or repetitive load on the soft tissue structures. The result may be unidirectional or multidirectional instability. A unidirectional instability means the shoulder has too much movement in one direction only. Multidirectional instability refers to a shoulder joint that has too much movement or laxity in several different directions at the same time.

Someone who can voluntarily dislocate both shoulders at the same time most likely has multidirectional laxity caused by generalized ligamentous laxity. Another possible cause of this type of instability is a disorder of the collagen fibers that make up the soft tissues. One example of this pathologic condition is called Ehlers-Danlos syndrome (there are other less common collagen disorders).

Your cousin should be encouraged to see an orthopedic surgeon for evaluation and identification of this problem. Most likely he will be encouraged to stop dislocating the joints as this can cause microtrauma each time it happens. Avoiding future problems from chronic dislocations is important. Treatment to strengthen the muscles around the shoulder may be recommended to help prevent further injury.

Shoulder instability can be very complex ranging from painful loss of motion to shoulder dislocation. Surgery to restore a pain free, stable joint requires careful examination by the surgeon. Before a decision can be made what surgical technique should be used, it is important to identify whether the patient has a unidirectional or multidirectional instability. It sounds like you have completed this step in the process.

A unidirectional instability means the shoulder has too much movement in one direction only. Multidirectional instability refers to a shoulder joint that has too much movement or laxity in several different directions at the same time.

Most of the time, this type of problem is caused by laxity or looseness of the shoulder capsule or damage to the capsule and labrum. The labrum is an extra rim of cartilage around the shoulder socket designed to give it a little more depth and holding power.

Treatment can begin with conservative (nonoperative) care with a physical therapist. You are headed toward step number two! This consists of a rehab program of rotator cuff strengthening exercises, scapular stabilization, and therapy to restore normal proprioception (joint’s sense of position). A physical therapist will set up and supervise the program. The therapist will pay close attention to helping you regain normal motor control, strength, endurance, and stability.

If a nonoperative approach fails to restore shoulder stability, then surgery to correct the capsular laxity may be required. After surgery, shoulder rehab is important. During the first six weeks, the patient wears an immobilizer to protect the healing tissue and does pendulum (Codman) exercises to keep the joint moving without disrupting the incision site. Six weeks after surgery, a rehab program of stretching and strengthening program is started.

Most of the time, this approach is successful but there are cases where surgery fails to achieve the desired results. Failure is most likely when the surgeon does not address the specific type of capsular laxity present. Other risk factors for a failed stabilization procedure include untreated lesions, stretched ligaments, bone loss, or compression fracture of the shoulder glenoid surface. The glenoid is the shallow shoulder socket.

A failed result after shoulder stabilization surgery is not the end of the line. Revision surgery can be done to address the ongoing laxity or instability. At this point, it is very important again that the surgeon re-evaluate you and make sure all aspects of the problem have been identified. There are fewer problems after revision stabilization procedures when the patients are young (less than 35 years old), have good bone density, and have not had other previous shoulder surgeries.