FAQ Category: Shoulder

The nonhealing rate after rotator cuff repair is fairly high (20 to 90 per cent). This is the case despite all the improvements in the surgical technique and the less invasive aspect of arthroscopic surgery. The reasons for such a high rate of tendon failure-to-heal remain unknown. Size of tear, age, and compliance with post-operative recommendations have been suggested as three of the top possibilities.

As a patient, you can’t do anything about the size of the tear or your age, but you can follow the surgeon’s recommendations carefully to reduce the risk of a retear or failure to heal. Having said all that, we can tell you there are some surgeons studying the effect of early motion after arthroscopic rotator cuff repair for small-to-medium sized tears.

Animal studies seem to suggest that a longer period of immobilization may actually enhance tendon healing. Early motion is thought to help reduce stiffness and pain but might be counterproductive. The results of a recent study from Korea provide us with some additional information.

They divided a group of patients who had similar characteristics (age, hand dominance, other medical or health problems) into two groups. All rotator cuff tears were small-to-medium in size.

Group one started passive shoulder exercises right from day one after the surgery. Group two was not allowed to move the arm until the brace came off four or five weeks later. Patients with small tears were able to remove the brace after four weeks. Anyone with a medium-sized tear wore the brace an extra week. Everyone did active-assisted movements after the brace came off.

The question then is: did the group who started early passive exercise have a better (or worse) result when compared with the group who waited until the brace was off to begin moving the arm? Using pain, function, and healing (as seen on MRIs and ultrasound studies), they found no difference between the groups.

On the one hand early passive motion didn’t assist healing. On the other hand, this approach didn’t cause harm by disrupting the healing tissue. The authors propose the idea that early passive motion isn’t required after arthroscopic rotator cuff repair. They point out that their patients all had small-to-medium sized tears.

It is highly recommended that you follow your surgeon’s instructions. But you can certainly make a follow-up appointment to discuss your proposed changes in the protocol. There may be specific reasons why the surgeon has made the recommendations you have been given. Knowing what those are might help ease your “itch.”

Here’s the drill after arthroscopic rotator cuff repair: you are in an abduction brace for four to six weeks. During that time, you may be given a series of passive exercises to complete. Passive exercise indicates that you move the arm without using muscle contraction to do so. The idea is to avoid active muscle contraction that might pull on the healing tissue and disrupt the sutures holding the torn rotator cuff.

The abduction brace stays on until your surgeon clears you and removes the movement restriction. Patients with small tears may be able to remove the brace after four weeks. Anyone with a medium-sized tear wore the brace an extra week. Large or massive tears require a six-week period of time immobilized.

As you start to wean off the brace, active-assisted exercise is prescribed. Active-assisted usually means you use your nonsurgical hand to help guide the operative side through the motions. It can also mean someone helps guide your arm but you are actively using your muscles as well.

What is the purpose of these exercises? The goal is to prevent postoperative stiffness, muscle atrophy (wasting), and loss of motion. At the same time, movement is designed to restore function. Some of the timeline may depend on the type of surgery you have (i.e., arthroscopic versus open incision repair).

With arthroscopic repair, there is much less cutting of the muscles. Even so, healing may still be disrupted by early motion. Studies with animals actually show a better tendon healing response when the limb is immobilized longer and exercise is delayed. It is possible the same principle is true for humans.

The debate of immobilization versus early movement following rotator cuff surgery remains under investigation for now. Eventually we may have clearer guidelines for how long someone should be immobilized following arthrscopic and open incision rotator cuff surgery.

It’s possible there are some additional undiagnosed or undetected problems here. The first thing that comes to mind is the possibility of a scapular (shoulder blade) fracture. Scapular fractures are rare but we are seeing more and more unusual and rare injuries among our veterans who have had traumatic injuries.

A traumatic force strong enough to break the scapula usually also causes other serious injuries. There can be head, neck, arm, chest, rib and even pelvic injuries along with the scapular fracture. These other injuries tend to be more life-threatening and receive immediate medical attention (as they should). This can leave some of the other more “minor” injuries undetected until much later.

Many times the scapular fractures are missed because the bone is well-covered by surrounding soft-tissues. It isn’t until the patient is out of the intensive care unit (ICU) that symptoms of neck, back or arm pain, along with numbness and tingling in the arm alert the physician to yet another problem. Loss of control over the shoulder and what feels like paralysis (called pseudoparalysis can be mistaken for conversion symptoms. X-rays and three-dimensional CT (3D-CT) scans are needed to make a clear and accurate diagnosis.

The imaging studies mentioned (especially 3-D CT scans) show if there is a fracture and the extent of any bony damage. Scapular fractures can extend into the shoulder joint affecting motion and function. CT scans also show if the bony displacement has changed the angles, shortened the bone or caused other deformities. These are key features that can alter shoulder function and point to the need for surgical intervention.

Scapular fractures (the shoulder blade) are rare but can be life-threatening. That’s because a traumatic force strong enough to break the scapula usually also causes other serious injuries. There can be head, neck, arm, chest, rib and even pelvic injuries along with the scapular fracture.

These other injuries are serious enough to threaten life and can prove fatal. For example, a broken rib can puncture the lung, a chest wound can lead to pneumonia, and head, neck, and spinal cord injuries can be very disabling.

Many times the scapular fractures are missed because the bone is well-covered by surrounding soft-tissues. It isn’t until the patient is out of the intensive care unit (ICU) that symptoms of neck, back or arm pain, along with numbness and tingling in the arm alert the physician to yet another problem. X-rays and three-dimensional CT (3D-CT) scans are needed to make a clear and accurate diagnosis.

The next dilemma is to decide the best treatment approach. Research-based evidence is not available so expert opinion is the next best thing for making treatment decisions. And experts in different parts of the world have not always agreed. In the United States, until recently, the approach has been nonsurgical sometimes referred to as “benign neglect” — letting it heal on its own as your surgeon has suggested.

But in other areas of the world like France, surgeons have used a more aggressive surgical approach. Several French studies have reported on the successful results using internal fixation (metal plates, screws, pins) to realign the misaligned pieces of the scapula and hold them together until healing takes place. This approach is gaining recognition based on a more complete understanding of these kinds of fractures and improved surgical techniques.

The challenge now is to identify which patients require surgery and which ones can still be successfully treated conservatively. That’s where you are with your daughter. There’s no magic formula or one-size-fits-all treatment plan for these patients. Management is individually determined.

Surgery is going to be more likely needed when there is excessive bony displacement or deformity, joint damage, and/or both. Scapular fractures in the presence of rib or chest injury are more likely to need surgery. Without sure proof that surgery will benefit the patient, surgeons must make these decisions based on their expertise and evaluation of the case.

For those patients who may be able to successfully heal and rehab without surgery, a shoulder sling is worn for several weeks. Physical therapy begins approximately one month after injury. The therapist progresses the patient gradually through a full range of rehabilitation activities. Therapy begins with passive motion and eventually includes strengthening and endurance training. The patient can expect to be in therapy for three to six months.

A Hill-Sachs lesion or defect is a fracture of the round head of bone at the top of the humerus (upper arm bone). Usually, this injury occurs when a person has his or her arm cocked back in a ball throwing motion. The shoulder is abducted (moved away from the body) and externally rotated.

In this position, the head of the humerus moves forward. With enough force and/or load, the forward movement can overcome the strength and restraint of the soft tissues holding the shoulder back. The joint capsule is stretched to the breaking point.

Once the soft tissues surrounding the shoulder have stretched enough to tear, then the shoulder can dislocate repeatedly. And with every dislocation, the damaged soft tissues give a little more until the shoulder is unstable and no longer stays in the shoulder socket (glenoid fossa). At the same time, the compression against the bone is enough to cause the fracture described as a Hills-Sachs lesion.

A small lesion or one that is oriented perpendicular (sideways) to the rim of the socket (glenoid rim) can be treated conservatively (without surgery). But larger lesions, parallel defects, and more serious damage often require surgery.

Once the decision has been made to do surgery, then the surgeon must figure out the best approach to take. The first decision will be whether to do the surgery arthroscopically or with an open incision. It may be necessary to combine several different procedures in order to treat all the bony and soft tissue problems that are contributing to the shoulder instability.

Surgical options include bone graft to fill in the bony defect, tissue filling called remplissage, and capsular shift to tighten up the soft tissues. In some cases, a shoulder replacement or resurfacing procedure may be the only way to treat the problem. A newer procedure called disimpaction is being investigated. In this surgery, the fractured bone is lifted up and a layer of bone graft is placed underneath to support it.

Long-term results with each of these approaches are unknown. There is a great need to identify patients who can benefit from conservative care versus those who need surgery. The role of age and activity level (active versus inactive) in treatment outcomes should be investigated as well.

A Hill-Sachs lesion or defect describes a fracture of the round head of bone at the top of the humerus (upper arm bone). Usually, the injury occurs when the person has his or her arm cocked back in a ball throwing motion. The shoulder is abducted (moved away from the body) and externally rotated.

In this position, the head of the humerus moves forward. With enough force and/or load, the forward movement can overcome the strength and restraint of the soft tissues holding the shoulder back. The joint capsule is stretched to the breaking point.

Once the soft tissues surrounding the shoulder have stretched enough to tear, then the shoulder can dislocate repeatedly. And with every dislocation, the damaged soft tissues give a little more until the shoulder is unstable and no longer stays in the shoulder socket (glenoid fossa). At the same time, the compression against the bone is enough to cause the fracture described as a Hills-Sachs lesion.

A small lesion or one that is oriented perpendicular (sideways) to the rim of the socket (glenoid rim) can be treated conservatively (without surgery). Rehab under the direction of a physical therapist may be all that is needed. Older adults are also usually directed toward nonoperative treatment. Even with small to mid-size lesions, rehab can be quite lengthy over a period of many months.

Larger lesions and bony defects that are parallel to the glenoid rim are usually just part of the total picture. In these more extensive injuries, other tissues (e.g., labrum, anterior capsule) are also damaged. Coexisting injuries like his require surgery to stabilize the shoulder and prevent worse shoulder instability.

Before a treatment plan can be determined, the surgeon takes a complete history, performs a physical examination, and orders imaging studies. X-rays, CT scans, MRIs, and ultrasound studies reveal the full extent of damage including location and direction of the lesion. Imaging studies also help identify the amount of bone loss for both the humeral head and the glenoid fossa.

Your best bet is to see an orthopedic surgeon for an evaluation. You may have something simple going on line a postural alignment issue or muscle imbalance. A short course of physical therapy may be all you need. But there could be a need for surgery to stabilize the shoulder at this point and only a surgeon can help you make that decision.

One of the most common causes of shoulder pain is this problem you mentioned: subacromial impingement syndrome or SIS. The term impingement tells us something is getting pinched. Subacromial impingement syndrome occurs when the rotator cuff tendons rub against the roof of the shoulder, the acromion.

Although SIS is one term, it actually represents a wide range of underlying pathologies. There could be a bursitis, rotator cuff tendinopathy, fracture, calcific tendinitis, or other change in the local anatomy contributing to the problem.

There are many factors that when present combine together to result in subacromial impingement syndrome. Aging with its many degenerative processes isn’t always very kind to the shoulder. Bone spurs form, the rotator cuff and other soft tissues fray and wear thin, and trauma all add to the development of mechanical shoulder pain. Loss of blood supply to the area is another reason why these problems occur.

Subacromial impingement syndrome and rotator cuff degeneration go hand-in-hand together. Much debate and controversy exist over the connection between these two conditions. Which comes first? Does the impingement cause tearing of the rotator cuff? Or does the rotator cuff degenerate and weaken over time resulting in impingement?

Sometimes there are what we call intrinsic factors such as muscle overload and weakness, shoulder overuse, and repetitive tissue microtrauma contributing to the problem. The shape of the bony structures of the shoulder (acromion, clavicle or collar bone, shoulder socket, round head of the humerus that fits into the socket) may have something to do with how the condition gets started.

Imaging tests such as X-rays and MRIs may help identify some of the intrinsic anatomical factors that put people at increased risk for shoulder impingement. In many cases, it’s really multifactorial with anatomy, age, and activity combined together to result in this problem.

A very good question. Let’s start with the type of problem you have. The term impingement tells us something is getting pinched. But with so many different soft tissues around the shoulder, exactly what is getting pinched can vary from one person to another.

The most common shoulder impingement is referred to as subacromial impingement syndrome or SIS. This type of impingement occurs when the rotator cuff tendons rub against the roof of the shoulder, the acromion.

Although SIS is one term, it actually represents a wide range of underlying pathologies. There could be a bursitis, rotator cuff tendinopathy, fracture, calcific tendinitis, or other change in the local anatomy contributing to the problem. And before a plan of treatment can be determined, an accurate diagnosis is needed. That’s where all these tests come in.

The physician usually begins with a detailed history of the problem and then conducts some clinical tests checking your movement and strength. None of the clinical tests available is 100 per cent accurate. By combining a few different clinical tests, the physician can get a better idea of what’s going on.

MRIs add to that information and are usually recommended before doing surgery or other invasive procedures. The only truly accurate test is an arthroscopic examination but that is a surgical procedure and is saved for last when it looks like surgery may be needed anyway.

You may be referring to a recently published report from surgeons at the well-known Kerlan-Jobe Orthopaedic Clinic in Los Angeles. The topic was postarthroscopic glenohumeral chondrolysis or PAGCL. The authors explore this condition covering risk factors, causes, and signs and symptoms.

Chondrolysis develops when the chondrocytes (cartilage cells) suddenly stop working. They are no longer able to make new cartilage cells to replace the old or to maintain the healthy state of the joint cartilage.

The main risk factor is the arthroscopic surgery itself. But many people have arthroscopic shoulder surgery without developing chondrolysis afterwards. There must be other factors at play here. In fact, the authors suggest there is likely a multifactorial etiology. Several or even many risk factors combined together result in postarthroscopic glenohumeral chondrolysis (PAGCL).

A review of studies with reported cases of PAGCL shows a list of potential risk factors. These etiologic factors include direct trauma to the joint during surgery, shoulder instability before surgery, the use of bioabsorbable sutures and other implants, heating the joint with radiofrequency to shrink the tissues, and the placement of sutures (anchors and knots) on the joint (articular) surface.

The authors explore the details of potential mechanical, thermal, and chemical causes. Mechanical causes include direct injury to the fragile cartilage when the arthroscopic probe or other surgical instruments come in contact with the cartilage surface.

As already mentioned, the use and placement of certain types of sutures may contribute to the development of chondrolysis. Loose or prominent sutures/knots rub against the cartilage causing severe wear and tearing. In some patients, the suture material may set off an immune response called a foreign body reaction. The body sets up a massive inflammatory response in an effort to get rid of the sutures or anchors.

Thermal causes (heating the joint) to stimulate a healing response may actually have the opposite effect of killing the chondrocytes. The use of pain pumps (chemical cause) placed inside the joint may help control postoperative pain but may also contribute to chondrolysis and PAGCL. Anyone with a combined set of risk factors (e.g., foreign-body reaction plus thermal or chemical factor) may be at increased risk for this type of rapid joint destruction.

With this information about potential risk factors and causes in mind, the authors make the following recommendations:

It is in fact true that a simple arthroscopic surgery of the shoulder for a rotator cuff tear or unstable shoulder joint can result in complete destruction of the joint. Within weeks to months, the entire surface of the shoulder joint (called the articular cartilage) is destroyed. Deep shoulder pain with rapid loss of motion (and then function) are the main symptoms of this problem.

Your son has a condition called postarthroscopic glenohumeral chondrolysis or PAGCL. Just as you describe, his shoulder has gone from age 22 to that of an older adult with osteoarthritis. And all he did was have arthroscopic surgery.

What went wrong and why did this happen? Studies show that the condition called chondrolysis develops when the chondrocytes (cartilage cells) suddenly stop working. They are no longer able to make new cartilage cells to replace the old or to maintain the healthy state of the joint cartilage.

The main risk factor is the arthroscopic surgery itself. But many people have arthroscopic shoulder surgery without developing chondrolysis afterwards. There must be other factors at play here. In fact, experts suggest there is likely a multifactorial etiology. In other words, several or even many risk factors combined together result in postarthroscopic glenohumeral chondrolysis (PAGCL).

A review of studies with reported cases of PAGCL shows a list of potential risk factors. These etiologic factors include direct trauma to the joint during surgery, shoulder instability before surgery, the use of bioabsorbable sutures and other implants, heating the joint with radiofrequency to shrink the tissues, and the placement of sutures (anchors and knots) on the joint (articular) surface.

Other possible risk factors being considered and investigated further include family history of early arthritis, patient history of a collagen disorder, and exposure of the joint surface to irrigation solutions or high concentrations of local anesthetics. There could also be some specific risk factor common to young patients that remains elusive (avoids detection).

Once the various risk factors and potential causes have been identified, the next step is prevention. When the destructive process begins, there is no going back. And without effective treatment, prevention is absolutely essential.

Postarthroscopic glenohumeral chondrolysis (PAGCL) is a rare complication of shoulder arthroscopic surgery. But when it happens, the consequences can be devastating. And since the primary age group affected is young adults, every effort should be made to screen for risk factors and avoid anything that might contribute to this condition. Until more is known about the true etiology (cause) of PAGCL, surgeons follow current recommendations to prevent this problem but in the end, it’s true that “it happens” and we don’t always know why.

Joint resurfacing has been around since the early 1980s. That gives us 30-years of data to examine in order to see how well this technique is working. And in a recent study from England one surgeon reviews studies published on this topic and present the results of his 340 patients who had this procedure done.

The patients in the study ranged in ages from 37 to 89 years old but the average age was 70 years old. The underlying diagnosis was rheumatoid arthritis or osteoarthritis. Follow-up was possible for at least four years and some patients were in the study for as long as 16 years.

They found that the patients who had the best results had an intact rotator cuff and a diagnosis of osteoarthritis. Overall patient satisfaction was high with 94 per cent of the patients saying their shoulders were “better” or “much better” than before resurfacing.

The results were compared with a group of patients who had a total shoulder replacement. The surgeon reported equally good results between the two groups with far fewer complications in the joint resurfacing patients. Total shoulder replacement has a greater risk and incidence of infection and bone fractures.

The surgeon suggested that his method of balancing the soft-tissue around the shoulder prevents erosion of the shoulder socket (glenoid fossa). By releasing some of the soft tissues, the humeral head can be realigned to fit in the center of the socket where it functions best. Glenoid erosion is more likely when there is a soft tissue imbalance remaining after joint resurfacing.

The author concluded that using a cementless resurfacing prosthesis for advanced arthritis of the shoulder yields very satisfactory results. There are fewer complications than with a total joint replacement. And the basic bone stock has been saved if it becomes necessary to fuse the joint or replace it with a full implant later. High rates of patient satisfaction with the joint resurfacing procedure are an added bonus all around.

Today’s patients with pain, stiffness, and loss of motion and function from shoulder arthritis do have some choices that weren’t available 30 years ago. As you have found out, a total shoulder replacement can be done. But even better is a procedure called shoulder resurfacing that makes it possible to get a “new” shoulder without losing much bone and without replacing the whole thing. Instead the damaged surfaces of the joint are covered with a resurfacing prosthesis or implant.

In addition to saving bone there are many other advantages to the resurfacing technique. For example, your normal shoulder joint anatomy is preserved. The prosthesis can be fit to you instead of the other way around.

The natural angle of the humeral (upper arm) bone is maintained. The cap that fits over the round humeral head has a peg that sets down into a hole drilled in the bone. The bits of bone taken from the hole are used to patch defects under the humeral cup. This means that the joint surface can be smoothed out and no bone is lost.

Joint resurfacing isn’t possible for everyone. The surgeon must evaluate each patient individually to determine all possibilities. Joint resurfacing is most likely an option when there is still some joint surface left to work with. At least 60 per cent of the joint surface must be present. The rest can be treated with bone graft or bone graft substitute.

Joint resurfacing can be offered to the patient who has an unstable joint from rotator cuff tears or insufficiency. The main goal of joint resurfacing for deficient rotator cuff disease is pain relief. Improved shoulder motion isn’t a main feature of this surgery without intact muscles to move the arm.

Anyone with pain, stiffness, and loss of shoulder motion from rheumatoid arthritis or osteoarthritis may be a good candidate. Anyone with shoulder joint infection, too much bone loss or surface erosion, or arm paralysis would not be considered for joint resurfacing.

It’s likely the surgeon who suggested joint resurfacing mentioned some reasons why you might be a good candidate for this procedure. Before making a final decision you can always ask the surgeon who suggested a total shoulder replacement about the idea of joint resurfacing. Or you could even seek a third opinion from another independent orthopedic surgeon.

The type of injury you just described is called a low-energy trauma and accounts for a large number of hip, shoulder, and wrist fractures and dislocations in older adults. The key phrase here is “older adult.” Though it doesn’t always mean every older adult is “fragile,” many are more fragile and at greater risk of injury than we realize.

Inactivity and deconditioning are common problems among the adults 85 years old and older. In fact, the results of inactivity and physical deconditioning start to show up at a much younger age (often even in the mid-50s).

Studies show that adults 65 years old and older and especially postmenopausal women in this age group are at risk for these so-called low-energy falls. They may momentarily be off balance, their leg(s) may give out from under them, or they hit a patch of uneven ground and can’t regain their balance. Down they go with potentially serious soft tissue, bone, and/or nerve injuries.

Adults in your father’s age range are at risk for recurrence, reinjury, or new injuries. The best way to combat this is by remaining active. Exercises of all kinds are beneficial including getting the heart rate up a bit, strength training, balance training, and stretching or flexibility exercises.

There are many programs for our seniors to help with this. There are sit-to-be-fit and gentle yoga programs on television. The local senior citizens center, YMCA, or local gyms often sponsor low-cost (even free to seniors) exercise programs.

Your local or State Council on Aging should be able to help you locate services nearby that your father can take advantage of. His primary care physician may also be aware of ways he can participate in more programs of this type.

Physical therapists are also good resources for assessment of balance, strength, and conditioning. The therapist can offer short-term, individualized, supervised programs that can be continued at home to further assist in preventing future falls and injuries. The therapist can make a home visit and advise you on ways to fall-proof your father’s home as an added feature in falls prevention.

If your mother did not have a follow-up appointment with anyone to re-evaluate her after the closed reduction of her shoulder dislocation, now would be a good time for that. In fact, given your description of her inability to move that arm, some type of follow-up would be advised.

It’s possible that fear of re-dislocation has immobilized her and that she actually has intact motion. But a prolonged period of time (three months) without moving it could also result in a frozen shoulder. There is also the fact that up to 40 per cent of all patients who dislocate the shoulder anteriorly (forward dislocation) also have additional injury to some other area of the shoulder.

The most common associated injuries reported include axillary nerve palsy, brachial plexus injury, detachment of the rotator cuff, and fracture of the greater tuberosity (bony bump on the head of the humerus). Any combination of these injuries is also possible.

Older patients (60 years old and older) are at greatest risk of multiple-nerve injuries. According to a recent study, women who dislocate the shoulder during low-energy falls make up the bulk of the group with associated (additional) shoulder injuries. This group is especially at risk for dislocation with associated injuries involving nerve damage. The same study showed that anyone with a rotator cuff tear or greater tuberosity fracture is also at increased risk for nerve deficits.

Your mother may need nothing more than a quick physical examination to confirm that nothing is wrong. She may just need encouragement to move the arm and use it normally once again. But if there is nerve damage, bone fracture, or some other injury then additional imaging (X-rays, CT scans, MRIs) may be needed. The sooner the problem is identified, the better her chances are for full recovery with proper treatment.

Large, full-thickness tears of the rotator cuff can be very challenging for patient and surgeons alike. Loss of motion and loss of strength leads to loss of function for the patient. Finding a way to repair the problem without re-tears and surgical failure is a goal surgeons strive for.

Arthroscopic examination does give the surgeon a look inside the joint that isn’t possible with any imaging study. At that point, he can see the location, type, and extent of damage to the rotator cuff. He will also be able to look around and see what else might be wrong. Often when there is an injury traumatic enough (or with enough force behind it) that the rotator cuff is torn clear through, there will be other soft tissues torn as well.

During the arthroscopic procedure, the surgeon can remove any loose pieces of tissue that might be floating around in the joint — a possible hazard for you later. If the rotator cuff can’t be repaired, the surgeon can at least clean up the area and possibly shave down the ragged torn tendon edges, a procedure called debridement.

The surgeon will also check to see if the torn tendon can be repaired. If it hasn’t retracted (snapped back away from the bone) too far, it might still be possible to stretch the tendon end back to the bone and reattach it.

The surgeon can also make other minor changes that might help improve your shoulder function even if it is impossible to restore the rotator cuff back to normal. For example, it might be helpful to remove any bone spurs that have formed and are causing pain and swelling by rubbing against the soft tissues or impinging joint movement.

If the rest of the rotator cuff is stuck down by adhesions, the surgeon can gently lift it back up and restor the normal slide and glide of the remaining tendons. And sometimes the end of the clavicle (collar bone) is shaved or even partially removed to give the rotator cuff more room to slide and glide and to take pressure off the tissue.

So, there are many different reasons why the surgeon might recommend an arthroscopic procedure. If you are uncertain about going ahead with this next step, talk to your surgeon. Find out more about what he is thinking about the need for further evaluation in your case.

Large, full-thickness tears of the rotator cuff can be very challenging for patient and surgeons alike. Loss of motion and loss of strength leads to loss of function for the patient. Finding a way to repair the problem without re-tears and surgical failure is a goal surgeons strive for.

In a recent report from Duke University, the successful use of a regenerative tissue matrix for 24 patients with massive irreparable rotator cuff tears is described. A regenerative tissue matrix is the use of donor tissue placed as a scaffold to help the repair along. It is used when the torn tendon has retracted (pulled back) so far from the bone that it cannot be stretched back and stitched back down.

By placing graft tissue between the end of the torn tendon and the shoulder bone, the surgeon is able to make a “bridge” and complete the repair. With this donor tissue in place, collagen fibers and blood vessels form to assist healing at the cellular level. This may be what you have heard about.

Patients like yourself who previously would not have been candidates for surgery and therefore unable to regain shoulder motion, strength, and function suddenly have a new opportunity for repair and recovery. In fact, if the results of these 24 patients are any indication, this technique is safe and effective without infection or tissue rejection.

There are some “yes, buts” to consider — meaning not everyone with an inoperable, irreparable rotator cuff tear can have this procedure. The patients in this study were selected very carefully for success. They did not have any shoulder arthritis. The tendon tear had not filled in with fat tissue. And for the most part, they still had fairly good active range of motion despite the rotator cuff damage.

The use of human dermal allograft (skin harvested from a donor) in this study is not approved by the Food and Drug Administration (FDA) for use as an augmentation procedure of this type. This means that the surgical technique presented in this study is therefore considered “off label.”

Even so, the technique was successful with good results. Three-fourths of the group had a fully intact repair as shown by ultrasound studies. The rest of the patients had at least a partially repaired rotator cuff. There was no one in the group who ended up with a complete tear after this procedure.

Everyone was satisfied with their results and said they would do it again if given a second chance. They all reported less pain, more motion, and better overall function. Follow-up was extended over a period of time from 29 to 40 months (two to three and a quarter years).

The authors concluded that the use of extracellular matrix scaffolds in the repair of massive rotator cuff tears is new and still experimental. But this approach offers hope to those who previously had no opportunity for surgical repair. The successful results of this small study may open doors for future studies to expand the number and types of patients who might benefit from this procedure.

Cortisone injections for various shoulder problems are often used in an attempt to reduce inflammation causing pain and swelling. One of the most common uses is for a condition called subacromial impingement. Subacromial impingement refers to pinching of the soft tissues (bursa, tendons) that pass underneath the acromion (the roof of the shoulder).

Studies have shown the value of corticosteroid injections as a means of reducing inflammation and pain. With accurate injection into the bursa, success has been reported in up to 83 per cent of patients. Now researchers are turning their attention toward finding out the exact dosages that work best.

Like yourself, some people simply respond better if the body isn’t overwhelmed by the amount of medication used. Other people may get better results depending on what phase of injury versus recovery they may be in.

For example, there is a question of whether patients with early symptoms get the same (more, less?) results with steroid injections when compared with patients who have chronic shoulder pain (lasting more than six months). In other words, if there isn’t active ongoing inflammation, should steroid injections even be used at all?

There was a recent study comparing a low-dose (20mg) of a long-acting corticosteroid to a high-dose (40mg) with patients who had a diagnosis of subacromial impingement. They found that low-dose corticosteroid injection for subacromial impingement was just as effective as high-dose and with fewer side effects.

Certainly talk with your physician about your concerns and questions. If you are going to have a series of one to three injections, ask about the possibility of escalating (increasing) doses from the first to third injection.

It is suggested that the low-dose injection be used as the first injection on a trial basis. Since many patients get up to three injections spaced apart, a low-dose injection could be followed by a higher-dose injection if results of the first injection are not satisfactory.

Each physician may offer different counsel to patients depending on the current problem, age, general health, and past medical history. Some surgeons may give you permission to do anything you feel up to. Others have a specific protocol they want you to follow.

As a general rule, patients advised receiving a steroid injection into a joint are cautioned against any heavy lifting or exercise. But after 10 days to two weeks, they are encouraged to start gentle range-of-motion exercises and to remain active as tolerated.

“As tolerated” usually means to do whatever you want to that doesn’t increase your pain and feels comfortable. Additional strengthening exercises may be added four weeks after the injection. If you are having a series of up to three injections spaced a week apart, there may be a different protocol prescribed.

Since you just had the injection, there’s nothing wrong with taking it easy over the weekend and contacting your physician on Monday. You will not invalidate the effects of the injection with this approach and could potentially protect the arm during the healing process.

Most of the time, steroid injections into the shoulder joint to control pain and inflammation have both an antiinflammatory as well as a numbing agent. This means that some of your symptoms will be masked so you don’t want to overdo it just because you can’t feel it.

We know that exercise is an effective tool used in regaining shoulder motion. The ideal exercise program has yet to be discovered. The program recommended here is based on evidence we have collected from a variety of studies. There is a need for further research in this area to identify the best type of exercise and timing for exercise following cortisone injections.

The acromioclavicular (AC) joint has come back into sharp focus in recent days. Because of changes in surgical technology, new advances have been made in the surgical treatment of this problem. You mentioned this condition by its more commonly used name: shoulder separation.

A shoulder separation is a fairly common injury, especially in certain sports. Most shoulder separations are actually injuries to the acromioclavicular (AC) joint. The AC joint is the connection between the scapula (shoulder blade) and the clavicle (collarbone). Shoulder dislocations and AC joint separations are often mistaken for each other. But they are very different injuries.

For more complete information on AC joint separation, see A Patient’s Guide to Acromioclavicular Joint Separation.

AC joint separations are graded from mild to severe, depending on which ligaments are sprained or torn. The mildest type of injury is a simple sprain of the AC ligaments. Physicians call this a grade one injury. A grade two AC separation involves a tear of the AC ligaments and a sprain of the coracoclavicular ligaments. A complete tear of the AC ligaments and the coracoclavicular ligaments is a grade three AC separation. This injury results in the obvious bump on the shoulder.

Treatment for a grade one or grade two separation usually consists of pain medications and a short period of rest using a shoulder sling. Just as you experienced 40 years ago and just as your granddaughter has been advised today.

Today athletes are more likely to be put in a rehabilitation program directed by a physical or occupational therapist. Restoration of normal alignment, posture, motion, and strength help athletes (and others) regain function needed for daily and sports activities.

The treatment of grade three AC (chronic or unstable) separations is more controversial. There is no “gold standard” or best known approach to the problem of an unstable AC joint. One of the reasons why it is difficult to identify a gold standard in the surgical treatment of grade three AC separations is the wide variation in the pattern of injuries.

The anatomic complexity of the joint is another reason why treatment is not straight forward or cut and dry. For example, with all of the ligaments connecting everything together, injury to even one ligament shifts the load and strain on the joint. In turn, the rest of the soft tissues surrounding the AC joint are adversely affected by these changes.

Surgical management of acromioclavicular joint dislocations (shoulder separation) has been updated in the last few years. New techniques, improved fixation hardware, and the study of the biomechanics behind these injuries has led to better surgical treatment of these complex AC joint injuries.

But before surgery is considered, almost everyone (no matter what grade their separation is) starts out with conservative (nonoperative) care. Only if the joint remains chronically painful or unstable is surgery considered as an option, but it is indeed a viable alternative.

The acromioclavicular or AC joint is the connection between the scapula (shoulder blade) and the clavicle (collarbone). Another term used to describe AC joint injuries is shoulder separation. A shoulder separation is a fairly common injury, especially in certain sports. Most shoulder separations are actually injuries to the acromioclavicular (AC) joint.

For more complete information on AC joint separation, see A Patient’s Guide to Acromioclavicular Joint Separation.

AC joint separations are graded from mild to severe, depending on which ligaments are sprained or torn. The mildest type of injury is a simple sprain of the AC ligaments. Physicians call this a grade one injury. A grade two AC separation involves a tear of the AC ligaments and a sprain of the coracoclavicular ligaments. A complete tear of the AC ligaments and the coracoclavicular ligaments is a grade three AC separation. This injury results in the obvious bump on the shoulder.

The advancement of arthroscopic techniques has made it possible to repair or reconstruct grade three AC separations without making a large incision to expose the joint and its soft tissue attachments. And advancements have been made in surgical techniques and fixation devices (hardware used to hold the joint together until healing takes place).

For example, surgeons have found that the separated joint can be held together with a graft (ligamentous tissues taken from some other part of the body or from a donor bank). Efforts to develop a synthetic (manmade) graft substitute have failed so far. Surgeons have returned to natural graft sources taken from tendons in the patient’s forearm.

They have also tried different suture techniques (e.g., suture sling fixation, cortical buttons, flip-button suture device) when putting the joint back together. Keeping the AC joint stable with load, movement, and activity is a challenge. For chronically dislocating AC joints, special “hook plates” have been devised to hold the widely separated joint together until soft tissue healing can take place.

The availability of these new graft and suturing techniques has made it possible for surgeons to refine their surgical technique. The treatment of chronic AC joint dislocation after failed conservative care is now possible with this new hardware technology.

Complications previously reported such as button suture migration (movement) and osteolysis (bone absorption) are greatly reduced now. These new fixation practices made possible by the use of arthroscopy has made the difference. In places where extreme trauma has resulted in an injured ligament that is not expected to heal, the combined use of new graft, suturing, and fixation techniques may make reconstruction successful now.

The open-incision surgical technique is still used by many surgeons. It makes the use of allograft tendon easier to reproduce anatomically correct ligaments for AC joint stability.

To summarize the answer to your question, the surgical management of acromioclavicular joint dislocations (shoulder separation) has been updated in the last few years. New techniques, improved fixation hardware, and the study of the biomechanics behind these injuries has led to better surgical treatment of these complex AC joint injuries.

More study is still needed to report on complications with various reconstruction strategies. Comparison of results between the open surgical treatment of AC joint injuries and partially open or closed (arthroscopic) procedures is also needed.