FAQ Category: Shoulder

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.

Dr. William J. Robertson of Massachusetts General Hospital in Boston offers the results of his own study of surgery for acromioclavicular (AC) joint pain. Comparisons were made in terms of results (shoulder function, patient satisfaction, pain) between two groups. The first group had an open incision approach for this procedure. The second group had all all-arthroscopic approach with very small puncture holes to insert the arthroscope rather than full sized incisions.

The acromioclavicular joint is located in the front of the shoulder where the acromion meets the clavicle (collar bone). The acromion is a curved piece of bone that comes from the back of the scapula (shoulder blade). It forms a little bony “roof” over the shoulder joint.

Sometimes the end of the clavicle that meets the acromion becomes degenerated and very painful. Conservative (nonoperative) care usually takes care of the problem. If you are facing surgery, you have probably already tried antiinflammatory medications and physical therapy. This approach to treatment should be given a fair trial over a period of at least three to six months. The goal is to reduce pain, restore normal posture and alignment, and improve motion and function.

If patients do not achieve a satisfactory response from this approach, steroid injections (up to three spread out over three to six weeks) may be suggested. When all else fails, then surgery becomes a consideration. Sounds like that’s where you are at in the decision-making process. Now, which way to go: open surgery or arthroscopic technique?

In the case of the 48 patients in this study, all had failed at least six months of conservative care. Surgery to remove the distal end of the clavicle was performed by Dr. Robertson. In 32 of the shoulders, arthroscopic surgery was performed. In 17 shoulders, the open incision method was used.

Given your question, you may find the results of these two groups of interest. The group who had arthroscopic surgery to remove the tip of the clavicle had less pain than the open incision group. But all other areas measured (satisfaction, shoulder function, willingness to have the surgery again) were pretty much the same between the two groups.

Dr. Robertson concluded that for chronic acromioclavicular (AC) joint arthritic pain, either surgical method (arthroscopic or open incision) is equally effective in alleviating painful symptoms and restoring normal motion and function. Open incision is more invasive and has greater reports of pain after the procedure. But four to five years later, the final outcomes were the same.

Surgeons who are less experienced with arthroscopy may want to continue with open incision procedures. Patients with large bone spurs or cysts may also need the open incision approach. For the experienced surgeon (like Dr. Robertson), operative time was equal between these two techniques so there wasn’t an advantage of one over the other from that perspective.

There were two caveats (“yes buts”) to this study. The first was the small size. With only 48 patients (a total of 49 procedures), the results may not apply to everyone. A larger sample size should be studied and compared.

The second point is that patients weren’t randomly assigned to one group or the other. They were given the choice of which approach they would prefer. The equal success between the two groups may be linked to the patient’s positive feelings about the technique used. Further studies should include not only a larger number of patients but also random selection of treatment for each one.

But we think the study reflects the kind of information you are looking for. There may be some individual factors in your case that would sway the surgeon one way or the other if the decision was left up to him or her. Don’t hesitate to ask for his or opinion. Most patients are happier when the decision is made together in a collaborative fashion. Good luck!

The acromioclavicular (AC) joint is located in the front of the shoulder where the acromion meets the clavicle (collar bone). The acromion is a curved piece of bone that comes from the back of the scapula (shoulder blade). It forms a little bony “roof” over the shoulder joint.

Sometimes the end of the clavicle that meets the acromion becomes degenerated and very painful. The standard treatment approach to this problem is conservative (nonoperative) care. Conservative care usually takes care of the problem. The patient takes antiinflammatory medications and works with a physical therapist. Treatment extends over a period of three to six months. The goal is to reduce pain, restore normal posture and alignment, and improve motion and function.

If you have tried all of these measures and still have chronic pain, then steroid injections (up to three spread out over three to six weeks) may be tried. When all else fails, then surgery becomes a consideration. Make sure before you head this direction, you have covered all your bases with each of the outlined approaches under the conservative care umbrella.

Now if surgery is truly the next step for you, there are two ways the procedure can be done: arthroscopically or with open incision. Here are a few things to know about how these two methods compare. Open incision surgery allows for direct visual inspection of the joint. The surgeon can remove exactly the amount of bone necessary to take care of the problem. But in order to do so, the surgeon must cut through the soft tissues, joint capsule, and ligaments supporting the acromioclavicular (AC) joint.

As you might guess, the arthroscopic procedure has just the opposite advantages and disadvantages. The surgeon does not make a large incision and therefore does not have a wide direct view of all the anatomic structures. But at the same time, none of the soft tissues are cut and therefore do not lose their integrity. Stability of the joint is maintained. And the surgeon can look around inside the joint to see if there are other areas of damage that need repair. That is a big advantage over the open incision approach.

You can certainly ask your surgeon this question — it’s a good one! Having this much information will give you a place to start in discussing this issue with the surgeon. Complications and problems (e.g., infection, fracture, failure of the wound to heal) are always possible with any surgery, no matter how minor. Your surgeon can also fill you in as to the more typical complications he or she sees following this type of procedure.

There are many possible reasons why a shoulder dislocation might occur more than once. We call this recurrent shoulder dislocations. One of the main reasons is if there’s been damage to the stabilizing features of the shoulder. One of these important anatomic features is called the labrum.

The labrum is a fibrous rim of cartilage around the shoulder socket. It gives the socket more depth and better holding power around the head of the humerus. A tear in the labrum or a pulling away of the tendon with a piece of the labrum can disrupt the natural stability of the shoulder joint.

When this happens, the natural healing process is for the torn structures to pull away from the joint and reattach further down from the original insertion point. The capsule and its associated ligaments get stretched out. The joint widens and then any stress or load on the joint that overpowers this new alignment of soft tissues can pull it right out again.

Some people with one shoulder dislocation do seem to be at increased risk for a second (recurrent) dislocation. For example, there is evidence to show that young age, male sex, and long delay between injury and surgery are the main risk factors for recurrent shoulder dislocations. Other studies have suggested the number of preoperative dislocations as being another possible risk factor for future dislocations. Participation in contact sports may be a risk factor as well.

For those individuals who have surgery to repair the damage, recurrent shoulder dislocation remains a possibility. In fact, studies show up to one-third of patients experience another shoulder dislocation after surgery. In a recent study from the Netherlands, two factors showed up as possible risk factors but without statistical significance. These included using less than three suture anchors and the presence of damage to the labrum.

In the group who had a shoulder redislocation after surgery, two-thirds had been repaired with only two suture anchors. None of the other reported risk factors were found to be influential in this study. The results confirm what surgeons know now that they didn’t know 10 years ago: two (or less) suture anchors simply aren’t enough to hold the shoulder. The need for at least three suture anchors is confirmed by the results of this study.

Two other comments of interest were made by the authors. First, as might be expected, patients who do not redislocate have better shoulder function compared with those who do experience a redislocation. And second, redislocation doesn’t always occur right away. More than half in this study didn’t happen until at least two years had passed since the surgery. Continued study is needed to better understand this second phenomenon.

Shoulder dislocation is a fairly common problem among many athletes. Athletes at greatest risk seem to be those involved in collision sports. Anyone of any age whether involved in sports or not who has ligamentous laxity and/or who works with the arms above chest level may be at increased risk for anterior (forward) shoulder dislocation.

Having one shoulder dislocation is scary enough. But knowing the shoulder could pop out of the socket again is very worrisome as your question suggests. Recurrent shoulder dislocations is the subject of a recent study that might help answer the question. In this study, orthopedic surgeons from the Netherlands add their efforts and expertise to many others looking for risk factors for recurrent shoulder dislocations.

Previous studies have pointed to young age, male sex, and long delay between injury and surgery as the main risk factors for recurrent shoulder dislocations. Other studies have suggested the number of preoperative dislocations as being another possible risk factor for future dislocations. As already mentioned, participation in contact sports is considered a risk factor as well.

In this study, the role of suture anchors in recurrent shoulder dislocations was explored. Suture anchors are the type of “stitches” that are used to reattach the torn tendon and capsule back to the shoulder socket. There has been some awareness that a low number (less than three) of suture anchors used might contribute to an increased risk of recurrent shoulder dislocations.

There were 67 patients (mostly professional or recreational athletes) in the study. They were all treated by the same orthopedic surgeon. Shoulder instability was caused by a traumatic event. Surgery to repair the damage was done for everyone arthroscopically using suture anchors. The suture anchors were absorbed by the body and therefore did not have to be removed.

After surgery, everyone was placed in a sling to immobilize the shoulder for six weeks. Then they all participated in a rehab program directed by a physical therapist. Return to sports activities was allowed when the athletes were deemed “ready” by the therapist (usually four months after surgery).

The reason this study might hold some information of interest to you is that the patients were followed-up for 10 years to give an idea of intermediate results. Ten years after the surgery, more than one-third (35 per cent) of the group had at least one redislocation. The number of cases was divided equally over time (an equal number occurred during the first two years, two to five years after surgery, more than five years after surgery).

Two factors showed as being possible risk factors but without statistical significance. These included using less than three suture anchors and the presence of damage to the labrum. The labrum is an extra layer of fibrous cartilage around the shoulder socket that helps keep the head of the humerus (upper arm bone) stable in the socket.

In the group who had a shoulder redislocation after surgery, two-thirds had been repaired with only two suture anchors. None of the other reported risk factors were found to be influential in this study. One other observation was noted: athletes involved in overhead sports actually had fewer (not more) shoulder redislocations compared to other sports participants.

The authors suggest perhaps these athletes had better muscle control or proprioception (sense of joint position) to explain the difference. Or it’s possible they decreased the intensity with which they played in order to protect the shoulder. Specific studies of volleyball players would be needed to really gauge whether or not this group is at greater or lesser risk than other athletes for recurrent shoulder dislocations.

The shoulder joint is a very complex anatomic structure. In the absence of injury, chronic overuse can be one potential cause of a rotator cuff tear. Sometimes the natural angle of the shoulder or perhaps a too-shallow shoulder socket predisposes a person to microtears or other nontraumatic damage. There could be some ligamentous laxity (looseness) that has been present since birth that you just didn’t know about.

There may be a problem called scapular dyskinesia leading up to rotator cuff degeneration. In recent years, the important role of the scapula (shoulder blade) in shoulder motion has been recognized.

The scapula and shoulder must move together in harmony and with just the right rhythm and flow. Without this dynamic dance, scapular dyskinesia can develop resulting in shoulder problems and contributing to rotator cuff problems and even shoulder instability.

Determining the cause of the shoulder problem is important so that the right treatment can be applied. Imaging studies such as X-rays, CT scans and MRIs often provide helpful clues. A clearer view of the anatomy can guide the surgeon when making recommendations for conservative (nonoperative) versus surgical treatment.

Rotator cuff strengthening often increases the ability of the humeral head to stay compressed inside the socket. A strong rotator cuff also helps the shoulder resist translational (shear) forces. Restoring normal proprioception (joint sense of its own position) has been shown to improve motor control, thus increasing dynamic stabilization.

The rehab program must address strength, endurance, proprioception, motor control, and coordination of the entire shoulder complex (including the scapula). Such a program is directed and supervised by a physical therapist. Patients must be advised to plan on at least a six month trial of concentrated efforts in rehab with a lifelong maintenance plan urged.

Some patients with shoulder instability may also do well with a rehab program while others will eventually require surgery. Sometimes recovery of stabilizing motor activity isn’t possible without shifting the capsule or repairing the rotator cuff. Other reconstructive techniques may be needed to fix the anatomic cause of shoulder instability. That’s where your surgeon will be able to advise you.

There’s never anything wrong with getting a second (and sometimes even a third) opinion when you are in doubt. It may be helpful for you to know that studies show that people can have severe symptoms with a minor tear of the rotator cuff. And it’s possible to have no symptoms despite a massive (full-thickness) tear.

There is also plenty of evidence that a conservative (nonoperative) approach can be very successful. With strengthening and flexibility exercises, it is possible to rehab the rotator cuff and prevent the tear from getting worse. If the tear progresses to involve a full-thickness (Stage II) tear or to involve other tendons (Stages III and IV), then surgery is more critical.

When the biomechanics of the shoulder are altered by a rotator cuff tear, rehab can become more challenging. Prevention of tear progression can also become a difficult target to reach. But you can be successful with compliance to the program and avoiding overloading the soft tissues until healing has occurred.

A recent cadaver study looking at critical tear size when surgery should be recommended highlighted these conclusions. Stage I is the place to get started with rehab. Stage II requires careful monitoring during rehab with progression to surgery if rehab is unsuccessful and/or the tear gets worse (becomes a Stage III or IV tear).

With your diagnosis of a Stage I tear, you are considered a good candidate for rehab.

Severely painful and limiting shoulder motion and function are the usual reasons why patients end up having a shoulder replacement.It is best to have an orthopedic surgeon evaluate you and find out exactly what’s going on and what you may benefit from in the way of conservative care before having a total shoulder replacement.

The usual first line-of-treatment for the kind of instability you are describing is with antiinflammatories and physical therapy. A program of strengthening and flexibility exercises can be very helpful and can even help some patients delay or avoid surgery altogether.

Sometimes what people with shoulder osteoarthritis feel is a shoulder dislocation is really what we call crepitus. Crepitus is the crunching, crackling, clicking, or clunking noises and feelings people experience when bone spurs or uneven joint surfaces rub against each other or get stuck. It may seem like a dislocation but isn’t always.

After evaluating your shoulder motion and performing special tests to identify the problem (or level of instability), your surgeon will be able to tell you if the shoulder is unstable and dislocating or if your feeling of dislocation is crepitus.

X-rays may be ordered (if that hasn’t already been done) to look for signs of arthritic changes at the joint surfaces and narrowed joint space. An MRI or other advanced imaging studies may be used to look for soft tissue damage.

Once your surgeon has all of the information available, a decision can be made as to the best treatment approach for you. That may end up being a joint replacement but likely conservative (nonoperative) care will be recommended first. There is help for your problem. Don’t delay in seeking medical services. Often early intervention can keep problems like this from getting far worse.

Whether they know it or not, every patient goes into any surgery with certain expectations. In the case of joint replacements, it’s typical to expect relief from pain and improved motion. Those two outcomes usually translate into better function, too.

Expectations are often individual based on age, general health, and preoperative symptoms (pain, fatigue, inability to take care of self, depression). Sometimes patients are influenced by what the surgeon tells them about what to expect.

According to a recent study from the Hospital for Special Surgery in New York City, younger adults expect more after total shoulder replacement when compared with older adults (65 and older). People wo have poorer health before surgery also tend to expect more afterwards. Anyone suffering pain (day or night) definitely goes into surgery expecting to be pain free afterwards.

It might be helpful if you could identify what is not satisfactory for you. Include in your list your symptoms and what it is you want to be able to do that you are unable to do at this point. Take your list to the surgeon and discuss what is reasonable nine months post-op. It may be possible that a short course of physical therapy would be helpful in tipping the scale from “not very satisfied” to “very satisfied” with results.

If your expectations are just too high, then that knowledge may help you reorder your thinking by lowering your expectations. That sounds simple and easy — we know it’s not. But sometimes that is still the best place to start.

Many people suffer from subacromial impingement syndrome (SIS). Manual laborers are especially susceptible when they are engaged in repetitive motions overhead, handling heavy objects frequently, or exposed to hand-arm vibration. Starting from age 30 and on, many adults in all occupations are affected by subacromial impingement syndrome (SIS).

In this condition, the soft tissues of the shoulder (e.g., rotator cuff, bursa) are getting pinched between the coracromial arch and the humeral tuberosity. The coracromial arch is the protective roof that is formed over the top of the shoulder.

It is made up of the acromion and the coracoid process (two separate parts of the shoulder blade) with the coracromial ligament between them. This structure is what keeps the shoulder from sliding up and out of the shoulder socket.

What’s the most effective treatment for SIS? According to a recent systematic review of the literature, there is no evidence that surgical treatment is better than conservative (nonoperative) care. And when surgery is done, there is no evidence that one technique yields better results than any other.

Conservative care is less expensive with fewer complications, so that should be tried first. And it sounds like that is what you are doing. So the question to ask yourself (and review with the therapist) is: are you seeing improvements and slowly getting better?

If you don’t get the results you were hoping for, surgery is still another option. And according to this same literature review, there is evidence to suggest arthroscopic decompression (taking pressure off those soft tissues getting caught under the acromion) is best done arthroscopically. Arthroscopic decompression is minimally invasive and patients seem to recover faster.

Since you are someone who likes the “proof” behind these recommendations, let’s review what the systematic review showed in terms of evidence regarding treatment for SIS. The researchers conducting the review were from The Netherlands.

They used two independent individuals to review data for quality. Comparisons were made between different study groups (e.g., those who received conservative care, people who were in the control group, and patients who had surgery). Conservative care consisted of the use of antiinflammatory medications, patient education, and physical therapy.

Surgical groups included arthroscopic versus open techniques. Different surgical techniques were also compared (e.g., removing calcium deposits, use of laser versus electrocautery to remove tissue, effect of
using platelet-leukocyte gel to support bone and tendon healing).

After analyzing the data in many different ways, the results still showed no difference in short-, mid- or long-term outcomes no matter how the problem was treated. There simply wasn’t one treatment approach that was superior to all others.

Individual studies showed the benefit of exercise for example. That piece of evidence combined with the knowledge that surgery is expensive and painful further supports the recommendation to continue with conservative care for subacromial impingement syndrome (SIS) until further notice.

It sounds like you are on the right track. You may experience some “plateaus” where no further improvement seems forthcoming. Stay consistent with your program and give it some time and go as far as you can before jumping on the operating table.

Platelet-leukocyte gel is a substance containing of a mixture of platelet-rich plasma (PRP), white blood cells (leukocytes), and thrombin (for blood clotting). It is taken from the patient’s own blood and applied to the surgical site.

It can also be added to autologous bone (taken from the patient) to create a biologically active bone graft when bone graft is called for in a procedure. This is not usually the case in a decompression procedure for shoulder impingement. In any case, platelet-leukocyte gel when applied after shoulder decompression works because the thrombin will activate the platelet-rich plamsa (PRP). This means the platelets release growth factors that can indeed help speed up healing and recovery.

These growth factors increase the production of collagen (the building blocks of soft tissues) while at the same time improving repair of the wound site. The platelet-leukocyte gel even has antimicrobial effects that help prevent infection.

Platelet-leukocyte gel is not something that is used routinely. More surgeons in Europe have started using it compared with U.S. surgeons. But it use is on the rise in the United States. There is evidence that an increasing number of clinicians are using platelet-leukocyte gel applications in various surgical settings and for different types of procedures.

You can certainly ask your surgeon about this but don’t be surprised if he or she is not using it yet. Studies so far show moderate evidence for the effectiveness of this product for patients recovering from shoulder decompression surgery.

More research is really needed before it would ever be adopted routinely by all surgeons. It’s possible the product works better for some procedures (or even for some people) than for others. Scientific study could identify factors that could predict success or failure to help guide surgeons in deciding when and with whom to use this treatment.

Surgeons everywhere are grappling with the fact that rotator cuff repairs aren’t always successful. There are many different reasons why this may happen. Let’s take a look at causes of failure from both the patient and surgeon side of the equation. That might help you review your own case, ask appropriate questions, and make an informed decision.

The two top factors that put patients at increased risk of rotator cuff repair failure are age and tear size. Increasing age starting at age 55 has been shown to be a key factor in repair re-tears. Studies show that the rate of healing in patients younger than 55 years of age is around 95 per cent. This declines to 75 per cent for patients between the ages of 55 and 64. The rate of healing takes another nose dive down to 43 per cent in patients 65 and older.

Tear size can also be matched with risk of retear centimeter by centimeter. For example, for every one centimeter increase in tear size, the risk of rotator cuff failure goes up more than two times. With more than one tendon involved, the risk of retear increases nine times.

Other patient-related factors include poor quality of tendon or muscle, smoking, and the patient’s overall health. Patients with chronic systemic conditions like rheumatoid arthritis, heart disease, or diabetes are more likely to experience re-tear after rotator cuff repair.

The role of the surgeon in rotator cuff success is important, too. Low volume (i.e., the surgeon doesn’t do very many of these procedures) has been linked with a higher failure rate. Studies place the number performed to qualify for low volume as fewer than three rotator cuff repairs per months. High volume (the surgeon performs more than three rotator cuff tear repairs each month) increases the likelihood of a good result.

Surgical technique is also important. The surgeon must accurately assess each patient for the best repair approach. The technique selected depends on whether the repair is for a single tendon (versus multiple tendons), full-thickness versus partial-thickness tears, and tear pattern. Tear pattern refers to the shape of the tear (U-shaped or L-shaped).

Revision surgery is only needed when the patient continues to have chronic pain months to years after the original surgery and the problem has been diagnosed as rotator cuff repair failure. All efforts to treat the problem conservatively (without surgery) have failed to change the picture for the patient. And (very importantly), the patient does not have multiple risk factors for failure.

The presence of pain and loss of motion doesn’t always signal a failed surgery. There could be some other complication such as infection or systemic disease referring pain to the shoulder. A careful evaluation is needed to sort out the cause of shoulder pain and need for further surgery. The surgeon performs various clinical tests, orders imaging studies, and considers the need for electrodiagnostic testing.

If you are certain the problem is a failed primary (first) surgery and you have gone through a conservative program of rehabilitation under the direction of a physical therapist and you still have pain, loss of motion, and decreased function, then surgery to revise the failed repair is likely indicated.

The information here should help you consult with your surgeon before making a final decision. You are also free to seek a second opinion if you think that might help.

It is a well-known fact that rotator cuff repairs aren’t always successful. Revision surgery isn’t always necessary after a failed rotator cuff repair. Some surgeons only recommend revision surgery when the patient continues to have chronic pain months to years after the original surgery.

It must be clear that the problem is a failed rotator cuff repair. The presence of pain and loss of motion doesn’t always signal a failed surgery. There could be some other complication such as infection or systemic disease referring pain to the shoulder. A careful evaluation is needed to sort out the cause of shoulder pain and need for further surgery. The surgeon will need to perform various clinical tests, orders imaging studies, and decide if electrodiagnostic testing is needed (to evaluate nerve function).

Revision surgery is not routinely recommended for everyone. Efforts should be made to treat the problem conservatively (without surgery). Your husband may not be a good candidate for revision surgery if he has multiple risk factors for failure.

You were likely counseled that before having a revision surgery for failed rotator cuff repair there are some things you should know. For example, you should have been told that the results are likely not going to be as good as with a successful first repair procedure. But the improvements in pain, motion, and function will probably be better than without the revision surgery. It sounds like you were told that recovery and rehabilitation are likely going to take longer after a revision surgery compared with the primary (first) repair.

This information is based on evidence from many studies reporting final outcomes following rotator cuff revision surgery. Surgeons report a 64 per cent good-to-excellent result with a 93 per cent patient satisfaction rate following arthroscopic revision rotator cuff repairs.

All is not lost if a patient experiences a poor or failed result after rotator cuff repair surgery. Massive tears with poor recovery may be treated with a shoulder replacement procedure. But the hope and goal of primary and/or revision rotator cuff repair surgery is to preserve the patient’s natural anatomy and function.

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?

Orthopedic surgeons have looked carefully for an exact source of external compression. They have tried removing different parts of the bone around the shoulder in an effort to stop acute bursitis and the impingement process. Studies have been done using cadavers (human bodies preserved after death) to try and solve the question of cause and effect. The effects of age and shape of the acromion have been examined as possible contributing factors.

There’s been an effort to find outside (referred to as extrinsic) factors for the rotator cuff degeneration and subacromial impingement. Low blood supply to the supraspinatus tendon of the rotator cuff has been blamed for tendon degeneration. But some experts suggest just the opposite — the impaired blood flow to the tendon may develop because the tendon has been damaged first.

It is likely that the cause of subacromial impingement syndrome (SIS) is really multifactorial. Each patient will have his or her own unique combination of reasons why they developed an impingement syndrome.

You are not alone in this dilemma. Many adults experience shoulder pain. One of the most common causes of mechanical shoulder pain is a problem labeled subacromial impingement syndrome or SIS. The term impingement tells us something is getting pinched. 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?

A natural consequence is a change in the way the muscles and tendons contract and work together to move
the scapula (shoulder blade). This will make more sense if we review a little anatomy. The bones of the shoulder are the humerus (the upper arm bone), the scapula (the shoulder blade), and the clavicle (the collar bone). The roof of the shoulder is formed by a part of the scapula called the acromion.

The main shoulder joint, called the glenohumeral joint, is formed where the ball of the humerus fits into a shallow socket on the scapula. A false joint is formed where the shoulder blade glides against the thorax (the rib cage). This joint, called the scapulothoracic joint, is important because it requires that the muscles surrounding the shoulder blade work together to keep the socket lined up during shoulder movements.

When the scapula and glenohumeral joint aren’t coordinated in their movements, a problem called scapular dyskinesia develops. Dyskinesia is another way of saying “incoordinated.” Most of the time, the three problems you are faced with (bone spur, rotator cuff degeneration, scapular dyskinesia) occur together. We aren’t sure exactly which came first or how to best treat these problems.

We are slowly identifying all the various factors involved and beginning to unwind cause and effect. Each patient will have his or her own unique combination of reasons why they developed an impingement syndrome.

There is nothing wrong with trying the least invasive approach first. Assess the results and proceed from there. It may be that combining different methods will yield the best results. But we suspect that the individual trial-and-error approach is necessary for now.

Until high-quality research answers all the questions of what and why, it is suggested that nonsurgical management has good overall results and should be the way to go first. Surgery can be equally successful in the hands of an experienced surgeon but should be reserved as the last resort.

Shoulder pain or the lack of shoulder pain is not always a reliable symptom to indicate the status of the rotator cuff. Studies show that a significant number of older adults actually have a torn rotator cuff and don’t know it. And shoulder pain can be caused by other problems other than a torn tendon (e.g., impingement, bone spurs, bursitis).

It would be a good idea to see your primary care physician or an orthopedic surgeon if you are experiencing a change in your shoulder (pain, loss of motion, loss of strength). In adults over the age of 50, degeneration is possible. In adults over 60, other diseases mimicking shoulder pain could be present (e.g., heart disease, bleeding ulcers, kidney disease).

The physician will conduct a clinical exam, order lab work if needed, and perhaps request an X-ray. If there is a suspicion that the rotator cuff is torn, then an ultrasound can be done. Studies show that ultrasound imaging is actually a very reliable way to look for tendon tears. The images show tear location, size (length), and depth. This additional information helps the physician guide you through treatment.

Small tears may have a chance of healing. With a rehab program, it is possible to strengthen other muscle fibers to help protect the torn tendon. Larger tears are more likely to get even bigger and cause problems. Your participation in recreational or sports activities or even loss of balance and a fall can put you at risk for further injury that might require surgery to repair the damage.

All of this is just speculation without a proper examination and diagnosis. Make an appointment with your physician to be sure. Many times, an early diagnosis and treatment can prevent worse problems. It certainly will put any concerns you have to rest.

Most people who have a rotator cuff repair are very pleased with the results. When you read reports on-line of “high” failure rates, you are most likely getting the surgeon’s view. Anything short of a perfect surgical result can be classified as a “failure.” So-called failure rates do range from low (13 per cent) up to 94 per cent. But the truth is the overall rate is most likely more like one-fourth to one-third.

And in those cases reported as “failed” procedures, there are patients who remain asymptomatic — in other words, without symptoms (no pain, no stiffness, no loss of motion). From the patient’s perspective, the surgery was a success. Meanwhile, surgeons around the world continue to examine their patients for any clues as to the reason for any failures and how to combat this problem.

For example, in a recent study, Austrian surgeons offered their expertise in answering the question of why there is such a high failure rate after rotator cuff surgery. In an analysis of 95 patients over an 11 year period of time, they found an overall failure rate of 33 per cent. Most of those weren’t really retears but rather a failure to heal. Their observations as reported in this article are very similar to what other surgeons are finding in other locations.

The patients were followed closely with physician examinations and ultrasound images taken every three months for the first year. Pain, range-of-motion, strength, and function were also evaluated. They used the American Shoulder and Elbow Surgeons (ASES) and Constant scores to assess these results. They also took a look at recreational and sports activity levels.

Continued follow-up was done in the same way every year. In this way, the surgeons were able to see at what point a prognosis or prediction could be made about the final results. One MRI was done about five years after the surgery.

The surgeons could see that patients with the larger tears were more likely to be in the rerupture group. And as expected, there was a direct relationship between retears and scores on the functional tests.
The question was then raised: with continued high rates of retears, should rotator cuff repairs be done? The authors conclude Yes because the majority (two-thirds) of their patients had a successful repair. They got significant pain relief and return of motion, strength, and function.

For those patients who had a failed result, this study supports the idea that it’s because the repair didn’t heal. And those reruptures don’t heal on their own. Small tears have a chance of self-healing but most retears tend to get larger over time. For patients who have a successful healing in the first six months, the long-term results are excellent.

Patients with large tears (more than two centimeters in size) can expect persistent pain and loss of motion, strength, and function. Thus, the authors conclude the timing (early) and size of tear do predict final clinical outcomes. The task remains to find ways to perform the surgery so that everyone has an excellent result and retears are eliminated (or at least decreased considerably).

Infection after shoulder replacement surgery is one of the more common complications reported with this particular procedure. Joint infection can go unnoticed with no symptoms for a long time. When it becomes a chronic, deep infection, the patient may experience pain, fever, and loss of motion. These are the symptoms that finally get them in to the doctor for diagnosis and treatment.

The physician relies on blood levels (e.g., C-reactive protein, white blood cells, erythrocyte sedimentation) to identify infection or inflammation. But the diagnosis can be delayed because lab tests aren’t always positive even when there really is an infection.

It’s unclear why some patients develop these infections and others don’t. Risk factors may include diabetes and alcohol abuse. Other possible risk factors include any chronic health problem (e.g., cancer, heart disease, rheumatoid arthritis) or a previous history of joint infection.

Sometimes the bacteria travels from somewhere else in the body (e.g., lungs, kidneys) via the blood stream to the joint. A history of pneumonia or other upper respiratory infection or kidney/bladder infection is an important red flag.

With more and more older adults getting total shoulder replacements, efforts to prevent and eliminate joint infections is becoming the focus of studies across the United States. Prevention of deep joint infections is the key to avoiding additional surgeries. More research is needed in this area to reduce the incidence of infections and determine the ideal treatment approach.

Shoulder replacements (called shoulder arthroplasty) are not done as often as hip and knee replacements. But more and more older adults are taking advantage of this available surgery. As with any joint replacement, complications and problems can arise. One of those problems is deep joint infection.

The ideal treatment for this problem has not yet been determined. Previous studies have shown that deep joint infections do not always respond well to debridement and irrigation procedures (cutting out the infection and cleansing the joint with fluid). Just cutting out the infected implant isn’t a very good option either because that leaves the patient with loss of hip motion and difficulty weight-bearing.

That’s why this idea of a spacer was introduced. The implant is referred to as a Prosthesis of Antibiotic-Loaded Acrylic Cement or PROSTALAC. It is used to replace the first (infected) prosthesis. Prosthesis is another word for the implant used to replace the joint.

The PROSTALAC is made by the surgeon for each individual patient. It is shaped just like the stem and round head at the top of the natural femur (thigh bone). There are different ways to create the mold for the PROSTALAC implant.

In most cases, the surgeon uses a tubular-shaped plate or flat dynamic compression plate and the formed the PROSTALAC implant around the tube or plate. Either of these approaches gives the spacer more support. In a smaller number of patients, no internal support beam or scaffold is used.

The infected implant is removed and the PROSTALAC implant put in place instead. In some patients, this device is considered a spacer — in other words, it holds the place of the femoral side of the joint until the infection is cleared up and a new prosthesis can replace it. Other patients elect to keep the PROSTALAC spacer as their permanent implant. Keeping the PROSTALAC spacer as the permanent implant avoids another (revision) surgery.

Surgeons who use this treatment approach to deep joint infection of the shoulder suggest the use of a spacer like the PROSTALAC can be very helpful. The implant can stabilize the joint, provide pain relief, and restore some shoulder function. But you should know that it’s not without its problems. For example, complications such as a second (recurrent) infection, dislocation, or fracture of the PROSTALAC have been reported.

Massive (very large) rotator cuff tears are at great risk of retears. Studies show a retear rate as high as 94 per cent. Not all of those retears are symptomatic but that is still not a very successful outcome.
Retears are considered “failures” that fall into one of two categories: mechanical and biologic.

Mechanical failure refers more to the technical aspects of the surgery. Perhaps the type of sutures used or the way the stitches are put in place contributes to mechanical failure. Some studies have pointed to the way the soft tissue attachment is prepared at the start of surgery. This area is called the footprint — the place where the rotator cuff pulls away from the bone.

Biologic failures occur when your soft tissue just don’t heal or hold as hoped. This has more to do with the tendon healing where it is repaired or reattached to the bone. There is some thought that if the healing tendon can be protected long enough from stress, strain, and overload, then the patient is much less likely to retear the repair.

Tears that occur while the patient is still in a sling are more likely to be mechanical failures. The person has not even started moving the arm or seeing the physical therapist yet. This points to the strong possibility of the repair itself being the problem (a mechanical failure where the suture and tendon interface).

There aren’t as many tears after six months, which supports the idea that once the repair is healed, unless there is a biologic weakness in the repair, the surgery should hold up quite well. Using serial ultrasound studies, the surgeons can see how the tendons are healing and that helps them know if the failure is mechanical, biologic, or both.

Studies have shown that the strength of the repair is superior when surgeons use suture anchors with a double-row fixation technique. Mechanical failures are more likely when holes are drilled through the bone and the tendons are reattached by threading them through the tunnels. The suspicion that where the tendon is stitched back to the bone (tendon-bone interface) is part of the problem or the “weak link” is another mechanical possibility under investigation.

Ultrasound images showing sutures in the gap between the tendon and the bone is an indication that the tendon has pulled away from the bone leaving the suture behind. The fact that the suture anchor is still in place and hasn’t shifted further confirms mechanical failure as the cause of early retears.

In cases where the failure didn’t occur until three months after rotator cuff repair, there may be a different story. There simply isn’t enough tendon-bone healing to hold the repair. This is more of a biologic failure. And that raises a whole new set of questions.

For example, are there some other biologic or patient factors to explain this result? Does it have to do with the patient’s age, general health, medications being taken, or the presence of other problems (e.g., diabetes, heart disease, cancer)? Some other studies have shown that the use of antiinflammatory drugs may have a negative impact on where the tendon is reattached to the bone.

Surgeons are actively studying the problem of rotator cuff retears looking for ways to improve the surgical technique. By recognizing there can be mechanical failures, biologic failures, or both it will eventually be possible to reduce and even eliminate factors contributing to any and all types of failures.