FAQ Category: Shoulder

Studies show that massive (very large) rotator cuff tears are at great risk of retears. There is evidence of a retear rate as high as 94 per cent. In a recent study from the University of Michigan in Ann Arbor, surgeons took a look at the timing of the tears to see if this might help explain situations like yours.

What they found might help you understand your own retear. They hoped to see if the timing of the tears might offer some clues as to the reason for the tears. Tears that occur early after surgery might be an indicator of a mechanical failure of the surgery itself.

They thought that perhaps the type of sutures used or the way the stitches were 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.

Another thought about the timing of tears has to do with biologic failure. 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.

What they found with this study was a high rate of early ruptures. The tears occurred while the patients were still in a sling. They had 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 weren’t any 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. Some studies have shown that the use of antiinflammatory drugs may have a negative impact on where the tendon is reattached to the bone. So this could be a factor as well.

It isn’t always possible to know when a retear has occurred. Many patients have retears that aren’t painful or problematic. The fact that your repair started bothering you after rehab and during your home program phase suggests a biologic reason (e.g., poor tendon healing) but don’t necessarily prove it.

In cases where the failure doesn’t occur until three months after rotator cuff repair, points more to a failure at the tendon-bone interface. There may not have been enough true tissue healing to hold the repair. And that raises a whole new set of possible risk factors (e.g., your age, your general health, the presence of other complicating health problems such as heart disease or diabetes).

In the end, it may not be possible to determine cause and effect. It’s likely there isn’t a single factor (mechanical or biologic) but rather, several combined together. As the surgeons who performed the University of Michigan study pointed out, at this point, all we really know is that there are some mechanical (surgeon) and biologic (patient) issues related to the surgical procedure that must be investigated further.

Tendon healing after rotator cuff repairs is a slow process. After surgery, patients are in a special abduction sling (looks like a square-shaped pillow under the arm). They have to wear this contraption for four to six weeks.

Some passive movements are allowed while wearing the brace but not all. It isn’t until the patient is weaned off the sling that active motion can begin. Then it takes another four to six weeks before strengthening exercises can begin.

The question often comes up (especially in sports athletes): is there any way to speed up recovery time? Surgeons are aware that the retear rate of repaired rotator cuffs is pretty high during those first three months. That’s why patients are put in an immobilizer and only allowed to do some passive motion. No tension is allowed on the surgically sutured tendon. Without some outside agent to help accelerate healing, the answer to the question is “no.”

There is one biologic product called platelet-rich plasma (PRP) that has been used to speed up tendon healing in other areas (e.g., elbows). But there aren’t a lot of studies using it for rotator cuff tears. In a recent study, orthopedic surgeons from Seoul, Korea compared two groups of patients with full-thickness rotator cuff tears.

One group (19 patients) was treated with platelet-rich plasma (PRP). The second group (23 patients) had the repair surgery without the PRP. Platelet-rich plasma (PRP) is the portion of your blood that contains the clear fluid and extra platelets. The platelets are the part of the red blood that contain growth factors known to accelerate or speed up healing. Studies show that PRP helps many types of tissue regenerate such as bone, ligament, cartilage, muscle, and tendon.

Despite their hypothesis that the platelet-rich plasma group would have better results, there were no clear differences in any of the measured outcomes between the two groups. In fact, at the three-month mark, the group without platelet-rich plasma (PRP) had slightly better results. Over time, the differences evened out.

Pain relief and improved motion was similar in both groups. The persistent loss of external shoulder rotation was also similar between the two groups. Muscle strength improved equally in both groups. In fact, patients were equally satisfied with results in both groups.

And there weren’t any harmful effects of using the PRP. But the specific use of this product in patients with a history of cancer has not been explored. It’s a very good question to raise in discussing your options with the surgeon. The decision may also be affected by the type and location of your cancer.

The retear rate of repaired rotator cuffs is pretty high during the first three months postoperatively. That’s why patients are put in an immobilizer and only allowed to do some passive motion. No tension is allowed on the surgically sutured tendon.

You are in the special abduction sling to protect the healing tendon. It isn’t until you are weaned off the sling that active motion can begin. Then it takes another four to six weeks before strengthening exercises can begin. And finally, for those who are engaged in recreational or sports activities, return to these activities is allowed six to nine months after surgery.

The use of an outside agent to help accelerate healing after rotator cuff surgery is being studied. One of the first studies to compare full-thickness rotator cuff repairs with and without platelet-rich plasma (PRP) was recently reported on.

They didn’t find a significant difference in results with or without this accelerant. . In fact, at the three-month mark, the group without platelet-rich plasma (PRP) had slightly better results. Over time, the differences evened out.

The expectation was for better results in the platelet-rich plasma (PRP) group and that isn’t what happened. Maybe nothing went wrong. The authors suggested that maybe there weren’t enough patients in the study to really measure differences in clinical results. The research term for that phenomenon is to say that the study was underpowered.

Other reasons for the initial delay in healing in the PRP group included the fact that this group did have more patients with larger tears and rehab was started slightly later than in the conventional group (group without PRP).

The authors also suggested that the dose of PRP they used wasn’t enough or that the placement of the gel packs could be a factor. It’s also possible that the way the arthroscopic surgery must be done (running fluid through the joint) could wash away too much of the PRP to make a difference. Swelling after surgery is another potential factor.

The timeframe you mentioned is still conservative and in keeping with how rotator cuff repairs are managed. MRIs can help show the rate and degree of tendon healing. Rehab isn’t usually accelerated without some visible proof that the healing tendon can handle the extra load and tension.

The early months after surgery are the most important. The best way to get optimal results is to follow your surgeon’s and your physical therapist’s advice every step of the way. Speeding up the process is good but not if it puts you at risk of a retear or rerupture.

You are right that studies have shown there’s a fairly high failure rate after rotator cuff repair. In fact, failure of the tendon repair to heal ranges from 20 to 94 per cent. There are many known or potential risk factors, including the one you mentioned: osteoporosis (decreased bone density).

Recognizing the role of osteoporosis in rotator cuff tear healing is a fairly new research finding. Once the correlation between bone mineral density and tendon repair failure was observed, we realized patients at increased risk for failed tendon healing can be identified. Surgeons can measure bone mineral density before surgery.

With careful management of low bone mineral density it may be possible to improve the healing rate of surgically repaired rotator cuff tears. How can this be done? If you smoke or use tobacco products, you can decrease (better yet, quit!) use of tobacco products.

Also eliminating alcohol while increasing your calcium and vitamin D intake are recommended steps. Proper exercise and medications (e.g., hormone therapy) are also known to increase bone mineral density level. Since osteoporosis and rotator cuff tears are both common in older adults (especially postmenopausal women), efforts must continue to educate everyone of the importance of osteoporosis prevention.

Consult with your physician to find out what your overall risk factors are and make every effort to reduce those that are within your control. These are just a few suggestions related to your question about bone mineral density. Your physician may have some additional thoughts specific to your health.

We couldn’t have expressed it any better but here is a bit of additional information that might help everyone facing rotator cuff surgery.

Most of the time, rotator cuff surgery is successful with excellent results. Patients experience pain relief, increased shoulder motion, and improved function. But there can be some problems. In particular, as your mother was told, the rate of rotator cuff repair failure can be pretty high.

Multiple studies have shown that the failure rate after rotator cuff repair ranges from 20 to 94 per cent. There are reasons for the high failure rate. It doesn’t just happen randomly. For example, we know that medical problems such as diabetes, high blood pressure, osteoporosis, and heart disease are risk factors for poor tendon healing.

And recently, a study from Seoul National University College of Medicine in Korea added some valuable information. After examining the medical records of 272 patients who had a rotator cuff repair, there were three significant prognostic factors for failed healing: 1) low bone mineral density (BMD), 2) fatty infiltration, and 3) tendon retraction. Low bone mineral density (BMD) is the hallmark finding in osteoporosis (brittle bones).

Without good, solid bone structure, the suture anchors used in the repair loosen and pull out before tendon healing occurs. Suture anchors are used to reattach the torn tendon to the bone. Statistical analysis showed that patients with low bone mineral density had 7.25 times more chance of failed rotator cuff tear surgery compared with patients who had normal bone.

The second prognostic factor (fatty infiltration) was found to be an independent risk factor for failed rotator cuff repairs. Patients with higher amounts of fatty infiltration were more likely to have unhealed responses. Of the four tendons that make up the rotator cuff, fatty infiltration of the infraspinatus tendon was the most significant prognostic factor.

The third and final factor was tendon retraction. The further the tendon pulls away from the bone, the greater the risk of tendon repair failure. There isn’t anything the patient can do to change fatty infiltration or tendon retraction. The surgeon can use specific surgical techniques to work with the soft tissues for the best results.

The real benefit of this study was in recognizing the role of osteoporosis in rotator cuff tear healing. By measuring bone mineral density before surgery, patients at increased risk for failed tendon healing can be identified.

With careful management of low bone mineral density it may be possible to improve the healing rate of surgically repaired rotator cuff tears. This is an important “take home” message for all of our readers. If you are an older adult and thinking about having rotator cuff surgery, rotator cuff repair may not be as successful as it is with younger patients. The best source of advice is your surgeon.

Ultimately, the final decision is the patient’s though and sometimes they do know what is best for themselves. Weighing the risk against the benefit is easier when there is additional information available about risk factors, predictive factors, and prognostic factors.

Shoulder impingement syndrome can be difficult to diagnose. Sure the physician can tell the symptoms that characterize this problem: you have trouble lifting your arm up overhead easily. The same thing may happen when you lift your arm out to the side and up. You get the arm up part way and then it either hurts too much to keep going or it just won’t go.

If you use your other hand to help lift the involved arm and get it past a certain point (usually between 90 and 120 degrees away from the body), then you can complete the full range-of-motion. This is a classic picture of what is referred to as shoulder impingement. You likely have the same problem in reverse: as you try to lower your arm, you might feel a painful catch. You have to use the hand on the painfree side to help the painful arm move back down to your side.

Studies show that there are really quite a few different problems that could be causing that type of clinical picture typically referred to as impingement. For example, rotator cuff tendinosis, partial-thickness tear of the rotator cuff, full-thickness tear, bursitis, or tight posterior capsule can all create symptoms of pain and limited motion known as impingement.

In order to make the diagnosis, the physician is directed to do exactly as yours has done…start with a few simple tests that don’t cost anything extra. Take an X-ray to look for something obvious (fracture, bone spur, arthritis). If that doesn’t yield the answer, then order an MRI. And finally, an arthroscopic exam is the most accurate (but more expensive) way to get inside that joint and find out what’s causing the problem.

An accurate diagnosis is needed to direct treatment. In the end, this can help direct treatment. You may start with conservative (nonoperative) care with antiinflammatory medications, cortisone injection(s), and/or physical therapy. But if you need surgery, the arthroscopic exam can be both diagnostic and treatment all rolled into one. It sounds like whatever is going on for you, it’s not a cut and dried easy-to-diagnose problem. The arthroscopic exam will likely clear up the diagnosis and set you on the right treatment course.

Shoulder problems labeled shoulder impingement syndrome often make it difficult to raise the arm overhead. Patients are able to raise the arm forward or out to the side to a certain point. But then the arm won’t go any further without help from the other hand lifting it up.

Another sign of shoulder impingement is pain that occurs when raising the arm from about 90 degrees until the person gets the arm up to around 120 degrees of motion. Then the arm continues on its merry way to the top, no problem. Pain often occurs when bringing the arm back down — and usually in the same place: when the arm is about 120 degrees away from the body moving back down to around 90 degrees. From 90 degrees down to the side is usually painfree.

This type of clinical presentation has been referred to as an impingement syndrome since the early 1970s when the term was first used. But better diagnostic tests such as MRIs, ultrasound, and arthroscopic exam are making it possible to clearly define the problem.

And that may mean the term ‘impingement syndrome’ is being replaced by a more specific term such as rotator cuff tendinosis. Tendinosis means the tendon is damaged from a previous injury but there’s no current active inflammation. The body’s attempt to heal the torn tendon failed to fully restore the natural, anatomic soft tissue structure known as the rotator cuff.

The most likely causes of impingement are rotator cuff tendinosis, partial-thickness tear, full-thickness tear, bursitis, or tight posterior capsule. Any of these conditions can cause the clinical presentation of pain and limited motion we still refer to as impingement.

In time, billing codes from the nonspecific terminology associated with ‘impingement’ may be changed to allow for more accurate categories. Once that step has been taken, then it will be possible for everyone to call each condition by its proper name and not lump them all into the broad, nonspecific category of ‘impingement.’

Impingement describes the functional limitation (can’t lift the arm over head smoothly) but not the underlying cause, which in your case is tendinosis. So, in a way, both physicians are correct.

With more and more older adults living longer, working longer, and remaining active longer, surgical repair of torn rotator cuff muscles is getting a second look. Instead of accepting a reduced quality of life due to pain, decreased motion, and loss of function, seniors are asking (even insisting) on equal treatment offered to younger patients.

And studies are supporting the positive long-term benefits of this type of approach. Surgeons typically still advise patients with rotator cuff tears to seek conservative (nonoperative) care before thinking ‘surgery.’ But when a solid concerted effort under the supervision of a physical therapist doesn’t yield the desired results, then surgery may really be the next best thing.

Improved technology and surgical tools has led to an increased number of rotator cuff surgeries being done arthroscopically in all age groups. Shoulder stiffness is no longer much of a problem with arthroscopic procedures.

Newer concepts in rotator cuff surgery include biologic augmentation of the repair. Graft material (either from a harvested tendon or grown in the lab from donor cells) is used to improve healing and support the repair site. This type of repair is especially helpful in older adults who have poor-quality rotator cuff tissue, osteoporosis, or other health issues that can impact healing (e.g., diabetes, heart disease).

So, even though your father has managed to get along okay with rotator cuff surgery, it’s possible that he has gotten used to a level of disability that isn’t necessary. His surgeon may not be seeing a financial opportunity for him (or her) self as much as making available a means of improved quality of life for your father.

If possible, go with your father to his next appointment and see what the surgeon’s thinking is on this recommendation. If you live too far away, ask your father for permission to contact the surgeon by phone to ask questions and discuss your concerns.

When faced with two opposing opinions about surgery, it may be a good idea to seek a third opinion. And there is nothing wrong with going back to the first two surgeons and asking for a review of their thinking on this decision. This repeat discussion may help clear some things up in your mind.

We can offer some information on this very topic from a recent study performed by the American Board of Orthopaedic Surgery (ABOS). They were looking for trends in surgeon practice. Starting in 2003 and going through 2008, data was analyzed to compare these two approaches when doing the Bankart Repair for shoulder instability.

They saw that the majority of surgeons are using an arthroscopic approach to the Bankart repair. In 2003, 71 per cent of the orthopedic surgeons did it this way. By 2008, that figure was up to 90 per cent. The reason for this trend shifting from open to arthroscopic Bankart repairs?

Well, there may be several. First, any arthroscopic surgery has the potential to be less invasive compared to an open incision approach. Second, improved surgical technique with arthroscopy has led to a lower rate of complications. And third, studies over time are showing improved final outcomes when this surgery is done arthroscopically.

The results of long-term studies (10 to 20 years later) are still lacking when it comes to looking at final outcomes for arthroscopic versus open Bankart procedures. But so far the short-term results reported have been very favorable.

The debate over whether arthroscopic surgery is superior to open incision for the shoulder continues. Recently, records from the American Board of Orthopaedic Surgery (ABOS) were used to look for trends in surgeon practice. Starting in 2003 and going through 2008, data was analyzed to compare these two approaches when doing the Bankart Repair for shoulder instability.

Shoulder instability means that the shoulder joint is too loose and is able to slide around too much in the socket. In some cases, the unstable shoulder actually slips out of the socket. If the shoulder slips completely out of the socket, it has become dislocated. If not treated, instability can lead to arthritis of the shoulder joint.

The most common method for surgically stabilizing a shoulder that is prone to anterior dislocations is the Bankart repair. In the past, the Bankart repair was done through a large incision made in the front (anterior) shoulder joint. This required damage to a great deal of normal tissue in order for the surgeon to be able to see the damaged portion of the joint capsule. The procedure was difficult and usually involved an attempt to sew or staple the ligaments on the front side of the joint back into their original position.

The arthroscope has changed all that. This special surgical tool gives the surgeon the ability to see inside the joint. The surgeon can then place other instruments into the joint and perform surgery while watching what is happening on the TV screen.

The arthroscope lets the surgeon work in the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery. If the surgery is done with the arthroscope, patients often go home the same day. Complications such as nerve damage or recurrent dislocation can still occur despite the method of repair. But the rate of problems is reportedly lower with arthroscopy compared with open incision.

Using the data from the American Board of Orthopaedic Surgeons (ABOS), over 4500 patients were evaluated. The number of arthroscopic versus open Bankart procedures was compared. Number and type of complications were available. Even the surgeon’s training and experience were scrutinized.

What did the ABOS records reveal? First, of all the shoulder surgeries reported in the ABOS database, 8.6 per cent were Bankart repairs. Second, more arthroscopic Bankart procedures are being done compared with open Bankart repairs. Starting in 2003 (earliest time when records of this type were available), there was almost a 3:1 ratio between arthroscopic versus open Bankart technique.

Over time (from 2003 to 2008), the number of arthroscopic Bankart procedures continued to go up until there was a 90 per cent incidence of arthroscopic Bankart surgeries. And in that same time period the number of nonfellowship and nonspecialized surgeons performing arthroscopic Bankart procedures also increased significantly.

The authors conclude that their belief at the start of the study (that the majority of Bankart procedures are being done arthroscopically now) was confirmed. This trend is understandable given the improved surgical techniques available with arthroscopy.

At the same time, studies have shown improved outcomes for patients having arthroscopic Bankart repairs compared with open repairs. They reported less pain, reduced deformities, improved function, and excellent patient satisfaction with the results.

And there were fewer complications with arthroscopic Bankart procedures. For example, the rate of postoperative dislocations was 0.4 per cent for arthroscopic surgery compared with 1.2 per cent for open incision repairs. The rate of nerve injuries was 0.3 per cent for arthroscopic Bankart repairs compared with 2.2 per cent with open repairs.

There may be some times when an open incision surgery is warranted. The surgeon makes that decision based on many, many factors. In fact, sometimes the final decision isn’t made until an arthroscopic exam of the joint has been done. There may be some specific reasons to perform an open procedure but for the most part, these surgeries are done arthroscopically for all the reasons mentioned in the ABOS study.

The four tendons of the rotator cuff attach to the deep rotator cuff muscles. This group of muscles lies just outside the shoulder joint. These muscles help raise the arm from the side and rotate the shoulder in the many directions. They are involved in many day-to-day activities. The rotator cuff muscles and tendons also help keep the shoulder joint stable by holding the humeral head in the glenoid socket.

Degenerative changes due to the aging process are the most common cause of rotator cuff tears in older adults. Studies show that once the rotator cuff starts to tear, the tear will continue to get worse and increase in size over time. These tears are divided into two basic groups based on severity: partial-thickness and full-thickness tears. As the names suggest, how far down the tear goes through the tissues determines the category.

The tendon tries to heal itself but often ends up just filling in the gap caused by the tear. Fat cells form the filler, but these are not structurally strong. This in-fill process is called fatty infiltration. Fatty infiltration does not improve shoulder motion, strength, or function.

Surgery may be needed but before subjecting patients to this type of invasive procedure, conservative (nonoperative) care is usually recommended first. Temporarily delaying surgical repair in favor of physical therapy does not seem to put the patient back in any way.

The therapist assists each patient by creating an individualized treatment program that addresses postural component and alignment factors first. Then restoring motion and strength are next. The therapist always keeps the patient’s goal, activity and lifestyle, and general health in mind. For those individuals who are still out in the work force, specific work requirements are determined as well.

For those patients who either have failed to improve with conservative care or who have massive tears unlikely to respond to a nonoperative approach, surgery may be necessary. The decision to have surgery and the timing of the procedure depend on several factors. For example, your general health must be taken into consideration. Any specific medical problems you may have that could compromise recovery are important, too.

Whether or not delaying surgical repair indefinitely will impact your potential recovery is difficult to predict. Your surgeon is the best one to asnwer this question. He or she will gauge your symptoms, assess the clinical presentation (range of motion, function), and review imaging studies (X-rays, MRIs) to determine severity of the situation.

Sometimes the final decision is best made during the arthroscopic examination. At that time, the surgeon can see the true extent of the damage and make the best treatment decision based on actual tissue pathology.

Adhesive capsulitis, sometimes called a “frozen shoulder” still baffles physicians and scientists alike. No one knows what really causes it — or how to treat it. Women, age over 40, and shoulder injuries (trauma) head the list of possible risk factors.

But adults of both sexes (male and female) who have serious health problems such as diabetes, heart disease, stroke, or thyroid conditions have a higher incidence of adhesive capsulitis than the general adult population.

The problem comes on gradually causing pain, loss of shoulder motion, and decreased function. It disrupts the person’s life during the “frozen” stage. And then the problem goes away as mysteriously as it came on. These three stages (freezing, frozen, and thawing) can last anywhere from months to years. In the end, most people come out okay without any major long-lasting effects.

In the three years you have had this shoulder problem, have you had medical testing to rule out the possibility of other causes such as diabetes or thyroid problems? Have you had a thorough musculoskeletal examination to identify other potential sources of the shoulder problem?

Spinal alignment, posture, muscle asymmetries are just a few things that could contribute to the start of the shoulder problem. Unrecognized repetitive motions or unusual carrying angle of the head, neck, shoulder complex could be factors.

In the end, your frozen shoulder may remain as much of a mystery as this same condition in many other adults. In fact, studies show that up to five per cent of the adult population are affected by this problem. That figure may actually be higher since not all people with this type of shoulder problem report it or seek help for it.

Adhesive capsulitis, sometimes called a “frozen shoulder” is a problem that comes on gradually causing pain, loss of shoulder motion, and decreased function. It disrupts the person’s life during the “frozen” stage. And then the problem goes away as mysteriously as it came on. These three stages (freezing, frozen, and thawing) can last anywhere from months to years. In the end, most people come out okay without any major long-lasting effects.

But, in the meantime, the painful symptoms, difficulty sleeping at night, and loss of shoulder function during the day can be very disabling. The patient’s quality of life suffers. What can be done to help the you during these three stages? There are four main treatment methods: 1) antiinflammatory medications, 2) physical therapy, 3) steroid injections, and 4) surgical manipulation.

As you have found out, the injection (a combination of a powerful antiinflammatory and numbing agent) gives immediate but often temporary relief from the pain. This allows you to roll onto that side at night or sleep uninterrupted for more than a few hours. It also makes it possible to move more freely and that’s an important part of the recovery process. As the saying goes, “motion is lotion.”

Studies show that combining a steroid injection with physical therapy can give you the best results. Although it’s true that any form of treatment (including doing nothing) yields the same final outcomes, it can be months and even years before the shoulder problem is resolved. The injection and rehab can get you through the difficult, painful stages and may even speed up the healing process.

One steroid injection isn’t likely to cause any significant problems. Patients are warned against repeated injections because the medication can weaken the soft tissue fibers. That effect can put you at risk for injury. The natural history of adhesive capsulitis is eventual resolution of the problem. A steroid injection can provide comfort and function through the early stages.

Joint replacements are usually done for one of three major reasons: 1) there’s been a traumatic injury that cannot be repaired, 2) there’s significant joint erosion from degenerative joint disease, and 3) the patient has rheumatoid arthritis.

The type of joint replacement (design) and surgery to put it in place can vary depending on the patient’s age, general health, and reason for joint replacement. Goals and desired activity level can also influence the type of implant and surgery performed.

Age and activity level prior to surgery are two significant factors that determine what a patient can do after joint replacement. Good-to-excellent general health with no other serious conditions go a long way in making it possible to regain full motion, strength, and function.

Participation in an active rehab program is another essential ingredient in restoring full function. All patients can expect at least a 12-week period of rehab before pain, stiffness, and swelling are no longer present and interfering with motion and function.

Many patients remain in rehab for up to five months or more. It is often six months before they can return to full physical activity and sports participation. A sports-specific rehab program is advised for anyone who intends to return to activities such as power lifting, football, mountain biking, and so on.

Shoulder dislocations are not uncommon. Most dislocate forward (called an anterior dislocation). Less often are the posterior shoulder dislocations. As the name suggests, a posterior shoulder dislocation occurs when the head of the humerus (upper arm bone) pops backwards out of the shoulder socket.

As you have discovered, there isn’t a great deal of information about the results and recovery of these injuries. Most of the published studies are actually individual cases or reports of a handful of patients. But there was a recent study done a group of orthopedic surgeons from The Shoulder Injury Clinic in England.

They took the time to look back at their medical records to find 112 patients with posterior shoulder dislocations. By reviewing the charts, they were able to put together a picture of what those patients looked like (called patient demographics). By analyzing the data collected, they were able to identify predictive factors for high- and low-risk of complications. And they looked at treatment and treatment results for patients with and without complications.

The most common complication following posterior shoulder dislocation was recurrent instability. Recurrent instability means the shoulder dislocated a second time or the shoulder could slip in and out of the joint (called subluxation). They found that when the force of the first dislocation was enough to damage the head of the humerus, the risk of a second dislocation (or recurrent subluxation) went up dramatically.

Other risk factors for recurrent dislocations were age (younger age — less than 40) and seizure as a cause of the first dislocation. In more than half the cases of recurrence in this group, the second dislocation also occurred during a seizure. Evidently, the force of shoulder muscle contractions during the seizure is enough to pull the shoulder out of joint.

Treatment consisted of wearing a sling for four weeks along with gentle movement exercises. Once the sling was removed, then the patients went to physical therapy for a 12-week program of joint motion and strengthening exercises. If the shoulder dislocated again, then a longer physical therapy program was needed. In some cases, surgery to repair the torn soft-tissues and bone lesions was needed to restore shoulder stability.

Even with treatment, all patients still showed loss of normal shoulder movement and function two years after the injury. The authors commented that it may be the case that all posterior shoulder dislocations would do better with surgery rather than conservative care. They are investigating this theory.

For those patients who are not at risk of recurrent dislocation, mild deficits in function may be acceptable. They may be able to get along just fine without surgery to repair damage done to the shoulder as a result of the dislocation. Those individuals who are at risk for another dislocation may do better with early surgical intervention. Future studies are needed to prove or disprove that idea.

Seizures as a cause of shoulder dislocation have been reported. Evidently, the force of shoulder muscle contractions during the seizure is enough to pull the shoulder out of joint. This can occur not only with epileptic seizures but also during alcohol or other types of drug withdrawal and diabetic seizures.

The initial shoulder dislocation is distressing. But there can be some additional problems to be concerned about. For example, a second (or third) dislocation is possible with future seizures. The more forceful the seizure, the more likely associated shoulder injuries can occur.

For example, rotator cuff tears (tendons and muscles surrounding the shoulder and holding it in the socket) are possible. The force of the humeral head as it shifts out of the socket may be enough to put a ding or defect in the bone. Blood vessels can get torn and nerves stretched or pinched. Any of these complications can cause further problems.

But fortunately, all of this is rare. Most of the time, seizure disorders are able to be controlled with medications and injuries of this type never occur. But a little education and preparedness go a long way.

So tuck this information in the back of your mind but don’t let it convince you that this will happen to your daughter. Talk with her physician about the likelihood of any of these kinds of complications to get a better perspective on the big picture.

When it comes to treatment of rotator cuff tears, this is a question many surgeons and patients face. Many studies have been done comparing the results of one method over another. There is general consensus that the first step is a course of conservative (nonoperative) care.

Conservative care often starts with the use of antiinflammatory medications. Physical therapy to correct posture and alignment as well as address loss of motion, weakness, and impaired function is important, too. The surgeon may recommend a steroid injection if there is improvement but continued pain or no improvement at all. If these efforts fail then surgery is considered.

It sounds like that’s where you are at right now. Surgery usually goes one of three ways: debridement, partial repair, or complete repair. Debridement refers to a surgical procedure in which the surgeon cleans the area of debris and torn fragments. The rotator cuff is then left to heal on its own. There are pros and cons to each technique.

The first advantages of debridement is that it is noninvasive. The procedure can usually be done arthroscopically. A small incision is made and a tiny fiberoptic video camera inserted into the joint gives the surgeon the ability to complete the debridement process.

Arthroscopic debridement can be done on an outpatient basis which tends to lower the costs. There are fewer complications after debridement (compared with partial or complete repair procedures). And rehab is shorter so there’s less risk of developing a frozen shoulder. You’ll be able to get back to your daily activities faster.

On the downside, there is the risk of reinjury with further damage and tearing of the remaining rotator cuff. But if that happens, then you will be re-evaluated as a potential patient for full reconstructive surgery.

Partial-thickness tears and full-thickness tears can often be repaired if the damage isn’t too much. But massive, full-thickness tears may be too much to allow for any kind of repair. The larger tears tend to fill in with fat and scar tissue making surgical repair more difficult. The tendon can retract (pull away) so far that it cannot be restored to its correct anatomical insertion. Poor quality of the torn rotator cuff is another factor the surgeon considers when deciding what type of surgery to perform.

Your surgeon is really the best one to advise you on the most appropriate surgical procedure to perform. The final decision is often made at the time of the actual procedure when the surgeon can see the location and severity of the lesion (tear).

Orthopedic surgeons from around the world continue to look for ways to improve results of surgery for rotator cuff tears (RCTs) of the shoulder. Of special interest are the results of surgery for massive RCT tears like yours.

The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. The rotator cuff connects the humerus to the scapula. The rotator cuff helps raise and rotate the arm.

The typical patient with a rotator cuff tear is in late middle age and has had problems with the shoulder for some time. This patient then lifts a load or suffers an injury that tears the tendon. After the injury, the patient is unable to raise the arm. However, these injuries also occur in young people. Overuse or injury at any age can cause rotator cuff tears.

A recent study from Germany addresses the question of what surgical treatment works best: complete repair, partial repair, or just debridement. Debridement refers to a surgical procedure in which the surgeon cleans the area of debris and torn fragments. The rotator cuff is then left to heal on its own. There are pros and cons to each technique.

The results of this study confirmed what others have said, too. First, the type of surgery (debridement, partial repair, complete repair) is usually decided during surgery. When the surgeon can see the location and severity of the lesion (tear) then the final decision is made.

Partial-thickness tears and full-thickness tears can often be repaired if the damage isn’t too much. But massive, full-thickness tears may be too much to allow for any kind of repair. That’s when debridement is done instead.

In the German study, the results (joint motion, function) were measured and compared before and after surgery for massive rotator cuff tears in 72 older adults. The good news is that everyone in all three groups improved. They had less pain after surgery, more motion, and could use the arm more.

A closer look at the data showed that the patients in the complete repair group had the best results. They seemed to gain more active (patient-controlled) shoulder motion afterwards. And more motion translated into better daily function. Taking a look at the results for partial repair versus debridement, there was no difference between the groups.

The results of this study are important when considering treatment of a complete rupture of the rotator cuff. Studies have shown that tears can be so massive that surgery won’t help. Re-rupture after rotator cuff tear is fairly common. No one wants to go through major surgery and a long rehab program only to retear the cuff.

Knowing that a complete repair yields the best results helps guide the surgeon when selecting the right course of action for each patient. It is still true that the best results occur with repair of small or moderate tears of the rotator cuff. The size of the tear really does predict the outcomes.

The larger tears tend to fill in with fat and scar tissue making surgical repair more difficult. The tendon can retract (pull away) so far that it cannot be restored to its correct anatomical insertion. Poor quality of the torn rotator cuff is another factor the surgeon considers when deciding what type of surgery to perform.

Your efforts to gain knowledge and understanding of your situation are commendable. This information will help you when the surgeon explains the planned surgery. It will also help appreciate if changes are made in what is actually done occur during the operation.

The term frozen shoulder has been around since the early 1930s. But recent research has been able to show that every stiff, painful shoulder isn’t necessarily a true “frozen shoulder.”

You’ve heard the alternate term for this problem: adhesive capsulitis. According to the authors of a recent review, frozen shoulder and adhesive capsulitis are not the same things. What’s the difference?

Frozen shoulder is a vague term similar to saying something like you have a limp when you walk. That doesn’t tell you very much about the problem, the cause of the problem, or how to treat it.

At best, a frozen shoulder describes spasming of the short rotator muscles of the shoulder or tiny adhesions around the joint or bursae. That’s the actual physical condition behind the shoulder pain and stiffness. Many conditions (not just one) can actually lead to this state of affairs.

On the other hand, adhesive capsulitis is a single problem of chronic inflammation of the joint capsule. The shoulder capsule is a covering of connective tissue interconnected with shoulder ligaments and tendons. They all help hold the head of the humerus (upper arm bone) in the shoulder socket.

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

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

Capsular restriction is the one factor that defines adhesive capsulitis separately from other conditions that can cause shoulder stiffness. Other problems like rotator cuff tears, tendinitis, shoulder arthritis, or nerve impingement can also cause loss of motion that looks just like adhesive capsulitis.

But in each of those other conditions, the motion loss is the result of multiple factors (not just one factor). Treatment focuses on the specific cause of the stiffness and that often has nothing to do with the shoulder joint capsule.

But if both conditions (frozen shoulder and adhesive capsulitis) look the same on the outside (stiff, painful shoulder), then how can the physician tell what’s causing the problem or how to treat it effectively?

A careful history and review of what has happened over the course of time helps. Patient characteristics can also point to the correct diagnosis. For example, adhesive capsulitis is seen most often in women between the ages of 40 and 60 who are sedentary (not manual laborers or actively engaged in exercise). And there is often a history of some other serious health problem (e.g., heart attack, stroke, diabetes, breast cancer, thyroid disease).

X-rays aren’t usually very helpful in distinguishing a frozen shoulder from adhesive capsulitis. They do help rule out fractures, arthritis, bone spurs, and osteopenia (decreased bone density). MRIs with dye injected into the joint (called magnetic resonance arthrography or MRA) will show changes in the joint capsule typical of adhesive capsulitis.

There is one clinical test the physician can perform that is very diagnostic. And that’s moving the arm passively without the patient’s help. If the shoulder resists movement into external (outward) rotation with the arm down at the side, it’s likely adhesive capsulitis. There’s no pain involved keeping the arm from moving (as there would be with a frozen shoulder). It’s more of a mechanical hold from a sticky/stuck capsule that’s keeping the joint from moving.

Many surgeons prefer to start treatment of adhesive capsulitis with conservative measures such as antiinflammatory medications and physical therapy.

If a nonoperative approach is given a concerted effort with no change, then surgery may be the next step. Assuming you have already completed at least three to six months of treatment with no change or a worsening of symptoms, then surgery is required. And manipulation or arthroscopic capsular release are, indeed, the two main choices.

Manipulation refers to a procedure in which the surgeon passively moves the patient’s arm through its full range-of-motion. The patient is sedated or anesthetized and completely relaxed so it is possible to complete this type of movement. Being anesthetized or sedated means there is no pain for the patient. And that means there’s no muscle splinting and guarding preventing motion.

Some surgeons prefer to try manipulation first because it is noninvasive. No incisions or puncture holes are required to gain access to the joint. But other surgeons feel that arthroscopic capsular release is a better approach.

Although the joint is entered, the surgeon is able to look inside and make a complete inspection of the joint. In this way, it is possible to both confirm the diagnosis and treat as specifically as possible. With arthroscopy, the capsule can be cut or even partially removed to free up motion. Studies comparing the two methods of treatment show better pain relief and function after arthroscopic capsular release.

Regardless of the approach, the postoperative care is very, very important. Every effort must be made to maintain the motion gained. Patient cooperation with positioning, physical therapy, and follow-up is essential for the best results. Expect to be diligent with all instructions for weeks if not months and you’ll likely have a very positive outcome.