FAQ Category: Shoulder

As you already know, the anatomy and biomechanics of the scapula are complex. With 17 muscles that attach to the scapula and the spinal accessory nerve and long thoracic nerves, there can be any number of different reasons why scapular winging might develop.

Causes of scapular winging are broken down into two groups: primary and secondary. Primary scapular winging occurs when one of the main muscles that hold the scapula steady stops working as it should. Make sure you thoroughly evaluate the trapezius, rhomboids, levator scapulae, and serratus anterior muscles for any impairments in strength, endurance, or motor control.

Injury to the nerve controlling scapular muscles is one cause of primary scapular winging. Athletes are at greatest risk for nerve paralysis causing primary scapular winging. Whether an athlete, homemaker, industrial worker or other individual anyone who suffers a fall, collision, or repetitive motion could develop this problem.

Secondary scapular winging is the result of a problem somewhere else in the shoulder complex. That other problem could be a rotator cuff tear, shoulder bursitis, shoulder dislocation, or a frozen shoulder. Part of your examination will be directed toward screening the shoulder joint as a potential source of the problem.

Osteochondroma (bone tumors) can also cause secondary scapular winging. With osteochondromas, there is usually a “clunk” that can be felt and heard as the arm moves away from the side just as you described.

An X-ray or other more advanced imaging would be needed to identify osteochondroma as a potential cause. If you have conducted a thorough evaluation and cannot identify the cause, it may be time to refer to a specialist for a medical diagnosis. There could be something else going on that cannot be easily determined without lab work or imaging studies.

What you may be seeing is something we call scapular winging. Scapula is another word for shoulder blade. Scapular winging, of course, describes the position of the scapula as it “sticks out.”

Sometimes you see scapular winging in young children. They haven’t developed the full strength of the arms and upper back yet. If they are skinny and all arms and legs, you might not think twice about the scapulae (plural for scapula and a scapula is the same as shoulder blade) sticking out.

But in adults, scapular winging (especially when it’s only present on one side) isn’t normal and can have some serious consequences. Without proper scapular positioning and movement, the arm doesn’t move normally. Lifting the arm overhead and then lowering it back down can become painful, difficult, and even impossible.

What causes this problem and what can be done about it? Causes of scapular winging are broken down into two groups: primary and secondary. Primary scapular winging occurs when one of the main muscles that hold the scapula steady stops working as it should.

Injury to the nerve controlling scapular muscles is one cause of primary scapular winging. Athletes are at greatest risk for nerve paralysis causing primary scapular winging. Whether an athlete, homemaker, industrial worker or other individual who suffers a fall, collision, or repetitive motion, you could develop this problem.

Secondary scapular winging is the result of a problem somewhere else in the shoulder complex. That other problem could be a rotator cuff tear, shoulder bursitis, shoulder dislocation, or a frozen shoulder.

Any injury or condition that can alter the way the muscles fire or cause muscular fatigue can result in impairment of the scapular rhythm needed for normal arm movement. Likewise, anything that changes the alignment of the scapula can have the same effects on scapular position and movement.

Before defining the treatment, an accurate diagnosis and understanding of the cause is needed. An orthopedic surgeon or physical therapist can help you with this. A review of your history and current activities will be conducted. A physical examination including observation of your movement patterns and testing of the muscles will be performed.

Most often, conservative (nonoperative) care is advised. Recovery and restoration of normal movement (and thus normal alignment of the scapula) can take several months up to several years depending on the underlying cause. Sometimes surgery is needed but that decision is way down the road for you at this point.

Shoulder joint replacement surgery (also called shoulder arthroplasty) is a great treatment for many people with shoulder pain from arthritis. But patients who don’t have enough muscle function to stabilize the joint may not be able to benefit from the traditional implant design — one that mimics the normal anatomic shoulder.

Instead, a different type of shoulder replacement, called reverse shoulder replacement has been developed. And it has worked so well, surgeons have expanded the number and types of patients who can qualify for this type. The reverse shoulder replacement does exactly as the name suggests: reverses the socket and the ball, placing the ball portion of the shoulder where the socket used to be and putting the socket where the ball or humeral head would normally be.

This new design gives a much more stable shoulder joint that can function without an intact rotator cuff. The artificial joint itself provides more stability by creating a deeper socket that prevents the ball from sliding up and down as the shoulder is raised. Shear forces are transformed into compressive forces.

This simple change allows the large deltoid muscle that covers the shoulder to lift the arm. The result is a shoulder that functions better, is less painful, and can last for years without loosening. Early studies have reported very favorable results — enough so that surgeons have expanded the number and types of patients who can benefit from this procedure.

Reverse shoulder replacement was only approved by the US Food and Drug Administration in 2004, so it is quite new. Some surgeons used them as early as 1998 when they first came out as a customized implant. European surgeons have been using them much longer with very good results. So finding someone with more experience than your surgeon may not be possible.

You may have some shoulder instability meaning the head of the humerus (upper arm bone) isn’t being held exactly in the middle of the shoulder socket where it belongs. If the humeral head is just slightly forward of the center of the socket, when you reach back, the head shifts back into place.

The clunk you feel may be the round head of the humerus making the change in position from being slightly forward of the center of the shoulder socket back to the middle of the joint. Some experts refer to this as a relocation of the humeral head.

Shoulder instability of this type is usually accompanied by tendon tears, muscle weakness, or some other type of biomechanical change in how the shoulder joint moves and works.

The best thing to do is get an accurate diagnosis. You will probably have to make an appointment with an orthopedic surgeon or physical therapist (possibly someone who specializes in shoulders).

This specialist will be able to test the structures of the shoulder and determine what’s going on and how to treat it. Early intervention can help keep the problem from getting worse, so don’t put it off. Call and make an appointment today.

Bony defects are commonly linked with recurrent shoulder dislocations (instability). Fractures in the bone, tendons that pull away from the bone, and tears in the fibrous rim around the shoulder socket are often part of the unstable shoulder following a traumatic injury.

Conservative (nonoperative) care for major defects in the bone on either side of the shoulder joint isn’t usually enough to recreate shoulder stability. Even with surgery, some patients have less than optimal results.

However, more than ever before, surgeons have improved the techniques used to repair these defects. Advanced imaging techniques with MRIs, CT scans, and ultrasound studies has made it possible to identify the location, type, and size of lesions before surgery is even scheduled.

Sometimes the less invasive arthroscopic type surgery can be performed. More often, open incision procedures are called for. The goal is to restore the normal joint surface while giving the patient a stable and functional shoulder with normal biomechanics and full joint motion. Meeting these goals just isn’t always possible without surgery with injuries like yours.

You may be referring to platelet-rich plasma (PRP) (also known as blood injection therapy). PRP is a medical treatment being used for a wide range of musculoskeletal problems.

Platelet-rich plasma (PRP) refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of blood platelets. Plasma is the clear portion of the blood in which all the other blood particles such as platelets, red blood cells, and white blood cells travel.

Platelets clump together to form blood clots and plug up holes in areas where there is active bleeding. Besides containing clotting factors, the platelets release growth factors that help start the healing sequence. With a concentrated amount of platelets, larger quantities of these growth factors are released to stimulate a natural healing response.

In some conditions, PRP treatment has been shown to enhance the body’s natural ability to heal itself. It is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

One area where the use of PRP has been questioned is in the treatment of chronic musculoskeletal problems like your shoulder instability. But the use of PRP for this type of shoulder problem has not been studied or compared with other types of treatment (e.g., physical therapy, prolotherapy, nip and tuck surgical procedure to tighten up the joint capsule called plication.

If you have not tried conservative (nonoperative) care under the direction of a physical therapist, this might be your next step. Talk to your doctor about your difficulties during daily activities. At the very least, the ways in which your shoulder instability is affecting your life should be documented. Any changes in function that occur over time should be recorded. This may help you justify the cost of surgery if and when the surgeon makes a recommendation for operative care.

The reverse shoulder replacement does exactly as the name suggests: reverses the socket and the ball, placing the ball portion of the shoulder where the socket used to be and putting the socket where the ball or humeral head would normally be.

This new design gives a much more stable shoulder joint that can function without an intact rotator cuff. The artificial joint itself provides more stability by creating a deeper socket that prevents the ball from sliding up and down as the shoulder is raised.

There are some problems that are unique to the reverse total shoulder replacement. The three most common problems with reverse shoulder replacements are neurologic injury, bone fracture around the implant, and hematoma (pocket of blood or other fluid trapped inside the joint).

Other reported problems include infection, dislocation, baseplate failure, and fracture of the acromion (piece of bone from the shoulder blade that curves over the top of the shoulder).

The first and potentially most damaging is neurologic injury. Cutting or pulling (traction) on the nerves to the arm can cause loss of sensation of the arm, hand, and/or fingers. Sometimes the reverse shoulder implant puts strain on the group of nerves to the arm called the brachial plexus. In other cases, the implant can displace (push aside) the nerve plexus creating loss of sensory and/or motor function of the arm. One other cause of nerve damage is scar tissue that can press (compress or impinge) nerves of the brachial plexus causing similar problems with sensation and movement.

Periprosthetic fracture is a break in the bone around the implant. Most of these fractures occur during the surgical procedure as the surgeon prepares the bone to receive the implant. The surgeon must be very familiar with the implant itself, its design and how it’s supposed to work, as well as the best way to hold the implant in place. The surgeon must be careful when handling the patient’s arm during the procedure. Extreme shoulder positions in a patient with weak or brittle bones can contribute to bone fractures.

Hematoma (blood trapped in the joint) is another common complication that doesn’t have a single cause but many possible causes. Proper placement of the implant is necessary to avoid fluid collection in empty areas or what are called dead spaces. Sometimes patients develop pathways of drainage called sinus tracts at the incision site where blood and fluid can pool causing a hematoma. Studies have also shown that infection and hematoma are linked.

Up to 10 per cent of all patients receiving a reverse shoulder arthroplasty develop a serious infection. Risk factors include multiple previous surgeries, a large-sized dead space, poor sterile technique, and revision (second) surgeries on the reverse implant. Surgeons use two methods of prevention for infections. One is to give the patient antibiotics just before the procedure. The other is to use cement that has antibiotic in it.

The simple act of reaching behind to scratch the middle of your back or (for women) undoing a bra-strap can dislocate a reverse shoulder implant. This action places the arm in a position of extension, adduction (arm close to the body), and internal rotation.

Any imbalance in the muscle tension around the shoulder or unusual shape of the shoulder socket can contribute to a dislocation with this motion. Placing the wrong sized socket or wrong sized round head that fits in the socket (or a mismatch of the two components) are additional reasons why dislocation can occur.

Revision surgery may be the only way to treat this problem. But first, the surgeon will try putting the shoulder back in the socket and then placing the patient in a sling for three to six weeks. Patients are cautioned to avoid shoulder extension, adduction, and internal rotation (those motions that can flip the shoulder out of joint) until fully healed.

Finally, baseplate failure is a design problem that surgeons and manufacturers of reverse shoulder implants are working on. The baseplate is part of the round component that attaches to the shoulder where the socket used to be. If the patient’s bone doesn’t grow in and around the baseplate, the shoulder joint may not be secure or stable.

Makers of the implants have provided locking screws that can be angled into the denser bone to help prevent the problem of baseplate failure. A central screw (right through the middle of the bone) also helps anchor the humeral prosthesis in place. Other design features under investigation include using thicker screws, a tilted baseplate, and offsetting the center of rotation.

That doesn’t cover absolutely everything that could possibly happen with this type of surgery. But it gives you an idea of the problems specific to the reverse shoulder replacement. If your surgeon (or the orthopedic/surgical staff) hasn’t filled you in on all the possible complications, don’t hesitate to ask for more information.

The natural history (what happens) to an unrepaired rotator cuff tear depends on several factors. The size of the original tear, the cause (trauma versus degenerative soft tissue changes), and your activity level since the tear can all make a difference.

The body does try to repair the damage. If the tendon pulls away from the bone too far, then the body fills in the gap between the end of the torn tendon (called the tendon stump) and the bone where it normally attaches. Scar tissue and fat cells are used to accomplish this fill-in work. The process is called fibrosis and fatty infiltration.

The longer the time interval between when a person injures the rotator cuff and surgery to repair the damage, the greater the risk of fatty inflitration forming and muscle atrophy (wasting and weakness).

So in a way, you could say this is “normal” — in other words, the natural course of events. But it is not a healthy result and may require surgery to repair the damage.

A tendon rerupture usually shows up on an MRI as an empty space where there is a gap between the bone where the tendon should be attached and the tendon itself. The end of the torn tendon is called the tendon stump. Usually this empty space is filled with fluid (which shows up on the MRI with a specific signal intensity to identify it as a fluid-filled spot).

So, although it is possible that your MRI was misread, it’s not likely. The signs of rerupture are pretty clear. Now, it is possible that the tear is only partial, in which case, you might not lose noticeable motion or strength.

In a recent study from Germany, 21 patients with an isolated subscapularis tear were followed from before to after surgery. The surprising finding from this study was that although 20 of the 21 patients had an intact repair and improved strength, one-fourth of those same patients had atrophy (wasting) of the upper portion of the subscapularis muscle.

The second half of the surprise was that none of these patients had any functional losses because of the muscle weakness. That could be the case with you as well. Sometimes when one part of the rotator cuff is deficient, the shoulder complex compensates and manages to keep everything moving in a way that seems fairly normal.

It’s only over time or when under stress (e.g., lifting weights or doing heavy manual labor) that the insufficiency (weakness) becomes apparent or causes problems. Some experts advise having the tendon rupture repaired before it comes to that. Others adopt more of a wait-and-see approach.

Although not very often, mistakes can be made and the wrong MRI results are recorded. If you are truly not sure that the MRI was read properly, ask your surgeon to review the records with you.

According to a recent review on posterior shoulder instability, this is the exact plan recommended. The term posterior instability tells us the shoulder has too much slide, glide, or movement backwards. Subluxation (partial dislocation) and even complete dislocation are often the end results of posterior instability.

Traumatic force (such as occurred in your son’s seizure episode) can be enough to damage the soft tissue around the shoulder (e.g., capsule, ligaments, rotator cuff, labrum). Three to six months of physical therapy (aided by a home exercise program) is the first-line of treatment.

The therapist identifies which muscles to strengthen and helps the patient regain normal rhythm of motion and motor control. This is especially important with the coordination of movement between scapula (shoulder blade) and humerus (upper arm).

If the instability persists, then surgery may be needed. There are some cases where surgery is recommended right away. This plan of care is most likely when there has been a traumatic injury. Damage severe enough to alter the bone or pull the soft tissues away from the joint may require immediate surgical intervention.

Some patients just aren’t good candidates for surgery. This includes people with uncontrolled seizures (even with medication) and folks who don’t follow their physical therapist’s advice or who don’t do their exercises. The postoperative rehab program is long and requires daily attention.

Once your son’s seizures are back under control, then surgery can be done if still recommended. The type of surgery depends on the lesion, extent of damage to the joint, and activity level of the patient (your son).

Someone with a chronically dislocating shoulder that doesn’t respond to conservative (nonoperative) care is usually a good candidate for surgery. But (and that’s a big “but”), a history of noncompliance with their physical therapy is a red flag.

When there are psychological problems, the risk of treatment failure is very high. Likewise, failure to cooperate with the rehab therapy is a cautionary flag. Patients who don’t go to their appointments and/or who don’t participate fully end up with failed a surgery. Understandably, surgeons are hesitant to consider these patients as good surgical candidates.

It wouldn’t hurt to go with your sister to a follow-up appointment and ask a few questions. There may be come missing information to complete this story. It may also be possible for you to help her participate fully in the recommended physical therapy and see what a concerted effort can do for her.

A Popeye deformity is defined as any abnormal shortening or defect of the biceps muscle. The biceps tendon attaches between the elbow and the shoulder. It helps you lift your arm straight up and bend the elbow. There are two parts: the short- and long-heads of the biceps. Each one attaches in a slightly different place on the arm.

A Popeye deformity is usually pretty obvious. There’s a dip where the long head of the biceps tendon has been surgically or traumatically released and retracted from the shoulder. A large bump along the front of the upper arm (making the biceps muscle look extra large) occurs when the muscle belly (not just the tendon) retracts (pulls back).

The most common problems are a cramp-like arm pain, loss of normal elbow strength (flexion or bending), and a change in the shape of the upper arm. This altered appearance of the upper arm is called a Popeye deformity.

This deformity is most obvious when the patient flexes the biceps muscle to bend the elbow. Picture the way Popeye (cartoon character) always showed off his bicep muscle after gaining strength from eating spinach. Only in the case of this problem or deformity, a “Popeye muscle” isn’t a sign of strength. Instead, there is muscle weakness.

Surgery is not always advised. If there is no loss of motion, strength, or function and it’s just a matter of a different appearance, then surgery can be avoided. If there is enough loss of motion and strength that you can’t do your daily activities at home or at work, then surgical repair may be necessary.

Your surgeon is the best one to advise you on this. He or she will perform an examination and take into consideration all aspects of this problem. If cosmetic appearance (i.e., how it looks) is important to you, then it would be a good idea to ask your surgeon about all treatment options.

There are many different causes of shoulder pain. Any problem inside or around the joint can create pain. One of the more common sources of shoulder pain occurs when there is some type of pathology of the long head of the biceps tendon (LHBT).

The biceps tendon attaches between the elbow and the shoulder. It helps you lift your arm straight up and bend the elbow. There are two parts: the short- and long-heads of the biceps. Each one attaches in a slightly different place on the arm. Pathology of the long-head of the biceps causing shoulder pain could be a partial tear of the tendon or tenosynovitis (inflammation of the sheath or lining around the tendon).

Another injury of the long head of the biceps causing shoulder pain could be a SLAP lesion. SLAP stands for superior labral tear from anterior to posterior (from front to back). The labrum is a rim of fibrous cartilage around the shoulder socket. The word “superior” tells us the injury is to the cartilage that covers the top part of the shoulder socket.

Treatment for any of these causes of biceps tendon problems may consist of surgery called a tenotomy. It sounds like that is the type of procedure your surgeon has recommended for you.

During a biceps tenotomy, the long-head of the biceps tendon is released from its attachment to the shoulder. Surgically cutting this portion of the tendon allows it to retract or move away from the shoulder. A tenotomy of this type removes the damaged, inflamed tissue from the joint. This particular tendon has a rich supply of pain nerve fibers so releasing it helps reduce shoulder pain.

Despite all good intentions in treating the shoulder pain by performing a tenotomy, sometimes after tenotomy surgery, the patient develops complications. The most common problems are a cramp-like arm pain, loss of normal elbow strength (flexion or bending), and a change in the shape of the upper arm. This altered appearance of the upper arm is called a Popeye deformity.

Studies show that tenotomy of the biceps tendon is most common in men. It is not recommended for young, active patients or anyone with concerns about appearance. Age is not a factor in predicting who might experience this type of complication but being male is a strong predictor.

Therefore, men who are involved in work or recreational activities that require strong elbow flexion and forearm supination (turning the palm up towards the ceiling) should be forewarned that strength loss could affect them.

This type of information may be of particular interest to folks like yourself who are carpenters, woodworkers, mechanics, and gardeners. Likewise, anyone who uses the forearms and elbows repetitively to complete daily work tasks will must be told of the possible complications of this procedure. Reducing shoulder pain in order to improve overall arm function may be worth the trade off.

Many adults who have a rotator cuff tear consider waiting to see if the shoulder will heal on its own without surgery. There has always been a question whether rotator cuff tears can heal without surgery.

It is clear that painful symptoms can be treated effectively without surgery. But does the torn tendon actually regenerate itself? And if the tear does heal (or at least decrease in size) — is the tissue quality of the healing site normal tendon tissue or scar tissue?

A recent study was done to observe over time what happens to full-thickness rotator cuff tears that are treated conservatively (nonoperative treatment). This study does not look at the quality of tissue repair but does evaluate size of the tear over time. For those who are trying to decide what type of treatment is best, the findings from this study might help you.

Ultrasound imaging was used to diagnose 61 tears in 51 adults 60 years old and younger. Follow-up ultrasounds were taken two to three years later. Patient age, sex (male or female), size of the tear, and patient symptoms were compared with the results of the ultrasound.

They found that half of the tears got worse (larger in size) over time and that an increase in tear size was accompanied by increased shoulder pain. One-fourth of the total group developed a second full-thickness rotator cuff tear. The rest of the group (26 tears accounting for 43 per cent of the total) were unchanged (not better or worse).

Analysis of the data did not show any link between the change in tear size and patient age, trauma as a cause of the initial problem, or size of the original tear. There did not appear to be any correlation between new tears and sex or trauma as a cause of the first tear. There was a clear relationship between increasing shoulder pain and the original rotator cuff tear getting larger in size.

The authors suggest that based on their findings, it looks like rotator cuff tears can get better — but most do not. Younger, more active adults with rotator cuff tears may want to consider surgery early on for full-thickness tears.

Conservative care (shoulder rehab) under the supervision of a physical therapist is a good way to get started. Failure to improve (reduce pain, increase motion, restore function) is another indication that surgery may be needed.

Ultrasound and MRIs are both used to diagnose shoulder problems involving the rotator cuff tendons. Some surgeons prefer one over the other as they have different advantages. In the case of ultrasound, it is a quick and easy, noninvasive approach. Both shoulders can be done with little added time or cost.

The transducer used in taking ultrasound pictures can be used to help compress or move tissue when necessary. Usually a fully torn tendon retracts (pulls away from the bone where it was attached).

The ultrasound technician uses the transducer to separate out the torn edges from the healthy tendon. This gives the surgeon a better view of the size of the tear and extent of the damage — important information when planning surgery.

Follow-up ultrasound images will give an idea of any changes that have occurred since the initial injury. MRIs may offer some additional information. Both can be valuable in planning treatment, especially if surgery is being considered.

It’s true there are certain changes that occur in the musculoskeletal system as we get older. For example, age-related loss in muscle mass, strength, and endurance of skeletal muscle is termed sarcopenia.

Sarcopenia involves both the reduction of muscle mass and/or function as well as the impairment of the muscle’s capacity to regenerate. Muscle mass is lost at a rate of four to six per cent per decade starting at age 40 in women and age 60 in men.

The greatest decline in both men and women occurs with inactivity, acute illness, and after age 70, at which time the mean loss of muscle mass has been measured as one per cent per year. At all ages, females appear to be more vulnerable to loss of lean tissue than males. However, in men and women, muscle strength can be maintained through exercise well into old age.

It remains unknown how much sarcopenia occurs as a result of decreased physical activity and exercise capacity or whether this decline is a function of age, lack of motivation, age-associated decreases in metabolism, or other factors such as anemia, diabetes, poor circulation or other chronic health problems.

Shoulder problems such as you have experienced are more common in older adults (65 years old and older). Rotator cuff tears (often accompanied by lesions of the biceps pulley), shoulder instability, osteoarthritis are the most common shoulder problems in this older age group. Everything points to the saying, “Use it or lose it.” Good nutrition along with daily activity and exercise seem to be the ticket to healthy aging.

Let’s start with describing the biceps pulley. The full name of the pulley mechanism is biceps reflection pulley. It is a sling of soft tissue fibers made from surrounding shoulder ligaments and tendons of the shoulder rotator cuff. The sling helps keep the biceps tendon inside a groove in the humerus (upper arm bone) along the front of the upper arm and shoulder.

Disruption of the biceps pulley (usually from a rotator cuff tear) allows the biceps tendon to sublux (partially shift out of the groove) or dislocate (pop out fully). The result can be anterior shoulder pain (along the front of the upper arm) and/or shoulder instability.

In a recent study, it was reported that one-third of patients referred to a shoulder specialist with a shoulder problem, indeed, have a biceps pulley lesion. In most cases, the biceps pulley lesion was present when the patient had a rotator cuff tear and SLAP lesion.

SLAP refers to a superior labral anterior-posterior tear. The labrum is a rim of fibrous cartilage around the shoulder socket. This little extra lip helps keep the shoulder in the socket. The SLAP lesion refers to a labral tear at the top of the socket (that’s what superior means) that goes from the front (anterior) to the back (posterior) of the socket.

The biceps tendon is intimately linked with the labrum because it attaches along the upper front area of the socket. In some SLAP lesions, the biceps tendon is also pulled away from the bone. In the study we mentioned, almost 80 per cent of the entire group had a biceps pulley tear and a rotator cuff tear at the same time.

Surgeons may not always be aware of the biceps pulley system. The loss of this restraining mechanism may contribute to continued shoulder pain after repair of a torn rotator cuff tendon. A proper inspection of the biceps pulley is advised. Repair of this anatomic feature may improve surgical outcomes.

Future study of this biceps pulley mechanism is needed to find out which comes first: degeneration and disruption of the pulley system or rotator cuff lesions? Since many of the biceps pulley lesions were in older adults, it may be that an injury to the biceps tendon leads to disruption of the pulley mechanism.

The end result may be weakening of the rotator cuff with eventual damage there as well. On the other hand, seniors are also at increased risk of rotator cuff tendon degeneration and disruption, which could create the chain of events that leads to biceps pulley lesions.

Pain that lingers after a shoulder surgical procedure is not all that uncommon. But you are right to wonder what’s causing it and what can be done about it. A follow-up visit to both your surgeon and your therapist would be a good idea. They will each look for different potential causes of the problem. Together, you will be able to figure out what to do to resolve the issue.

From your description, it sounds like you could be experiencing a problem called coracoid impingement. Coracoid impingement refers to a pinching of the soft tissue structures by the coracoid process.

The coracoid process is a small hook-like structure at the top front part of the scapula (shoulder blade). The coracoid process works together with the acromion to stabilize the shoulder joint.

The patient’s first inkling that something is wrong is a dull, aching pain along the front of the shoulder. As the arm moves forward and up, across the chest, or internally rotates, the coracoid pinches against the subscapularis tendon, subcoracoid bursa, and/or the biceps tendon.

Coracoid impingement is an uncommon problem and rarely occurs alone without some other change in the nearby anatomic structures contributing to the problem. For example, rotator cuff tears or degeneration or an unusual shape or length of the coracoid bone can lead to coracoid impingement. Calcium build up in the subscapularis bone or the formation of a ganglion cyst can also cause impingement in this area.

Coracoid impingement just doesn’t occur by itself. There is usually another reason why this additional problem has developed. It should be considered as a possible cause of anterior (front) shoulder pain after shoulder surgery to repair a torn rotator cuff or relieve pressure under the subacromion.

The patient’s history can offer helpful clues. There is often a previous history of fractures of the humerus, coracoid, or glenoid (shoulder socket). Prior shoulder surgery is another contributing factor.

The surgeon will search carefully for factors such as rotator cuff damage or degeneration, shoulder joint instability, or arthritis. A re-examination of the shoulder is next. The physician looks for tenderness over the coracoid process, pain when the arm is moved across the chest, and weakness of the subscapularis muscle.

Other signs and symptoms may include shoulder instability, pain on testing the biceps tendon, and generalized weakness of the rotator cuff. An arthroscopic examination (using a special scope to look inside the joint) is the best way to find out what’s causing the problem. You may have had this done before (or as part of) the last surgery. It is a very helpful tool in diagnosing the cause of your pain.

The problem of coracoid impingement is rare and and occurs most often along with some other shoulder pathology. It may go unrecognized until the main problem is treated. It does require separate treatment before the painful symptoms resolve. Don’t hesitate to make another appointment with your surgeon. Earlier follow-up is often better to avoid compensation patterns of movement and other problems developing.

You may have developed a complication of arthroscopic surgery called chondrolysis. Chondrolysis is defined as a generalized (all over) loss of the articular (surface) cartilage of the joint.

The fact that the condition is generalized (rather than a local area of cartilage loss) shows that this is more than just a mechanical problem. If it were a suture rubbing away the surface cartilage, then only one or two bare spots would form.

But when the entire surface of the humeral head (round ball of bone at the top of the upper arm) and the inner layer of cartilage in the shoulder socket are missing, then it’s time to take a closer look.

A recent study about this problem was done at the University of Washington in Seattle. It is the largest study of its kind and probably the first to look at risk factors for chondrolysis after shoulder arthroscopic surgery.

They found that 19 per cent of the patients who had arthroscopic shoulder surgery developed symptoms of chondrolysis within 18 months of the procedure. After analyzing all the data, they were able to see three potential risk factors.

Most notably, it looks like injecting a specific numbing agent (marcaine) into the joint at a high enough dose (0.5 per cent) is the most significant risk factor. Pain and loss of shoulder motion were the first symptoms reported. The pain began within the first 18 months after shoulder surgery. In all cases, marcaine was injected into the joint after the procedure.

Anyone who had shoulder surgery without the use of an intra-articular (inside the joint) injection did NOT develop chondrolysis. Likewise, when a lower dose of marcaine (0.25 per cent) or a different drug (e.g., lidocaine) was used there were no reports of chondrolysis.

A couple other factors were identified as increasing the risk of chondrolysis after intra-articular injection of marcaine. The use of suture anchors in the glenoid (shallow groove, shoulder socket) was one risk factor.

Younger patients were also more likely to develop chondrolysis after intra-articular injection of marcaine following arthroscopic shoulder surgery. The link between age and chondrolysis isn’t clear.

Surgeons have found that reducing pain after shoulder surgery helps speed up recovery. As a result, more aggressive pain control measures are now in use. One of those methods is to inject a local anesthetic (marcaine, lidocaine, bupivacaine) directly into the joint after surgery.

This study shows that the practice of postoperative infusion of marcaine actually contributes to the destruction of the joint surface. There may be other risk factors or a combination of reasons why this condition develops after shoulder arthroscopic procedures. Clearly, you are not alone and every effort is being made to pinpoint and prevent the problem for others.

Chondrolysis is defined as a generalized (all over) loss of the articular (surface) cartilage of the glenohumeral joint. The glenohumeral joint refers to both sides of the shoulder joint: the round head at the top of the humerus (upper arm bone) and the glenoid (shallow groove that functions as the shoulder socket).

The fact that the condition is generalized (rather than a local area of cartilage loss) shows that this is more than just a mechanical problem. If it were something specific (e.g., bone spur, loose cartilage, suture from surgery) that is rubbing away the surface cartilage, then only one or two bare spots would form.

But when the entire surface of the humeral head and the inner layer of cartilage in the shoulder socket are missing, then it’s clear that something else is going on. Reports of chondrolysis after arthroscopic shoulder surgery are not uncommon. The reason why this develops in some (but not all) patients is being investigated.

That may help other (future) patients but doesn’t help your sister right now. Her surgeon is the best one to answer the question of “what now”. Treatment may depend on several factors including her age, the extent of damage, and clinical presentation (her signs and symptoms, especially level of pain and loss of function).