News Category: Shoulder

The year is 1945. Harry S. Truman is sworn in as the United States’ 33rd president. World War II is coming to an end with the defeat of Germany and Japan. The Alaskan Highway is now open, and Joe DiMaggio is getting out of the Army and joining the New York Yankees.

Many people know about these events, even young adults who weren’t born until much later. But there’s one thing you probably don’t know about 1945. Dr. J. S. Neviaser came up with the term adhesive capsulitis to describe a painful shoulder condition.

In the normal shoulder, a thick joint capsule wraps around the head of the humerus (upper arm). With adhesive capsulitis, the capsule tightens up. Synovial fluid in the joint dries up, and the joint becomes inflamed. It’s a well-known diagnosis today, and a common shoulder problem in the general adult population.

Even after more than 50 years, there isn’t a single best treatment for the problem. Doctors at the Hospital for Special Surgery (Cornell University) in New York report on the results of one treatment. It’s called capsular
distention.

In this procedure, a liquid salt solution called saline is squirted into the shoulder joint capsule. The saline stretches the capsule to the breaking point. When no further resistance is felt, the capsule is ruptured. A video X-ray called fluoroscopy helps guide the doctor. A dye injected into the joint shows leakage outside the capsule as another sign of rupture.

The authors say this method works best for adhesive capsulitis at a certain stage. It improves range of motion and decreases pain for patients with moderate to severe pain and loss of motion (stage II). They suggest using capsular distention in stage II adhesive capsulitis for the best results.

In days past, shoulder surgery was always followed with the use of a soft sling or hard brace. The sling or brace kept the joint from moving during the healing. Having some scar tissue helped hold the joint stable.

With the new methods of surgery using arthroscopy, long periods of immobilization with a sling are no longer needed. Arthroscopy allows the doctor to insert a slender instrument right into the joint. This gives the doctor a view inside and makes it possible to repair the problem without opening up the entire joint.

One exception remains: the Bankart repair. This operation is used to repair a torn labrum. The labrum is the rim of cartilage that surrounds and deepens the shoulder socket. The repair can now be done with an arthroscope, but the sling is still used for days to weeks (depending on the doctor).

This study compared two groups of patients after the Bankart repair. One group had the regular rehab program with sling immobilization. The second group had an accelerated (faster) program. Group two only used the sling to sleep at night. They started moving the shoulder and exercising right from day one after the operation.

The researchers found no difference in the long-term results between these two groups. In other words, two years after the operation, everyone had the same amount of motion, strength, and function. What they did find was a big difference in the short-term results.

Right away, the group without the sling who had early movement had less pain. They also regained motion and strength much faster. Patients in the accelerated rehab were happier with the program than patients in regular rehab.

Some doctors continue to use a sling with patients after the Bankart repair. It has long been thought that the shoulder is less stable and to be held immobile for a longer time after a Bankart. The authors of this study think early movement is safe after a Bankart repair for a small tear of the labrum.

Two doctors from the United States Center for Sports Medicine in St. Louis, Missouri, offer these thoughts on repairing the rotator cuff tendons of the shoulder:

Over 50 doctors from nine countries put their patients together for a multicenter study. The topic was shoulder replacement surgery in patients who had previously dislocated the shoulder.

All patients had a condition known as dislocation arthropathy. (Arthropathy is any disease or problem in a joint.) After shoulder dislocation, patients often end up with a weak, unstable joint. Arthritic changes can also develop. Pain, loss of motion, and decreased function send patients to the doctor. Repairing torn muscles and replacing part or all of the joint is often the advised treatment.

The authors of this study looked at the results of shoulder replacement in patients who had an anterior (forward) dislocation. About half the group already had some kind of operation to repair the problem. Age was important to the outcomes. Patients who dislocated their shoulder before age 40 had a better result after shoulder replacement than patients who are over 40 at the time of the injury. The authors also noted that patients who had a shoulder replacement because of osteoarthritis (with no prior dislocations) had better results than those with a dislocation.

The authors conclude that patients with shoulder dislocation get good results with a shoulder replacement. They give one caution. Patients with prior dislocation often have a high number of reoperations and problems after shoulder replacement. No reason was given for this finding.

Physical therapists often treat injured athletes so they can get back on the playing field. Therapists know that training a single muscle in one arm or leg isn’t enough. Muscles on both sides of a joint are often affected by an injury to one side of the joint.

This was shown clearly in a recent study of overhand athletes. These players are involved in racquet sports, volleyball, swimming, and field events. Shoulder pain from impingement is common. Impingement in the shoulder means “pinching” of some structure inside or outside of the shoulder joint.

It’s well known that the scapula (shoulder blade) plays an important part in normal shoulder motion. When the shoulder is injured, movement of the scapula changes. What researchers don’t know is which comes first: muscle imbalance or impingement?

This study measured speed and timing of muscles around the scapula. Two groups were tested: one group with shoulder impingement, and one without. The researchers found the biggest differences occur in the timing of shoulder muscle activity. They were surprised to find delays in muscle activity of both the injured and uninjured shoulders in the patient group.

The researchers conclude that treatment of sports injuries must correct the timing and coordination of muscle activity around the shoulder. This must be done on both sides. For now it looks like muscle imbalance occurs first, and then impingement.

Arthroscopy has changed many joint operations from being “open” (with a large incision) to “closed” (with only one or two tiny puncture holes). The arthroscope is a tool used in closed surgeries. It allows the doctor to look inside a joint and even do repairs without ever opening the joint.

Using an arthroscope to repair a torn rotator cuff in the shoulder is still fairly new. Studies comparing rotator cuff repairs with or without arthroscopy are
underway. Some doctors think arthroscopic repair can’t be done with good results. Others suggest just cleaning up the area of injury, without repairing the tear.

This study looked at 50 patients with large tears. All were repaired with an arthroscope. Several doctors recently joined together to look at the results of arthroscopic repair of large rotator cuff tears. Success was measured using pain, function, range of motion, strength, and patient satisfaction. Patient responses were given number ratings. The results were tallied to get an excellent, good, fair, or poor result.

Most patients in this study had a good or excellent outcome. The results are similar to other studies of small- to medium-sized tears. Patients were followed for at least a year and sometimes as long as five years. The results are important because there’s so much debate over the best treatment of large tears.

The authors conclude that a perfect repair of a large rotator cuff tear isn’t needed for an excellent result. Arthroscopy can be used to restore normal mechanics of the shoulder even in large tears. They think that most tears of any size can be repaired this way.

You’ve heard of a snapping turtle, but what about a snapping scapula? The scapula is your shoulder blade. Normally, this bone glides smoothly across the chest wall. But fractures, tumors, trauma, and muscle weakness can put an end to this smooth motion. Painful snapping that is both felt and heard can be the result. This snapping is called crepitus. It is not always clear what causes snapping scapula.

Snapping scapula is treated with steroid injections or exercise. But some patients have surgery to shave bone from the underside of the scapula. The idea is to make the surface smooth so it doesn’t bump along during shoulder movement. Only one corner of the scapula is thinned this way. Doctors use an arthroscope to do the operation. An arthroscope is a tiny fiber-optic TV camera that is inserted into the space between the scapula and the chest wall. It alows the doctor to see and work on the problem area. In this study, doctors tried a very new way to insert the arthroscope. The opening avoids nerves and blood vessels while still giving doctors a good view inside.

The authors report zero technical problems with this new method. No damage occurred to the nerves or blood vessels. All patients got pain relief, and all but one went back to work. The crepitus was better, although only two of the 10 patients had complete relief from the snapping.

Police talk about cases as being open and closed. It means the case was solved quickly. When orthopedic surgeons talk about open and closed, it means something entirely different.

Arthroscopy has changed many operations from being open (meaning that surgery involves a large incision) to closed (meaning that surgery involves only one or two tiny puncture holes). The arthroscope is a tool that allows the doctor to look inside a joint and even do repairs without ever opening the joint.

Using an arthroscope is still a fairly new operation for a torn rotator cuff in the shoulder. Studies comparing rotator cuff repairs with or without arthroscopy are underway. This study looked at 50 patients with large tears. All were repaired using an arthroscope.

These doctors from Georgia and Mississippi joined together to look at the results of arthroscopic repair of large rotator cuff tears. Success was measured using pain, function, range of motion, strength, and patient satisfaction. Patient responses were given number ratings. The results were ranked as excellent, good, fair, or poor. Most patients in this study had a good or excellent outcome. The results are similar to other studies of small- to medium-sized tears. Patients were followed for at least a year and sometimes as long as five years.

The results are important because there’s so much debate over the treatment of large tears. Some doctors think arthroscopic repair can’t be done with good results. Others suggest cleaning up the area of injury but not repairing the tear.

The authors conclude that a perfect repair of a large rotator cuff tear isn’t needed for an excellent result. Arthroscopy can be used to restore normal mechanics of the shoulder even in large tears. They think that most tears of any size can be repaired this way.

Sheep have an important role in the operating room. It’s from animal studies that doctors first learn what works and what doesn’t. Often these studies are done in sheep. In a Turkish laboratory researchers are testing sheep tendons to find the best way to repair torn tendons.

Finding the best repair method is important. It needs to hold while giving the shoulder strength. Even a short period of inactivity can cause the shoulder to quickly become weak and stiff. That means that surgical repair of a torn rotator cuff must be strong enough to allow early shoulder motion.

This study reviews the results of four different methods to repair the shoulder rotator cuff. Four tendons make up the rotator cuff. One attaches the infraspinatus muscle to the shoulder. Studies are underway to improve the way this tendon is repaired.

The four repair techniques use different kinds of sutures or stitches to reattach the torn tendon to the bone. Sometimes there is only one suture. It’s threaded through a tunnel in the bone and anchored on the other side. There may be double sutures and double tunnels. The suture can also be tied in one of several ways. Various combinations were tried in this study.

The authors summarize for doctors which suture material, knot, and method give the best strength. Technical studies like this help doctors know which methods work best and which ones have the least problems.

Treating fractures of the upper arm can be difficult, especially in older adults. Replacing the ball on top of the shoulder is one treatment option. This procedure is called hemiarthroplasty.

Patients get good pain relief with this method, but they may not get the full use of their arm back. Finding ways to tell who will have a good result will help doctors make treatment decisions. This study from Scotland measured the overall survival rate of the replacement part. The authors came up with two models to predict results by looking at all the factors affecting implant success.

One model looks at early results (up to six weeks after injury). The second model looks at results for weeks seven through 12. In both models, age is the most important factor. Older patients (older than 70 years) have the poorest outcome.

Other factors in the early period have to do with the patient. These include tobacco and alcohol use and if there is nerve injury. Surgery-related factors are more telling in the long-term results. In both groups, factors to consider include the patient’s level of motivation, the effect of physical therapy, and whether there are other injuries in the shoulder. A longer study with more patients is needed to look at these variables.

The authors think there are ways to tell who would be right for a hemiarthroplasty operation after severe shoulder fracture. Younger, motivated patients in good health and with good mental ability have the best results.

Extracorporeal shock wave therapy (ESWT) has been used for kidney stones, heel pain, and other ailments. It has recently been used for calcific tendonitis of the shoulder. In this condition, calcium deposits form within the shoulder. No one knows exactly why the calcium deposits form, but they can cause pain and limit movement in the shoulder. No one knows exactly why ESWT seems to work, either. The theory is that it breaks up the calcium deposits and promotes healing in the tendons.

These doctors in Taiwan had already done research showing that ESWT was an effective treatment for calcific tendonitis of the shoulder. In this study, they compared ESWT to transcutaneous electric nerve stimulation (TENS), a treatment used for pain.

Patients with calcific tendonitis of the shoulder were divided into two groups. One group had two ESWT sessions, two weeks apart. The other group had TENS treatments three times a week for four weeks. Shoulder pain and function were rated before treatment and again at two, four, and 12 weeks. Special imaging tests were also done to measure the calcium deposits.

Both groups got better with treatment. However, the ESWT group had better shoulder range of motion and less pain, and their results held up better at 12 weeks. The calcium deposits in the ESWT group also shrank more. The authors found that ESWT was especially helpful in breaking up calcium deposits that form in the shape of an arc.

The authors conclude that ESWT is a much better treatment than TENS for calcific tendonitis of the shoulder. They feel that ESWT is also more effective than other treatments, including steroid injections, ultrasound, and surgery.

Every muscle in the body has a specific job. The deltoid muscle of the shoulder has two jobs. It’s a mover and a stabilizer. It lifts the arm up, and it helps press the end of the upper arm bone (the humeral head) into the shoulder socket.

The deltoid muscle is triangular, with a wide top and a narrow bottom. It has three parts: anterior, middle, and posterior. The deltoid is an anterior stabilizer, which means it keeps the shoulder from dislocating forwards. One of the times this is important is when the arm is in an extreme pitching position for baseball.

Many studies have been done to look at the “mover” function of the deltoid. This is the first to report on the role of the deltoid as a stabilizing muscle. A three-dimensional tracking device was used to monitor the muscle. The effects of location and load on stability were measured.

All shoulders were tested with the arm in the cocked position, as if ready to pitch a ball. In this position, the arm is away from the body, the shoulder is outwardly rotated, and the elbow is bent in a 90-degree angle. In all the tests, there were no differences in work load among the three parts of the deltoid. Each part worked equally to stabilize the shoulder in this position.

The authors conclude that the deltoid muscle should be strengthened in any shoulder rehab program for anterior instability. Exercises for the deltoid muscle may be just as important as a program for other shoulder muscles, such as the rotator cuff and biceps.

Calcific tendonitis of the shoulder is not well understood. In this condition, calcium deposits form on the tendons around the shoulder. They can cause pain and loss of function. Treatments range from anti-inflammatory drugs to surgery, but there is no clear best treatment.

Shock wave therapy is a fairly new treatment for calcific tendonitis. It involves sending shock waves into the body. It has shown promise in treating other conditions. These doctors in Taiwan tested how well shock wave therapy worked for calcific tendonitis of the shoulder.

Shock wave therapy was done on 39 shoulders with calcific tendonitis. All patients got local anesthesia before treatment. About two-thirds of the patients felt discomfort at the site. Most patients got only one treatment, but some had two or three treatments. Follow-up was done over two to three years. The results were compared to a group of six patients who knew they were getting phony treatments. Their follow-up only lasted about six months because they went on to get other treatments.

Results looked good in the group who got shock wave therapy. About 62 percent had good or excellent outcomes six months after treatment. Better yet, about 91 percent had good or excellent outcomes two years after treatment. In almost 60 percent of the patients, X-rays showed that the calcium deposits had completely disappeared. In some patients this happened as early as two weeks after shock wave therapy. No calcium deposits came back after two years.

No one knows exactly why shock wave therapy works. These authors think it works by improving blood flow and tissue regrowth in the injured area. They recommend shock wave therapy as a safe and effective way to treat calcific tendonitis of the shoulder.

Shoulder injuries affect more than just the shoulder joint. The scapula (shoulder blade) is often involved, too. In fact, changes in the position and function of the scapula occur in 68 to 100 percent of all shoulder injuries.

This report gives information about the scapula to help guide treatment. Normal scapular function is reviewed in detail. There are many factors that can change scapular motion. When the shoulder blade moves or is positioned abnormally, the problem is called scapular dyskinesis.

The authors point out how posture, injury, and muscle weakness can cause scapular dyskinesis. Muscle tightness and muscle incoordination can make the problem worse. The effects of dyskinesis are also reviewed. For example, a baseball pitcher can’t throw properly without full and normal scapular motion.

Ways to test and measure the scapula are presented along with motions that can be done to correct the problem. The legs, hips, and trunk must also be checked for possible problems that can contribute to scapular dyskinesis. Changes in total body posture can have a direct effect on scapular motion.

Finally, treatment by a physical therapist to reduce symptoms and restore normal movement patterns is discussed. The authors conclude that scapular retraining must be part of any shoulder rehabilitation.

Subacromial impingement syndrome is a common disorder of the shoulder. In this condition, the acromion (the tip of the shoulder blade) pinches the soft tissues underneath it. Arthroscopic surgery is often done to remove the end of the acromion and release the pressure that is causing the pain. This procedure is called arthroscopic acromioplasty.

This surgery is widely used with good success. It is often done in patients whose impingement was caused by their work and who are getting Worker’s Compensation benefits. Some studies have shown that Workers’ Compensation patients are less likely to have good results or return to work after surgery than patients who don’t get Workers’ Compensation. These authors looked at patients who had the surgery to see if there was any difference in outcomes between the two groups.

The author looked at patients who had the same surgery done by the same doctor. The patients also had similar rehabilitation programs. The Worker’s Compensation group and the other patients were compared for pain levels and function (both before and after surgery), time taken to return to work, and physical demands of their jobs.

The results showed that both groups had successful outcomes from the surgery. The only significant difference was that the Workers’ Compensation group took an average of more than four weeks longer to get back to work. However, most of the Workers’ Compensation group had higher physical demands at their jobs. The author determined that the higher physical demands accounted for the longer times in returning to work.

The author concludes that arthroscopic acromioplasty generally has a good outcome. His study suggests that there shouldn’t be a great deal of concern about doing the surgery for Worker’s Compensation patients. He also notes that this research could help guide doctors in establishing realistic time frames about when patients can return to work.

Rotator cuff tears are common shoulder injuries. But they are difficult for researchers to study and can be hard to diagnose. Doctors use many different tools, including MRIs and arthroscopy, to view them. And rotator cuff tears can cause a wide range of symptoms among different patients.

These authors did this study to test just how unpredictable rotator cuff tears can be when doing research. They compared the patients of 10 different surgeons. The patients answered questions about other medical problems, whether they got disability or Workers’ Compensation benefits, general health, and shoulder function.

What the authors found is that all 10 surgeons had patients that looked very different on paper. The surgeons had different percentages of men and women, a wide variation in the cause of the tear, different ways of diagnosing the tear, and patients who had tried different treatments before surgery for a wide range of time.

The authors caution that all these varying factors mean that researchers need to be careful when doing research on rotator cuff tears. Using data from just one doctor might not give an accurate picture of all patients with rotator cuff tears. And when studying patients from many clinics, researchers need to control for all the variables.

Before having surgery, patients are told what can go wrong during or after the operation. The most common complication after shoulder joint replacement (arthroplasty) is shoulder instability. Instability means that the joint is unsteady and could even dislocate.

Knowing what causes this problem may help doctors prevent it. Shoulder instability may not have a single cause, as these researchers determined. They studied patients at the Mayo Clinic, each of whom had a second surgery to repair a failed shoulder arthroplasty.

After recording what they found wrong during the second operation and how they fixed it, the authors came to some conclusions. One-third of all patients had an accident or injury that appeared to cause a soft-tissue imbalance. Either a muscle had torn or the joint capsule was too loose or too tight.

Poor positioning of the joint implant is another common cause of failure. Sometimes, the wrong size implant is used. In other patients, too much bone is removed when putting the implant in place. Bone loss is directly linked to shoulder instability.

Some of the bad news can get worse. The second surgery for a failed shoulder replacement often fails, too. Researchers at the Mayo Clinic say that every effort must be made to prevent instability in the first operation.

Studying failed shoulder replacements is important in finding ways to prevent this from happening in other patients. For example, if too much bone is removed, a bone graft may be needed. The authors advise looking for more than one cause during the operation. Each problem that is encountered can then be repaired at the time of the first arthroplasty.

Between 1975 and 2000, a total of 2,568 patients had a shoulder joint replacement (arthroplasty) at the Mayo Clinic in Rochester, Minnesota. In those 25 years, only 13 of those patients had a diagnosis of arthritis from infection, a problem that is much more common in the hip and knee.

Most patients with shoulder infection are treated with antibiotics first. Sometimes, surgery to make the joint smooth is needed. When these treatment options fail, a total joint replacement may be the next step.

There’s some concern that re-infection will occur in the new joint. Although this study was small, it showed that shoulder arthroplasty can be done after infection. There’s only a small chance of re-infection afterwards. The authors also report that a full rehabilitation program gives better results than a limited program.

Even though the risk of re-infection is low, there are still some possible problems. Damage to the joint from the first infection may leave the patient with bone loss and muscle weakness. Surgical complications such as nerve damage, bleeding, and loosening of the implant are common.

The authors of this study suggest other doctors take several important steps before replacing a shoulder joint after infection. Proper patient selection is the key to success. First, doctors are encouraged to use lab tests to make sure there is no sign of infection in the shoulder. And they should consider using imaging tests to study the condition of the bone and the shape of the joint.

If a stable implant isn’t possible, then other forms of treatment are advised. Overall, patients receiving a shoulder arthroplasty after infection don’t have the same good results as patients without infection.

If given the chance, would you have the same surgery again? Doctors find this a useful measure of success. Dr. Bennett of Sarasota, Florida, asked 37 patients this question after shoulder surgery.

Each patient had a massive tear of the rotator cuff. The rotator cuff is a group of four muscles and their tendons that surround the shoulder. The repair was done by arthroscopic surgery. The doctor used a special tool to enter the shoulder joint without a large incision. A tiny TV camera at the end of the arthroscope allows the doctor to see inside the joint and make repairs.

All but two patients were happy with the results of their surgery. They said that they would do it again to get pain relief and increased motion. Dr. Bennett reports that newer repair methods make it possible to repair massive tears. In the past, some of these damaged tendons couldn’t be saved.

The arthroscope makes it possible for the doctor to find the torn tendon and slide it back in place. Sometimes there isn’t enough tissue to reattach it to the bone in the right place. New ways to reconstruct and reshape the rotator cuff make it possible to restore function in such cases.

For example, when repairing a large tear, the surgeon uses as many side-to-side stitches as possible. This is called margin convergence. With margin convergence, less tissue is needed to reattach the tendon to the bone.

Not all rotator cuff tears can be repaired. However, the arthroscope gives the doctor many more options to try. Most patients are happy with the results and would have the surgery again.

Fifteen years ago, doctors used a large incision to open the shoulder and repair a torn tendon or muscle. Now they can use an arthroscope to look inside the joint and make repairs without opening the joint.

An arthroscope is both a surgical tool and a tiny TV camera. Doctors like the arthroscope because it allows them to see the joint without a big incision. Patients report they have less pain and a quicker return to normal. Some studies show patients use fewer drugs for pain after all-arthroscopic surgery.

Many studies show good results with arthroscopic surgery for the shoulder. Doctors have gone from using an open incision to arthroscopic-assisted operations and, now, all-arthroscopic repair. This study looked at the result of shoulder tendon repair using the arthroscope alone versus a mini-open operation with the arthroscope to help.

The results of this study show that return of shoulder motion was much faster for the all-arthroscopic group. The doctors think this is the result of less pain, less muscle spasm, and easier rehabilitation. Patients in the arthroscopic-assisted group were more likely to have a condition called fibrous ankylosis. In such cases, the shoulder doesn’t get the full motion back.

The authors report that an all-arthroscopic operation takes extra training and a higher skill level on the part of the surgeon. When a doctor has this training, the all-arthroscopic method is a better choice. Patients get full motion with less pain and faster recovery.