News Category: Shoulder

If you’ve hurt your shoulder and you’re seeing a physical therapist, expect to get down–on your hands and knees. Putting weight through the shoulder is a common way to do exercises when rehabilitating shoulder injuries.

Physical therapists plan rehab programs for each patient. They make sure the exercises target the right muscles. Studies like this one help therapists make these decisions. It’s important to know which muscles are working in each position. Therapists also need to know when and in what order to do each exercise.

Therapists at the University of Kentucky tested 18 healthy adults in seven different weight-bearing positions. These exercises where the hands are placed on a stable surface are called closed kinetic chain (CKC) exercises. They improve joint position sense and strength. During CKC activities, muscles on both sides of the joint work at the same time.

The authors found that of all the positions used, being on hands and knees is the easiest for the shoulder. It’s probably the best exercise form to start with. The “prayer position” (sitting back on the heels with hands on the floor) is the next step. Raising one arm or one leg while on hands and knees puts more force on the muscles. The one-arm push-up is an example of how challenging these exercises can get.

Therapists still don’t know the best time to start CKC exercises. Studies that test normal muscles are helping answer this question. Other studies are needed to compare damaged tissue to normal in these same seven positions. Measuring muscle activity while the tissues are in various stages of healing may be a part of future studies.

This study shows the demand on shoulder muscles for weight-bearing exercises used in shoulder rehab. The information can help physical therapists know what muscles are working and how strongly these muscles contract with each exercise. This will guide clinicians in finding the best programs for each shoulder patient.

Surgical treatment for shoulder injuries improves every year. Doctors are looking for new ways to help patients with long-term shoulder pain. In this study, a special type of shoulder joint replacement was used for rotator cuff tears.

The rotator cuff is a group of four muscles and tendons that circle the shoulder. Treatment for a rotator cuff tear depends on the severity of the injury and may include physical therapy, cortisone injections, and several types of operations.

Rotator cuff tears may be partial or complete. Surgery is often needed when a complete or full tear of the rotator cuff occurs. If left untreated, the patient can end up with severe pain, loss of motion, and trouble doing daily activities. In severe cases, surgery may include a shoulder joint replacement called arthroplasty.

To put in a new joint, the surgeon takes off the end of the upper arm bone and replaces it with round ball on a stem. The stem is implanted into the arm bone. The ball fits into the shoulder socket. The old, damaged socket is removed and replaced with a plastic or titanium cup. When only one of these two parts is removed and replaced, it’s called hemiarthroplasty.

This group of doctors tried a new method to treat problems from a full tear of the rotator cuff. They used a bipolar implant, which has a stem with a ball on the end that swivels. Bipolar implants have been used before for arthritis and fractures. Only two other studies have reported on its use with massive rotator cuff tears.

With this new type of implant, all of the patients were able to have pain-free sleep. Most patients also had pain-free use of their arm and rated their results as “excellent.” The authors of this study believe that the bipolar method is a good option when treating this problem. Pain relief is more reliable than with standard hemiarthroplasty.

Shoulder joint replacement surgery is the answer for many adults with painful arthritis. This operation to replace the ball and socket is called total shoulder arthroplasty (TSA). Sometimes only half of the joint needs to be replaced. This is called a hemiarthroplasty. Many studies show that shoulder joint replacement can help relieve pain and improve function.

Doctors at The Cleveland Clinic Foundation agree with these findings. They also looked at four factors that might affect the success of the operation. First, does a tear of a muscle or tendon around the joint mean problems later on? Second, how does bone thinning affect the joint implant? Third, does a loss of shoulder joint motion before surgery make any difference afterwards? Finally, if the joint moves out of the socket, will this affect the TSA?

On the basis of 128 shoulder TSAs, the authors made some comments. Loss of motion before replacement surgery is only a risk factor if the person can’t rotate the arm out very far (external rotation). Motion is better after TSA when moderate to severe bone thinning and damage is present before the operation. This is because smoothing the joint surfaces makes it easier for the joint to move.

Tears to the muscles or tendons around the joint (called the rotator cuff) don’t seem to make a difference. The implant works just as well whether the tear is repaired or left alone. However, a shoulder joint that moves out of place before the surgery is more likely to be unstable afterwards.

The authors note that when any of these factors is present, a total joint implant is needed. Simply replacing half the joint (hemiarthroplasty) may not be enough.

Many people have shoulder pain. Most have a hidden problem with the scapula (shoulder blade), but don’t know it.

The scapula is a very important part of the shoulder. The scapula gives the upper arm (humerus) a socket for the ball of the shoulder joint to fit into. The scapula and humerus move together smoothly. The muscles around the scapula pivot, protect, position, and propel (move) the arm.

When a pitcher throws a ball the muscles of the scapula give the arm holding and throwing power. During swimming, the scapula helps position the upper arm, allowing the swimmer to lift the arm out of the water.

Normally, the scapula moves out of the way of the muscles and tendons in the shoulder. This keeps these tissues from getting pinched, a condition called shoulder impingement.

Conditions that cause abnormal scapular movement can lead to shoulder impingement. Poor posture, such as a stooped position of the head and neck is one cause. Another comes from weak stomach muscles and a swayback position of the spine. Torn shoulder tendons can also change the way the scapula moves and functions.

Anytime the scapula gets out of sync with the shoulder, problems are likely to occur. These can and must be treated in order to restore normal shoulder motion. Exercises to improve motion, flexibility, strength, and coordination are included in a scapular rehab program. The goal is to fix the problem by regaining normal function, not just by reducing painful symptoms.

Some types of surgery are not helpful for all types of patients. This is especially true for a new type of shoulder surgery called laser capsulorrhaphy. A laser is used to heat up and shrink loose tissues around the shoulder joint. The result can be a steady and stable shoulder joint. But which patients do best with this type of surgery?

It may depend somewhat on what caused the shoulder to become loose in the first place. Joint laxity occurs in three groups of patients. The first group is born with general laxity in all the joints. This kind of laxity is congenital laxity. The second group has a history of repeated damage from overuse. This is called acquired laxity. The last group can think of a specific event that caused the damage. This is called posttraumatic laxity.

Doctors at the Cleveland Clinic Foundation studied patient reports of success after this type of shoulder surgery. Twenty-five patients with loose shoulder joints had the laser treatment.

The doctors found that laser treatment for unstable shoulders works well for some, but not all patients. By their own report, patients with acquired laxity have the best results. Those with laxity from birth that affects all the joints have less chance of success with this form of treatment. The authors don’t advise a second laser treatment when laser capsulorrhaphy doesn’t work the first time.

Shoulder arthritis is usually caused by osteoarthritis (OA). OA can happen after an injury or a fracture, or from the changes of aging. With OA, there is a gradual wearing away of the joint. Rheumatoid arthritis (RA) is different. RA is the most common form of inflammatory arthritis. It can affect many parts of the body, including the joints. Patients with RA of the shoulder may need very complex medical care.

This article gives an overview of the treatment of shoulder RA. The goal in treating RA of the shoulder is to stop pain, improve motion, and increase function. Getting there may take a series of steps, from drugs to physical therapy to surgery. Patients may need several kinds of doctors and therapists. Besides the regular (primary care) doctor, the patient may need to see an orthopedic surgeon, a rheumatologist, and physical and occupational therapists.

RA of the shoulder often comes on slowly and gets worse over time. Pain, swelling, and loss of motion occur as the joint and nearby soft tissues are affected. Pain may be mild at first with only small losses of motion. As the symptoms get worse, the patient loses function. It becomes hard to reach items on high shelves or a wallet in the back pocket. Over time, severe pain keeps patients from carrying out many daily tasks.

Doctors use X-rays, MRIs, and CT scans to see the amount and type of RA damage in the shoulder. Doctors base their treatment decisions on this information and the results of their exam. The first treatment steps are anti-inflammatory drugs and physical therapy. Surgery may be needed if drugs and physical therapy no longer control the pain. Loss of motion and function may also point to the need for surgery.

This author notes that many factors should be considered before doing shoulder surgery for RA. For example, the timing of the operation and the type of surgery depend on how much bone has been lost. If the shoulder joint is being replaced, the bone has to be strong enough to hold the artificial joint. Some joint implants can’t be used in younger, more active patients.

Doctors agree that the most disabling problem should be taken care of first. Giving the patient as much function as possible is the goal. However, some doctors say that problems in the hand or wrist are more important than problems in the elbow or shoulder. Other doctors suggest that elbow motion is the key for patients to use both the hand and the shoulder. Sometimes, more than one operation is needed.

Clearly, treatment of RA of the shoulder is no simple task. Most patients, however, can find relief with some combination of conservative treatments, physical therapy, and surgery. The author encourages a team approach to tackle the problem.

When the shoulder dislocates over and over, surgery is usually needed. Doctors have used the Bankart repair for years to treat this type of injury. In this operation, the shoulder is opened up and the damage is repaired.

Now newer technology is challenging this older method. Doctors are doing the Bankart repair with an arthroscope. This means the surgery can be done without cutting the shoulder joint open. A slender device with a tiny TV camera on the end is inserted into the joint. This allows the doctor to view inside the joint on a TV screen. This is called a “closed repair.”

There are a few changes in the way the operation is done. The results of an open Bankart repair are similar to a closed repair. In this study, this was true for almost everyone regardless of age, sex, or number of times the shoulder had dislocated. Patients younger than 20 years seemed to do better with the open Bankart repair.

Studies to compare open to closed operations for shoulder injury from dislocation are increasing. The Bankart repair can be done using an arthroscope when there aren’t any bone fractures or torn capsular tissue in the joint. More studies to compare other factors between these two methods are underway.

The National Football League (NFL) keeps records on players’ injuries. This information can be used to help analyze injury patterns. Future trends in training, playing, and equipment may come from the results of this information.

For example, a survey was sent to 28 NFL team doctors. The doctors were asked how many complete tears of the shoulder rotator cuff were treated. Results of treatment were compared with the different methods of treatment.

Offensive linemen and linebackers had the most rotator cuff tears. Most of the time, it was caused by a fall onto the shoulder. Only a small number of players had to end their career because of this injury. More than 90 percent kept right on playing through the season. Surgery to repair the injury was usually delayed until after the season. A small number of players were able to return to the field without surgery.

Players who had surgery usually returned to the game within four or five months. This compares to at least 12 months in the nonathletic adult. Patients on worker’s compensation often never return to work. Team doctors did report that the football players who returned to play were not totally without symptoms.

Doctors are reporting a new shoulder problem in elite golfers. These are competitive golfers at the amateur, collegiate, or professional level. These golfers swing 2,000 times or more each week, and they golf with a handicap of five or less.

In technical terms, the problem involves shoulder impingement and posterior instability. Impingement is a pinching of tendons or soft tissue between two bones of the shoulder. This occurs during movement. Overuse can lead to a loss of soft tissue form and strength around the joint. This results in an unstable joint.

The golfer may begin to notice problems in the “lead” arm during the back swing. This occurs either at the beginning of a swing or at the top of the back swing. The lead arm is the one that first crosses the body during the forward swing. For a right-handed golfer, this is the left arm.

Pain and a “pop” or “clunk” are the most common symptoms of these two problems. The pain is caused by stress on the lead shoulder as it moves into a position that loads the shoulder joint. Over time and with overuse, the fibrous tissue around the joint (called the joint capsule) can get stretched out or torn. The back of the shoulder (posterior) becomes unstable at the top of the back swing.

This can cause the head of the humerus (the top of the long upper arm bone) to slip out of the shoulder socket. The golfer then hears and feels a pop or clunk when the head slips back into the socket.

Treatment is most successful when both problems are identified and treated. Now that doctors are aware of these conditions, studies will be done to find out what treatment is best. For now, a rehab program of strengthening the muscles is advised before surgery. Surgery is done to take pressure off the pinched tissues. If the capsule is torn, it can be repaired and tightened up.

Shoulder joint replacements come in several types. Some are cemented in place, while others aren’t. Sometimes the complete joint is replaced, while in other cases only half of the joint must be replaced.

Most of the time, the cause of the problem is osteoarthritis of the joint. The head of the humerus (upper arm bone) develops bone spurs and the joint space gets smaller. This usually results in pain, stiffness, and loss of motion. In some cases, the rotator cuff is torn. The rotator cuff is a group of four muscles whose tendons surround the shoulder joint. The tear can be small (partial tear) or large (complete tear).

Over 500 cases of shoulder joint replacement were followed by a group of 57 doctors in nine countries. The focus of the study was to see if tears in the rotator cuff needed to be repaired at the time of the joint replacement.

It seems that small tears of a single tendon don’t affect the outcome. A much greater problem is fatty degeneration in the shoulder muscles. This is a condition in which the muscle fibers are replaced by fat tissue. The reason for this is unknown. It’s likely that age has something to do with it. Fatty degeneration is more likely to occur in muscles that have been damaged or injured.

The presence of fatty degeneration in the rotator cuff means greater pain, less motion, and less strength after shoulder replacement. Still, even with fatty degeneration, the results are better with shoulder joint replacement than without.

Shoulder dislocations in adults are fairly common. At the Mount Sinai Hospital in New York, the emergency room treated 42 cases in six months. Putting the head of the humerus (upper arm bone) back in the socket isn’t usually hard to do. There are many ways to do it. This treatment is called shoulder reduction.

One of the most common ways to treat shoulder dislocation is to use intravenous anesthesia. This puts the patient to sleep and relaxes the muscles. The doctor can then manually release the shoulder. This method is safe, but it requires staff to monitor the patient for up to three hours after the procedure.

In the early 1990s, a group of doctors injected lidocaine into the shoulder joint. Lidocaine is a form of local numbing medicine. The patient is then placed face down on a table with a 10-pound weight attached to the hand. The weight applies a traction force to the shoulder and brings it back into the joint.

Doctors at the hospital compared the two methods of shoulder reduction. One group of patients received the injection and traction. The second group had the more traditional manual reduction with an intravenous anesthetic.

The doctors found that there was equal success reducing the shoulders with either method. The actual treatment took about the same amount of time, and the patients had the same amount of pain and discomfort. There were two ways in which the shoulder injection method was better. The first was cost. The injection costs about 50 cents, compared to almost 100 dollars for the intravenous sedation. The second was time. Patients who received the shoulder injection didn’t need to be watched closely after the procedure. They could leave the hospital sooner after arriving than the sedated group. The sedation method also took the time of hospital staff. Nurses and other staff were needed to monitor the patients who had been sedated. All in all, the lidocaine method required less manpower, money, and time.

More and more people are getting involved in athletics. This means more injuries. The rotator cuff of the shoulder is a common area of sports injury. Activities that require raising the arms and throwing overhead are often the source of shoulder problems. Sports such as swimming and golf also place the athlete at risk of injury.

The subscapularis muscle is an important shoulder muscle. It is a large muscle along the inside (front) of the scapula (shoulder blade). It’s very active during overhead motions. Scientists used to think it worked as a single muscle. Now they know it has two parts: the upper and lower subscapularis.

The two portions of the subscapularis may have separate functions. Recent research shows that the upper part of the muscle is more important during throwing. The upper portion is also more active when the arm is held away from the body. The lower portion works the most when the arm is held at the side and the forearm is brought across the body.

Finding out the specific actions of each muscle is important. This information can be used to plan rehab programs for shoulder injuries. Any exercise program for the subscapularis should probably train this muscle as two separate units. This study showed that moving the arm diagonally “down and across” the body works both parts of the muscle. A special form of push up also worked both muscles.

Many studies now show that exercise must meet the needs of each individual. This applies to the injured athlete and the athlete in training. Matching each person’s needs with his or her goals is the key to success. Knowing how each muscle works is the first step in planning these programs.

In the 1970s, doctors found a way to surgically relieve shoulder pain caused by impingement. Impingement means something is getting pinched. In the shoulder, impingement usually involves a tendon or bursa that is getting pinched between the shoulder bones. The bursa is a fluid-filled sac that reduces friction between the tendon and the bone.

Impingement surgery involves opening the joint and removing part of the bone, ligament, or bursa. This is called surgical decompression. The result is pain relief and increased shoulder motion and function.

In the 1980s, doctors improved on this operation. Using a new tool called an arthroscope, doctors could perform this same operation without cutting open the shoulder. Now, doctors are trying to further improve results.

They want to know which one of the structures involved is the main problem. Is it thickening of the bone, the ligament, the bursa, or all three? How much bone should be cut away? Doctors decide this at the time of the operation. The decision is based on experience and judgment.

Doctors in France studied 41 shoulders using X-rays and imaging before and after the surgery. They found that the success of the operation doesn’t always depend on how much of the bone is cut away. Results of the decompression likely depends on several factors.

The next step is to see if the good results come from simply removing the bursa. A new study by these researchers is already underway.

Thermal capsulorraphy uses heat to repair torn and stretched tissues in a joint capsule. It can be as effective as traditional surgery at stabilizing loose shoulder joints. The only hitch is that heat can injure nerve sensors in the joint.

Some of nerves inteh shoulder are used to sense position and movement, providing a “sixth sense.” This sixth sense is called proprioception. Doctors have assumed that thermal capsulorraphy damages these sensors. This in turn would make it harder to recover full use of the shoulder.

These researchers tested that theory. They selected 20 patients who had thermal capsulorraphy to fix an unstable shoulder. All had good results from surgery. At least six months later, the patients went through several tests of proprioception. The tests involved being blindfolded and then having to copy certain shoulder and arm movements. Both shoulders were tested in all patients.

To their surprise, researchers found that sensations of position and movement were equal in the injured and uninjured shoulders. They even found that the injured shoulders were actually better in certain types of tests. Researchers suggested some reasons for these surprisingly good results: the process of rehabilitation, the healing properties of heat, and the new stability of the repaired joint capsule.

Much has changed in the world of rehabilitation for dislocated shoulders. Shoulder dislocations cause a wide range of damage and shoulder instability. Ideally, doctors could find the right treatment for both problems.

The best way to do this is to understand the anatomy of the shoulder and how it works. This includes the structures that hold the joint together, such as ligaments and cartilage. It also includes the more moveable parts, such as nerves and muscles.

The shoulder joint is designed for motion. This means it gives up some of its “holding” capacity to allow for nearly 360 degrees of movement. Under stress or with trauma, the shoulder joint can dislocate. Usually, this occurs in a forward (anterior) direction. In a dislocation, the soft tissues around the shoulder get stretched in a forceful way.

Without tight tissues around the joint, the risk of another dislocation goes up. About 70 percent of people who dislocate a shoulder will dislocate it again if they don’t have surgery to repair it. This is especially true for anyone under 20 years of age.

Rehabilitation after injury (with or without surgery) has changed a lot in the last 10 years. Without surgery, the arm is no longer held still in a sling for six weeks. A sling may be used, but only for a short time. Patients are usually sent to a physical therapist for an exercise and rehab program.

Physical therapy helps strengthen shoulder muscles and time their movements and actions. The therapist must help the patient’s joint respond to quick changes in position. Training the nerve input to coordinate shoulder movement is often necessary. All of these treatment methods help prepare the shoulder for a return to full daily activities and sports participation.

Many questions come up if you are thinking about having a shoulder joint replacement. For example, you may want to ask your doctor, “How much better will I be after the operation?” or “Is there any chance my shoulder will be worse than it is now?”

Doctors at the University of Washington in Seattle have some answers to these questions. Their information is based on 128 of their own patients. Overall, patients got back about two-thirds of the shoulder function that was gone before surgery.

After replacing the arthritic shoulder joint with an implant, patients could once again rest comfortably with their arm by their side. They slept comfortably, and could put their hand behind their head. There were other skills that returned after the operation. These included tucking a shirt in, washing the other shoulder, carrying weights, and lifting various objects.

People with severe arthritis may benefit from a new shoulder joint. Patients in this study regained at least two-thirds of lost function after surgery. Improvement is greater in people who have worse shoulder problems before the operation. Overall, the odds are good that a shoulder replacement is worth the time and effort it takes to recover from the surgery.

There was a time when every United States dollar was backed by an equal amount of gold. That was called the “gold standard.” In medicine, when something is the tried and true method of treatment, doctors call this a gold standard. Surgery to cut open the shoulder was once the gold standard of treatment for shoulder impingement. Like the gold that used to back up the dollar, this has changed over time.

Shoulder impingement is a condition more common as we age. Soft tissues can get pinched or pressed by the moving shoulder bone. This often results in a painful loss of shoulder motion.

The cause commonly occurs while working with the arms overhead. In more than half of all cases, there is a large tear in one of the shoulder tendons. Sometimes, these injuries occur as a result of trauma, such as a car accident.

An operation to cut open the shoulder and make the needed repairs became the gold standard in the early 1970s. Now many doctors use an arthroscope to do the same thing. In arthroscopy, a slender instrument is inserted into the joint. It has a tiny TV camera on the end. This allows the doctor to see inside the joint.

Small surgical tools are passed into the joint. Fixing the torn tendon and releasing the impinged tissues by this method isn’t easy. Doctors must learn how to do it and train properly. A new study reports an easier way around this.

One orthopedic doctor at a sports medicine center tried something new. He used a small incision directly through the skin and the acromioclavicular (AC) joint. The AC joint is on top of the shoulder, where the collarbone connects to the shoulder blade (the scapula). The incision makes a small opening. The doctor repairs the torn tendon through this small opening.

Results with this method were just as good as with arthroscopy. About 90 percent of the patients had excellent results. They were pain-free and could use the arm overhead. The patients had most of their motion back and could complete daily activities. The authors of this study think that with a 90 percent success rate, surgery should be done sooner than later.

When a shoulder dislocates, surgery isn’t always needed. Sometimes all patients need is a sling to keep the shoulder from moving. The sling is used during the healing phase, which takes about six weeks. This type of treatment may work best for the patient who has dislocated the shoulder for the first time. The chances of dislocating again are generally less if there’s no major damage to the soft tissues around the joint.

A second dislocation is likely if the bone has fractured or if the rim around the shoulder has torn. This is because the natural structures holding the joint in place have been damaged. All of these tissues, including the bone around the joint, help hold the joint steady and stable. Anyone with serious damage to the soft tissues around the joint will likely need surgery to repair the injured shoulder.

Athletes aren’t the only people who have shoulder problems. People of all ages tear the rotator cuff in the shoulder. The rotator cuff is a group of four muscles and their tendons that surround and help hold the shoulder joint in place. A rotator cuff tear affects one or more of these tendons.

Like many injuries, a full tear in the soft tissue or a break in the bone is easier to treat than a partial tear or sprain. Doctors are gathering information and comparing cases to find out the best way to treat partial tears of the rotator cuff. There are many treatment options. Surgery itself offers many choices.

Doctors at the Mount Sinai Medical Center in New York have joined the ongoing search. They reviewed the charts of 86 patients who had partial rotator cuff tears. Each one had surgery to repair the damage.

The study showed some trends. A large tear in any patient needs full repair, not just cleaning up the area. Older patients with small tears had better results. The authors of this study aren’t sure why this is so. Perhaps older patients are less active, or maybe they complain of pain less often than young, active patients.

The results of this study agree with previous studies. Large tears of the rotator cuff (when the tear is more than 50 percent through the tendon) need a full repair. Small tears (less than 50 percent) can be usually treated with a smaller operation. The torn fibers are shaved away, but the tendon is allowed to heal by itself.

The shoulder joint is a ball and socket joint. The end of the upper arm bone (humerus) is shaped like a round ball. This fits into the socket of the scapula (wing bone). Tendons, ligaments, and cartilage on all sides hold the joint steady and in place.

Even with almost 360 degrees of shoulder motion, the head of the humerus stays firmly in the socket. In fact, it stays in the center during all motions. The four rotator cuff tendons around the shoulder are the key to keeping this central position.

A solid and stable shoulder joint is important for all athletes. When the shoulder joint is hurt, it can become unstable. The head of the humerus can move out of the socket (a dislocation). Sometimes, this happens because of a known injury to the tendons or joint. This is called traumatic instability. In other cases, the cause of the dislocation is unknown. This is called atraumatic instability, meaning without trauma.

New computer technology is helping doctors understand these injuries better. A three-dimensional (3-D) view of the shoulder joint is now possible. To get this view, virtual reality software is used on a multiprocessing computer.

Studies have been done using this new equipment. In the normal shoulder, muscle activity is able to keep the head of the humerus in the center of the socket. This is not always true for the injured shoulder joint. It is also clear that shoulder motion is different between traumatic and atraumatic injuries.

When there is traumatic injury, the joint gets off center. This occurs when the arm is raised overhead with the elbow out to the side. By comparison, atraumatic instability causes the humeral head to move off center with all movements.

These new facts about shoulder instabilities will help doctors. In cases of unclear or unknown history, 3-D studies of the shoulder can show the type of instability. Treatment to help the muscles center the joint may be the key to getting back joint stability.