Shoulder Motion in 3-D

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.

Tennis in the Middle Ages

Tennis is one of the few sports that adults continue to play into the middle-aged years. This is true for both recreational and competitive play. However, shoulder problems are common in these groups.

The overhead and repeated motions of the arm can cause damage to the shoulder in older tennis players. The chances that a rotator cuff injury will occur go up with age. This is especially true in adults over 50 years.

Most middle-aged tennis players who hurt themselves are very interested in returning to the game. For this reason, doctors are measuring how long it takes for adult athletes to return to tennis. Doctors want to know what kind of surgery works best to get these players back in the game.

Surgery can be done with an open incision or by arthroscopy. Arthroscopy is a way to do an operation without using a large cut to open up the joint. Instead, a small cut is made and a slender instrument with a tiny TV camera on the end is passed through the opening. By watching a video screen, the doctor sees what needs to be done and makes the needed repairs.

About 80 percent of middle-aged adults who have shoulder surgery can go back to tennis. This is true for both types of surgery (open or arthroplasty). However, they may not return to the same level of play as before the surgery. Some may still have shoulder pain. There is often a loss of power while playing tennis compared to the pre-injury status.

There are many reasons why the rest don’t return to tennis. In some cases, the doctor may discourage tennis to prevent other injuries. Sometimes, the patient just isn’t able to follow a strict exercise program in order to return to play. In all cases, proper rehab after surgery is very important to a good result and playing tennis again.

Surgery Advised for First-Time Shoulder Dislocation

People under 30 years old who dislocate their shoulder for the first time have a 75 and 95 percent that the same shoulder will dislocate again. Researchers continue to study whether surgery is the best choice after a first-time shoulder dislocation.

There is still a chance of a second dislocation after surgery. Yet it is less likely than without surgery at all. Treatment without an operation consists of immobilization. The shoulder is held against the body with a sling for four weeks. Then, a program of exercises is prescribed and supervised by a physical therapist.

It takes about four months to get better without surgery. After this, the patient can return to work or sports. For those patients who are treated with surgery, the operation is done as soon as possible. This is usually within the first two weeks after the injury. After surgery, a rehabilitation program lasting four months is typical.

Doctors are trying to find out why some people dislocate the shoulder a second time. What are the risk factors for reinjury with or without surgery? It may be the level of activity a patient resumes after injury or surgery. People in the military have heavy physical demands placed on them. In the general population, some people are unwilling or unable to change the way they use their arm. These patients seem to be at greater risk for reinjury.

Surgery to repair a first-time shoulder dislocation can help restore the joint. This is the treatment advised for young, athletic adults (under 25 years of age). Any tissue that is torn is quickly repaired. This helps the joint get its normal function back. This approach shows less chance of a second dislocation.

Melting the Factors That Slow Recovery from Frozen Shoulder

Shoulder pain and loss of motion are symptoms of a condition called adhesive capsulitis. This is also known as “frozen shoulder.” Adhesive capsulitis is a common problem after shoulder tendinitis or bursitis. Another proposed cause is impingement from pinching of tissues in the shoulder.

Some people get this problem without knowing why. There wasn’t an accident, injury, or trauma. There is no arthritis. X-rays are normal. The problem simply comes on by itself. In these cases, it is called idiopathic.

If someone with a frozen shoulder has other problems, shoulder symptoms are often worse, and it usually takes longer to get better. The presence of other problems are called comorbidities. These are physical or social factors that affect a person’s health besides the main diagnosis. These could be other diseases such as diabetes mellitus or high blood pressure. Migraine headaches, low-back pain, cancer, depression, and tobacco or alcohol-use are all considered comorbidities.

In the case of idiopathic adhesive capsulitis, the most common comorbidities are low-back pain, diabetes mellitus, and high blood pressure. Social factors such as tobacco use and legal action also appear to slow healing. Without these comorbid factors, patients would have fewer symptoms and get well sooner.

Doctors can expect a longer treatment course and poorer results for some patients. This is especially true for frozen shoulder of an unknown cause when other physical or social problems exist.

Underhanded Results for Overhead Athletes

Both the hip and the shoulder joint have a fibrous rim of cartilage around the joint called the labrum. This rim deepens the joint and gives it more stability. Stability balances the joint and holds it steady.

Athletes commonly tear the labrum in the shoulder joint. This often requires surgery. A small screw may be used to hold the labrum in place. Repair of a labral tear is successful in a majority of patients.

However, athletes who play overhead sports don’t have as good a result. Overhead sports include volleyball, baseball, and tennis. The reason for the difference in results is unclear. The athletes have full motion after the repair, but they can’t seem to return to full sports activity without pain. Perhaps a greater physical demand on the shoulder makes a difference with overhead sports. Researchers continue to study this problem in hopes of returning all athletes back to full sports activity.

All the Right Shoulder Moves

Two joints in the body that are made for movement are the hinge joint and the ball and socket joint. The elbow and knee are hinge joints. The shoulder and hip are ball and socket joints.

When the arm is lifted overhead, the ball part of the shoulder (called the head of the humerus) drops down and back in the socket. If there isn’t enough space for this to happen, the rotator cuff tendons can get pinched. This is called impingement.

Impingement can be caused by many factors. There may be a loss of blood supply to the area or aging and damage to the rotator cuff. Changes in the way the joint moves can narrow the space inside the shoulder joint. Altered joint movements can also worsen impingement problems.

If the ball doesn’t stay centered, it may slide around and get too close to other structures in the shoulder. Impingement may result. Sometimes the back of the shoulder joint gets tight. This forces the ball up and forward as the arm is raised. This too can cause impingement.

Treatment of shoulder impingement involves strengthening the muscles around the joint, especially the rotator cuff muscles. Stretching tight tissues, especially in the back of the shoulder joint, is also important. These two treatments help to restore the normal movement of the ball in the socket. Learning more about how the shoulder joint actually moves will help improve treatments for shoulder impingement.

Shoulder Research Revisited

In 1982, two doctors wrote a paper that changed the way shoulder exercises were done. Dr Jobe and Dr. Moynes studied the movements of baseball pitchers when throwing a ball. They saw that one muscle in the rotator cuff is very important for athletes using a throwing motion. Called the supraspinatus, this muscle moves the arm out away from the body. It also keeps the shoulder joint in the socket when the arm is hanging down at the side. Their research showed which exercises strengthen the supraspinatus muscle.

Since that time, doctors, physical therapists, and athletic trainers have used the “Jobe exercises” to strengthen the rotator cuff. Now, twenty years later, researchers have newer and better technology available. It is possible to retest these exercises and see if they really are the best ones to strengthen the supraspinatus muscle.

In the past, EMG (electromyography) studies were done. Needle electrodes were put into the muscles. These measured the electrical activity of the muscle fibers. The results with EMG were different from study to study. This is because the electrodes change position when the muscle moves. Only a small number of muscle activity could be measured at one time.

Today, MRI (magnetic resonance imaging) is used to measure muscle activity and relaxation. This is a much better measure of muscle function than EMG. Researchers found that two of the three Jobe exercises are still the best in moving the supraspinatus muscle.

The “empty can” exercise is done by lifting the straight arm upward and slightly outward with the thumb down, as though a can were being emptied. The “full can” exercise is similar, only the thumb is up. Thumb up or down, MRI results show these two exercises give the best workout for the supraspinatus muscle.

Volleyball Serves Up a Case of Shoulder Weakness

A 24-year-old man came to the doctor with a weak right shoulder. The shoulder wasn’t painful, but for two weeks the man hadn’t been able to do basic tasks such as put on a seat belt or open the refrigerator door. He hadn’t hurt the shoulder doing anything in particular. Why the sudden weakness?

In order to diagnose the problem, doctors did a physical exam and two special tests. First, they used electromyography to check the activity of the shoulder muscles. This test uses electrical recordings to track muscle activity. The test showed low muscle activity in the man’s right shoulder. The infraspinatus muscle was the problem area. This muscle covers most of the shoulder blade and allows the arm to rotate outward.

Next, the doctors did magnetic resonance imaging (MRI). MRI scans show “slices” of the soft tissues inside the body. The patient’s MRI showed a cyst in his shoulder.

The patient had surgery to remove the cyst. He did range-of-motion and strengthening exercises for six weeks after surgery. Within eight weeks, he was able to go back to volleyball and other activities.

Doctors suspect that intense and repetitive activity such as volleyball, construction, weight lifting, or fencing can upset the normal function of the shoulder. This is thought to form a cyst in the passageway of the suprascapular nerve. This nerve goes to the infraspinatus muscle. As the cyst grows, it can trap the nerve and cause weakness in the infraspinatus muscle. For some unknown reason, this occurs mostly in men. Once diagnosed, the problem can be resolved with surgery and physical therapy.

Tackling Shoulder Instability in Football Players

Once a shoulder dislocates, there’s a good chance it will do so again. This is called repeat shoulder instability. This condition is especially common among athletes who play contact or collision sports such as football.

What’s the best way to prevent repeat shoulder instability in football players? Arthroscopic surgery, or surgery that uses special instruments to avoid making large incisions in the skin, may give less pain and better movement after surgery. However, football players who have this type of surgery often dislocate their shoulders again.

Doctors evaluated a standard “open” technique for football players with shoulder instability. Open procedures use larger incisions to expose the joint for surgery.

Fifty-eight football players had open surgery for repeat shoulder dislocations. Their average age was 18. After surgery, patients did at least four months of physical therapy to prepare them to return to sport.

Almost all of the patients returned to football for at least one year after surgery. Many of them played for two years or more. There were no complete dislocations after surgery. Two patients had partial dislocations. Most of the patients (84 percent) regained normal movement in the shoulder. None lost a significant amount of movement. About three years after surgery, 95 percent of patients had a good or excellent result.

Doctors feel that the open technique has several advantages over arthroscopic surgery for this group. With open surgery, doctors can see more of the joint. This allows them to restore needed tension in the shoulder by reinforcing damaged tissues. These steps help keep the shoulder strong.

Open surgery to stabilize the shoulder allows football players to return to sport with less risk of repeat dislocation. Most football players who have open surgery have good motion and function later. For this high-risk group, open surgery seems to work better than arthroscopy.

Popeye’s Torn Biceps Tendon

When children want to show how strong they are, they flex the upper arm and point to the bulge. This is the biceps muscle. It attaches to the shoulder and to the elbow in two parts. One part helps lift the arm, and the other bends the elbow.

When the biceps muscle is torn, it sometimes bunches up and makes a bulge. This happens even when the person isn’t trying to “make a muscle.” This is called the Popeye deformity. Interestingly, when a doctor cuts the biceps tendon, the muscle doesn’t bunch up or change the way the arm looks. This is probably because the doctor cuts the biceps tendon up high enough in the shoulder that the tendon gets caught in a groove in the bone and stays there. A torn biceps muscle pulls back into the main part of the muscle and causes a bulge.

For people with shoulder pain and muscle spasm from a biceps problem, doctors want to know what surgery works best. Is it better to cut the tendon and let it reattach by itself? Or is it best to cut the tendon and sew it in place?

In the long run, it doesn’t matter which operation is used. Pain and spasm are gone and no “Popeye” deformity is visible with either method. This is equally true for both men and women. In the short term, cutting the tendon without reattaching it results in less pain and less time off work.

A torn biceps tendon can be repaired with one of two different operations. It can be cut and allowed to reattach by itself, or it can be cut and reattached with stitches. When deciding what type of surgery is needed for a painful biceps tendon, doctors may be helped by knowing that the end result is the same with either method.

Rotator Cuff Tears: Should You Operate?

The rotator cuff is a group of four tendons that support the shoulder joint. Researchers suspect that five to 40 percent of people may have tears in the rotator cuff without even knowing it. Most of the time, rotator cuff tears cause pain and other symptoms. Often these symptoms are treated with rest, physical therapy, and medications. But how successful is nonoperative treatment?

Research suggests that about half of patients are satisfied with the results of nonoperative treatment. Pain decreases, and range of movement improves. Shoulder strength usually stays about the same, however.

When is surgery necessary? In general, patients who have had shoulder pain for more than six to 12 months will do better with surgery, as will those with larger tears (more than three centimeters).

The rate of pain relief is better with surgery (85 percent) than with nonoperative treatment (50 percent). Surgery improves shoulder strength whereas nonoperative treatment does not.

Some doctors have suggested that the longer patients wait to have surgery, the worse their results will be. This is based on the unproven idea that rotator cuff tears tend to increase in size over time. In general, smaller tears have better results from surgery than large or massive tears. Although some tears may get bigger over time, this is a slow process. No study has shown that delaying surgery leads to poor results. However, early repair is still preferable for new tears.

Compared to nonoperative treatment, surgical treatment of rotator cuff tears gives more pain relief and shoulder strength. Nonoperative treatment may be a good alternative for older, less active patients.

Hottest Techniques in Shoulder Surgery

The ball and socket joint of the shoulder normally moves with ease in all directions. However, the joint can become unstable, moving too far or slipping when it shouldn’t. When the shoulder is able to shift too far in more than one direction, it is called multidirectional shoulder instability. When this happens, pain, “popping,” and dislocation can occur.

Treatment for shoulder instability is with medications (antiinflammatories), physical therapy to strengthen the muscles, and changes in activities. Surgery may be needed if symptoms keep on after three to six months of regular therapy. The purpose of the surgery is to tighten up the shoulder joint.

This can be done in several different ways. The joint may be opened up so stretched tissue can be pulled tight and held in place. The same result can occur without cutting the joint open. The doctor uses a tool called an arthroscope, a slender instrument inserted into the joint with a TV camera on the end. This allows the surgeon to see inside and tighten the shoulder joint without a large scar and without too much tissue damage from surgery.

A newer method uses arthroscopy and laser to the treat the joint. Laser is a form of light energy that creates heat. This heat can be applied to the joint to shrink and stiffen the tissue. Researchers are reporting the results of laser heat for multidirectional shoulder instability. The amount of heat used and the length of time needed for healing with this treatment are still unknown. More studies are being done to compare this method with the standard surgery for shoulder instability.

Tennis Anyone? Served with or without Pain?

Have you ever tried to power a tennis ball over the net? That overhand serve isn’t as easy as it looks. Try doing hundreds of them each day and see how your shoulder feels.

For a small number of tennis players, this kind of repetitive motion causes damage to the shoulder. In particular, there is a tendon that can get pinched on the back (posterior) side of the shoulder joint. Shoulder pain starts when this tendon, called the supraspinatus tendon, gets pressed against the rim of the joint. Most players grin and bear it. Many are helped by nonoperative treatment such as physical therapy. For some, surgery is needed.

One study of 28 tennis players looked at the results of surgery for this problem. The doctors removed the torn tendon and smoothed the joint where the tendon had rubbed against the outer rim.

The final outcome was not ideal. Only half of the patients could return to tennis. Almost all of the patients who did return to the game had quite a bit of pain while playing. Why the poor results? Doctors think there may be other unseen damage in the shoulder joint.

There is new information about shoulder injuries in tennis players. Serving the ball overhead can cause the deep surface of the supraspinatus tendon to get pinched. Surgical treatment for this problem has not been very helpful. Doctors think there may be more to the problem than meets the eye. Better treatment will evolve as more specific information about the damage to the shoulder joint is uncovered.

Treating Minor Rotator Cuff Tears: When Less Is More

Like most injuries, tears to the rotator cuff–the tendons that surround and support the shoulder joint–are a matter of degrees. If the tear is slight, involving less than a quarter of the tendon, it is called a “grade 1 tear.” If the tear is medium-sized, involving more than a quarter but less than half of the tendon, it is a “grade 2 tear.” If the tear goes through more than half of the tendon, it is a “grade 3 tear.”

Deep tears must be repaired or stitched back together in order for the shoulder to function properly. But another treatment called acromioplasty may be sufficient for minor tears. With acromioplasty, surgeons shave part of the acromion bone on the point of the shoulder. A ligament over the top of the shoulder is cut, and injured tissues are removed. This takes pressure off the injured rotator cuff and promotes healing.

Acromioplasty can be done using an arthroscope. This slender instrument has a camera on the end that can be inserted through a small incision to let the doctor operate. Arthroscopic acromioplasty is a less invasive procedure than rotator cuff repair. But is it successful for patients with grades 1 and 2 tears?

One hundred patients had arthroscopic acromioplasty. Some of the patients had shoulder impingement, meaning the tendon was pinched, without rotator cuff tears. Some of the patients had grade 1 tears. Most of the patients had grade 2 tears. The patients had all tried nonoperative treatment such as exercises and medications without success. 

How did patients fare with acromioplasty? Overall, the results were excellent. Patients with rotator cuff tears did just as well as those without tears. About five years after acromioplasty, most patients had little or no pain, and good shoulder strength and motion. These results were stable over time. Patients did not develop shoulder problems later on, as some researchers worried they might.

Treatment was considered to have failed in eight patients (eight percent). These patients had persistent pain after surgery that did not change over time. Most of the failures happened to patients with grade 2 tears. Failures were also more common when the tear was located on the top surface of the tendon.

Acromioplasty is a reliable treatment for shoulder impingement and minor (grades 1 and 2) rotator cuff tears. Most patients have immediate relief from this procedure. When the treatment fails, it fails early, and the results do not change over time. Failures may be more likely for patients with grade 2 tears in the top surface of the tendon. These tears should probably be sutured together rather than treated only with acromioplasty.

The Incredible Shrinking Shoulder

Advances in medical technology are happening more and more quickly. Researchers are concerned that new treatment methods are being used before they are fully understood. Thermal capsulorrhaphy for the shoulder is one of the new methods in question.

With thermal capsulorrhaphy or heat shrinking, radiofrequency energy is applied shrink the tissue (capsule) around a joint. This makes a tighter, more stable joint. The treatment has been used for a variety of problems. Researchers suspect that doctors are using the treatment for many different problems because they don’t really know what it does best. It’s important to find the proper uses and limits of this procedure.

So far, results of thermal capsulorrhaphy for shoulder joints have been very positive. However, longer follow-up is needed to see how patients do later on. Studying the records of patients who had poor results can give clues about who should (or should not) have this procedure. One group of doctors did this review process with 106 patients who had thermal shrinkage of the shoulder joint.

The doctors found that patients who had previous shoulder operations and multiple dislocations did not have good results from thermal shrinkage. Most problems happened about six months after the procedure. It was unclear whether shoulders that were loose (unstable) in more than one direction were helped by thermal shrinkage.

When it comes to thermal shrinkage for the shoulder joint, some patients are better candidates than others. Patients who have had previous shoulder surgeries and multiple dislocations are less likely to benefit from this procedure. According to the authors, sports activity and looseness in more than one direction may also lead to poor results, though more research is needed.

Want Strong Shoulders? Don’t Slouch

Shoulder problems are common among athletes. These problems may be caused by trauma, but most come from overuse. Overloading the muscles and nearby soft tissues is easy to do when movements are repeated over and over.

The four muscles around the shoulder, called the rotator cuff, have been the subject of much research on shoulder strength. Recently, a new focus of study has come to light. It seems that the shoulder blade, also known as the scapula, has an important role in shoulder strength. Researchers want to know the strength of the shoulder when the scapula is in different positions. A round-shouldered or slouched posture puts the scapula in a forward position. This is called a protracted scapula.

Previous studies have shown that this position causes shoulder pain in many people. The protracted position narrows the space in the shoulder joint needed for movement, puts strain on the ligaments in the shoulder, and decreases shoulder strength. A group of physical therapists teamed up in a motion analysis lab to study this problem.

Ten adults with no shoulder or neck problems were tested. The strength of each person’s shoulder was measured with the scapula in three different positions: forward, in the middle or “neutral,” and pulled back or “retracted.”

The strength of the shoulder was less when the scapula was either pulled back or pushed forward. Strength was affected in equal amounts in these positions. Strength was best when the scapula was in the middle or neutral position.

The position of the scapula is important for shoulder function and strength. If the scapula is slouched too far forward or pulled too far back, shoulder motion and strength are reduced. This is an important finding for physical therapists working with patients on shoulder rehabilitation. Further studies are being done to test the strength of the shoulder with the arm straight forward versus out to the side. This information will help therapists plan treatment to strengthen the shoulder.

Inside the Shoulder: A New Look at an Old Problem

Amazing things are happening in the world of orthopedics. Technology continues to improve, helping doctors find the tiniest tears in tendons and joint surfaces. When MRI (magnetic resonance imaging) doesn’t show any problems, arthroscopy may give a clearer picture. The arthroscope is a tiny TV camera that can be inserted into a joint through a very small incision.

The shoulder is an area where arthroscopy has helped tremendously. Many people develop a shoulder problem called impingement. This occurs when part of the soft tissue around or inside the shoulder gets pinched. This tissue could be a tendon or bursa (soft sac to cushion the shoulder).

Different kinds of impingement occur in different groups of people. The most common or “classic” case happens in middle-aged, nonathletic individuals. In this case, a bursa and tendon in the front of the shoulder get pinched by a bony arch that crosses over them. A second type of impingement can occur in younger athletes. Most of these individuals do a lot of throwing and develop shoulder pain and impingement. This is most likely to happen when a tendon tears a little and starts to fray. The frayed edges get pinched against the rim of the shoulder joint when the arm is in a certain position.

Using arthroscopy, doctors have found a third kind of impingement. This kind usually doesn’t show up in MRIs. It happens in younger adults who are not athletes. Although it looks like classic impingement, the arthroscope shows a very small area where the labrum has started to fray. This is the cartilage around the rim of the socket where the shoulder bone inserts.

Earlier and more specific treatment can be provided as more and more doctors identify the exact damage inside the shoulder with arthroscopy. The smallest of tears can cause significant pain and difficulty moving the arm. Finding the exact cause of the problem may keep small tears from becoming big ones.

Swapping Activities for a Stable Shoulder: The Slippery Slope of Shoulder Dislocation

Have you heard the one about the man who went to his doctor with a bad shoulder?
Patient: “Doctor, it hurts when I do this.” (The patient moves his arm up and down.)
Doctor: “Then stop doing that.”

It’s natural to assume that if you dislocate your shoulder during an athletic activity, you should find another activity or sport to play. In fact, this is often the case. Many patients do change to activities with less strain on the shoulder. But this may not always be necessary.

A group of Austrian doctors studied 500 cases of shoulder dislocation. They hoped to identify patients with the highest risk of dislocating the shoulder again (called a “recurrence”). The goal was to advise these patients to have surgery to repair and stabilize the shoulder joint.

The doctors compared patients who dislocated their shoulders again with those who didn’t. They found that putting the arm in a sling and going to physical therapy did not prevent a second dislocation. Patients with fractures along with the dislocation had less risk of dislocating the shoulder again. Anyone with decreased shoulder movement, especially turning the arm out from the side, also had less risk of recurrence.

The most reliable risk factor for another shoulder dislocation was age. Patients between the ages of 21 and 30 were more likely to dislocate the shoulder again. This was because these patients continued to do high-risk sports or returned to full activity too soon after injury.

In the Alpine region of Austria, doctors recommend surgery to repair shoulder dislocations. This advice is aimed at adults between 21 and 30 years of age who do high-risk sports. The surgery should be done early, without waiting for another shoulder dislocation. This step is not recommended for patients between 21 and 30 who do not do high-risk activities.

Nonsurgical Treatment Makes the Grade for Shoulder Separation

There are still some injuries that do not have tried-and-true treatments. Shoulder separation is one of them. Despite many different treatment approaches, there is no general agreement on the best way to treat this problem.

Shoulder separation occurs when the collarbone gets pulled away from the bone it attaches to (the acromion) at the shoulder. This can happen because of a sports injury or car accident. It’s called an AC separation. This type of injury is usually given a “grade” from I to IV to describe how far apart the joint has separated. An X-ray is used to determine the grade.

A grade I or II AC separation is often painful, especially with any movement of the arm overhead. There may not be any visible changes, but on examination the doctor or therapist may feel a larger space in the joint. Pressing on the joint increases the pain. With a grade III AC separation, the collarbone moves up so that it is no longer even with the acromion. This leaves a visible bump on top of the shoulder. With a grade IV separation, the joint is dislocated and an even larger bump is present.

Grades I and II are mainly treated without surgery. Surgery is usually recommended for a grade IV. Grade III falls into a gray zone. It remains unclear whether surgery is really necessary for a grade III AC separation.

A group of doctors and therapists studied 20 patients with grade III AC separations that were not treated with surgery. Instead, these patients were treated with slings for comfort. They also started range of motion exercises early. The researchers compared the results of these patients with those of patients in other studies who had surgery.

The researchers tested patients’ range of motion and strength up to a year after injury. At the end of a year, most patients who did not have surgery (80 percent) were satisfied with their results. Patients who were not satisfied had other concerns, such as lawsuits and veterans’ benefits. The “failure” rate of 20 percent was similar to that of patients who had surgery for this same problem.

The “wait and see” approach seems to work for most people with mild to moderate shoulder separations. Most people with grade III AC separations do well without surgery. A small number of people may need surgery, but this may be determined at a later date. Unfortunately, it is impossible to predict who will have a poor result without immediate surgery.

Buttoning Up a Torn Rotator Cuff

Surgeons are constantly looking for ways to improve rotator cuff repair. The rotator cuff is made up of four shoulder muscles whose tendons form a “cuff-like” attachement on the top rim of the shoulder.

A new approach to rotator cuff repair uses an anchoring or fixation device. This is called a button anchor. There are many different kinds of anchors available. Anchors may be made of bone or biodegradable materials such as metal or plastic. The surgeon drills a hole in the large bony bump on the shoulder. The anchor is then inserted through the hole and turned crosswise. The torn tendon is attached to the anchor with tiny stitches.

How do surgeons know the anchor will hold? Studies of new surgical methods begin on human cadavers (bodies preserved for scientific study). After the anchor is put in the cadaver, the arm is moved thousands of times. This mimics the number of times a shoulder would move during a typical six-week rehabilitation program.

Once this proves successful, the same process is repeated on live pigs. Then human trials begin. Human subjects are carefully followed for at least a year. So far, there have been very few problems. Occasionally, the anchors move or pull out of the bone, and sometimes the stitches break. Overall, however, the anchors hold up very well.

Doctors are beginning to use anchoring devices to button down the soft tissues of the torn rotator cuff. The most successful type of anchor button is made of bone. This anchor holds well and blends in with the original bone in less than six months. With very few complications and impressive results, this new approach to rotator cuff repair looks promising.