Rotator Cuff Repair–Again

Surgeons carefully study the results of their handiwork. When surgery doesn’t have a good result, they want to know why. Then they can make whatever changes are necessary. In the case of rotator cuff repair, pain relief and good motion occur in up to 90 percent of cases. Other past studies are not so optimistic, suggesting that unsatisfactory results occur in up to 25 percent of cases.

When contemplating rotator cuff surgery, the doctor must decide which surgical technique to use. This decision is made by looking at the size of the muscle tear, the size and shape of the bones, and the health of the tissue. The best result occurs when the tendon can be repaired directly. In this case, the tendon is replaced using its original attachments with a secure tendon-to-bone repair.

When a repaired rotator cuff has a poor or unsatisfactory result, the surgeon may have to perform a procedure called a revision. Revision surgery is usually the second or third surgery after the initial injury and repair. In a revision, a direct repair is not possible. The tendon may have to be reattached in a new location slightly forward or to the side of its usual place. Sometimes a piece of tendon from another place in the shoulder has to be used to replace the original tendon. There are many different ways to perform a revision.

Revision surgery on the rotator cuff is most successful when four conditions are met: (1) the deltoid muscle is not torn; (2) the rotator cuff tissue is in good condition; (3) the patient has good motion before the revision; and (4) there has only been one prior surgery. Evaluating each patient for these four conditions can help assure a more successful revision and greater patient satisfaction.

Unusual Muscle Tear in a Recreational Athlete

Shoulder problems are common in adults. Problems can come from injury, overuse, or aging. The rotator cuff is the most likely place for them to develop. This cuff consists of four muscles and their tendons, which attach around the shoulder to give it strength and motion.

Tears of the rotator cuff occur most often in two of the four muscle-tendon units. Occasionally, the third muscle is injured. Rarely, the fourth muscle, or subscapularis, is involved. The first case of a subscapularis tear without major trauma, overuse, or signs of aging has been reported.

A 49-year-old man with a history of a minor car accident and mild right shoulder pain started a weight-training program at home. He began a program of biceps curls using eight-pound dumbbells. Within two days, he started having severe right shoulder pain.

The doctor carefully examined him, making special note of the location of all painful symptoms. Touching and observing areas that were not painful also provided useful information. Some of the movements and tests could not be performed because of extreme shoulder pain. The doctor ordered MRI studies (magnetic resonance imaging) to confirm the diagnosis of a subscapularis tear.

The MRI showed this was a partial tear that did not require surgery. Fluid above the muscle seen on the MRI also proved this was not a long-term problem but one that occurred suddenly. MRI is not always needed, but it can be used to identify unusual rotator cuff tears. The test also shows the extent of damage. This is extremely helpful information for doctors when deciding whether surgery is needed.

In this case, a six-week program of physical therapy resulted in a good outcome. The patient progressed through a program of exercises for motion, strength, and proprioception (training to fine-tune the joint’s sense of position). The patient returned to work and recreational sports without any further problems. 

Early diagnosis of a partial tear of the rotator cuff is important. By starting treatment early, the patient can avoid tearing the muscle completely, which would require surgery. Doctors use MRI studies to identify muscle or tendon tears and to design the best plan of treatment.

New Treatment for Shoulder Cysts: A Case Report

If a patient has a ganglion cyst, or small tumor, pressing on the nerve above the shoulder blade (the suprascapular nerve), diffuse shoulder pain and loss of shoulder strength may result. The symptoms are similar to a rotator cuff tear. Cysts of this kind are most often seen in men in their 30s or 40s who do manual labor or play sports involving a lot of overhead movements, such as volleyball or tennis.Until now, treatment for this problem has usually involved surgery. Doctors can either do open surgery to remove the cyst, or they can use an arthroscope to take out the cyst without making big incisions in the skin. Sometimes nerve problems that come from these kinds of cysts can be managed without surgery.These authors report on a case that was treated a different way. A 33-year-old man with a history of playing tennis and handball came to the doctor with weakness and pain in his right (dominant) shoulder. The symptoms had lasted nine months. The patient said pain increased with overhead movements, such as serving in tennis.A physical exam showed muscle weakness as well as tenderness in the deep notch in the upper part of the shoulder blade (the suprascapular notch). An MRI revealed a ganglion cyst, and mild tendinitis in the rotator cuff. Instead of opening the shoulder or doing arthroscopy, the doctors aspirated or “deflated” the cyst using suction. While the shoulder was numb from anesthesia, the doctors used ultrasound to find the cyst. They inserted a large needle that sucked out the contents of the cyst. Then they injected a small amount of anesthetic, to ease discomfort. Within six months of the procedure, the patient’s shoulder was as strong as his other shoulder. He was able to get back to tennis without pain. Up to a year after the procedure, the cyst had not come back.This procedure is less invasive than surgery. There is less risk of complication, such as injury to the suprascapular artery and vein. The authors believe this method may be an alternative for patients who don’t want to have surgery or arthroscopy for cysts compressing the suprascapular nerve in the shoulder.

Arthroscopic Release of Frozen Shoulder: Don’t Shrug It Off

Stiff or “frozen” shoulders usually get better with physical therapy. Those that don’t may undergo “manipulation under anesthesia.” Doctors stretch the shoulder joint until it releases while the patient is asleep. What if this doesn’t work? In the past, patients who didn’t improve with manipulation either lived with their symptoms or had open surgery to release the tight tissues around the shoulder joint.

Now there’s a new option. Doctors can release the stiff shoulder using an arthroscope, a tool that works like a TV camera under the skin. This procedure is less invasive than open surgery. It’s been shown to improve movement and reduce pain in some shoulders.

Shoulder stiffness can come after surgery, such as rotator cuff repair. It can also follow fractures. Sometimes it has no known cause at all. Does the cause of stiffness affect whether the arthroscopic treatment works? Is it harder to “loosen” a shoulder after surgery or fracture?

To find out, these authors treated three groups of patients. Thirty-three patients had shoulder stiffness from surgery. Six patients had stiffness from fractures. Eleven had stiff shoulders without any known cause. Manipulation failed to restore at least 80 percent of shoulder movement in these patients, so the arthroscopic treatment was tried. Patients started a home exercise program (one hour a day) right after surgery. They were also encouraged to use the treated arm in everyday activities.

Patients were examined about two years after treatment. There were no complications from surgery. Four of the patients who’d had prior surgery still had stiffness. These patients went on to have open surgery on their shoulders. Overall, patients had good results from the arthroscopic procedure. They had more movement in their shoulders at follow-up. They also had less pain and more function. And they felt more satisfied with their treatment.

Patients who’d had surgery before didn’t get quite the same benefit as the other groups. At follow-up, they had more pain, less function, and less satisfaction than the other groups. They also tended to have slightly less movement in their shoulders. These differences weren’t related to the formation of scar tissue after previous surgery.

The authors feel that arthroscopic release is a reliable way to restore shoulder movement when physical therapy and manipulation have failed. Patients whose shoulder stiffness comes from surgery benefit from this treatment. However, their gains may be less than those of other patients. This is probably due to the lasting effects of the initial injury and surgery.

Pop Goes the Shoulder: Better Treatments for Dislocations

Surgery to repair problems in the shoulder has changed quite a bit since a newer method called arthroscopy came along. This new procedure lets doctors insert a tiny TV camera right into the shoulder joint, allowing them to see and treat most damage that has occurred inside the joint. Before arthroscopy, doctors had to cut the shoulder joint open to make repairs.

Some people have a shoulder that dislocates repeatedly as a result of a traumatic injury. The shoulder joint forms where the upper arm bone (the humerus) inserts into a socket. With a shoulder dislocation, the top part or “head” of the humerus actually pops out of the socket. The socket is called the glenoid.

Normally there are many surrounding structures to hold the bone in place. Ligaments surround the ball and socket, forming the joint capsule. Along with the joint capsule, muscles and tendons work to keep the head of the humerus in the socket. When an injury causes damage to any of these soft tissues, dislocation can occur.

The round socket has a tough ridge around the edges. This ridge, called the glenoid labrum, deepens the socket, which helps keep the humeral head in place. When the labrum is torn, which commonly happens with a dislocation, the shoulder joint becomes unstable and prone to repeated dislocations.

Surgeons using the arthroscope to repair damage to dislocating shoulders noticed a high rate of dislocation after the operation. This problem has been solved by a group of doctors who discovered a missing link. They studied a group of 42 people with recurring dislocations.

The doctors showed that if the capsule around the joint is still loose or stretched out, it too must be repaired. A new way to tighten the capsule is with a heat treatment called thermal shrinking. This uses radiofrequency energy delivered through a special probe. The doctor is able to view the probe through the arthroscope. The labrum also needs to be repaired if it is torn.

With these changes to the operation, almost everyone (38 out of 42 people) could return to their previous activities. This included sports that require overhead arm motion. Only three people had any further dislocations.

Any injury that tears the ligaments, tendons, or labrum can cause the shoulder to dislocate. For anyone with a shoulder that dislocates over and over, surgery is usually necessary. Using an arthroscope, surgeons can repair damage in the shoulder and reduce the chances of future shoulder dislocation. This includes reattaching the labrum and tightening the capsule.

Open Surgery to Stabilize the Shoulder: It’s Not a Closed Book

Open surgery has been the standard surgical treatment for dislocated shoulders. Open surgery for the shoulder involves a large incision through the skin and muscles in order to fix the injured shoulder.

Open surgeries take time and expertise. They can lead to complications, such as infection and damage to the rim of the socket. Sometimes a procedure like this can end up reducing the range of movement in the shoulder.

In 1993, a new technique was introduced. The procedure uses an arthroscope. This instrument works like a TV camera below the skin. It lets surgeons see inside the shoulder without having to make big incisions.

With arthroscopy, patients usually recover more quickly. They may also have less pain after surgery. But the procedure may be less effective than open surgery when it comes to keeping a dislocated shoulder in place. Research shows that nine to 20 percent of patients who have arthroscopic surgery dislocate their shoulders again. However, arthroscopic techniques have improved. Some surgeons now use special tacks that are absorbed by the body as the shoulder heals.

These authors wanted to compare the results of open and arthroscopic surgeries. One hundred-seventeen patients (119 shoulders) volunteered for the study. These patients had had at least one shoulder dislocation, followed by another full or partial dislocation. The patients were mostly men. Their average age was 27. (Ages ranged from 15 to 62.) Roughly three years had passed since their injuries.

Patients were given a choice between the two kinds of surgery. If they couldn’t decide, the surgeon picked for them. In the end, 53 shoulders had the open procedure. Sixty-three shoulders had the arthroscopic procedure.

Afterwards, patients wore slings for four weeks. They started strength exercises at six weeks. Contact sports were allowed at six months if shoulders were totally stable.

The authors followed up with 108 patients two to five years after surgery. The arthroscopic group was contacted about eight months before the open group.  Significantly, the arthroscopic group had fewer dislocations before surgery (six versus 10 per patient).
 
Nine shoulders (15 percent) in the arthroscopic group had another dislocation or partial dislocation two to five years after the surgery. The same was true of five shoulders (10 percent) in the open group. The difference between groups was felt to be slight.

Movement was slightly better in the arthroscopic group. Other than that, there were no differences between groups in shoulder strength or function. There were also no differences in complications from surgery or need for more surgery.

Both procedures seemed to have good results for most patients. The authors think that looseness in the shoulder may determine how well surgery works in either case. They feel that decisions about surgery should be based on patients’ preferences and doctors’ experiences with both kinds of surgery. These things should come before patients’ age, history, or participation in sports when deciding which type of surgery to have.

Cadets Salute Arthroscopy for the Treatment of Dislocated Shoulders

If you dislocate your shoulder, the usual treatment calls for a sling followed by rehabilitation. Unfortunately, this doesn’t reduce the chance that you’ll dislocate your shoulder again. If you’re young, you’re at an especially high risk for re-injury. Studies have shown that up to 94 percent of athletes under age 25 who dislocate their shoulders do it again.

Is there a better treatment? One that prevents re-injury in young patients? These authors looked at a surgical treatment for young athletes who dislocated their shoulders. The procedure involved an arthroscope–a camera-like device that lets surgeons see inside the joint. It requires very small incisions. (This is different from “open surgery,” in which surgeons make bigger incisions to see the joint.) Special tacks were used to keep shoulders in place.

The participants were 57 cadets at West Point. Six of them chose not to have surgery. They wore slings for three weeks and then did strength exercises. The goal was to return them to full activity in three months.

The rest of the patients chose surgery. Three of them had injuries that could not be fixed with arthroscopy; these patients had open surgery instead.

The other 48 patients had the arthroscopic procedure. Forty-five were men and three were women. Their average age was 20. Most of the patients were injured while boxing, playing football, doing military training, or wrestling.

Patients had surgery within 10 days of injury. After surgery, they wore a device to keep their shoulders from moving for a month. Strength training started at two months. Full activity was allowed four months after surgery.

Two to five years after surgery, 88 percent of the shoulders that had the arthroscopic treatment were completely stable. When asked to rate their shoulders on a scale from one to 100, with 100 being totally normal, patients who had arthroscopy gave their shoulders a 96. All of the patients with stable shoulders were able to return to sports. These patients also scored well on physical function.

Six patients who had the arthroscopic procedure dislocated their shoulders again. These injuries happened within a year and a half of surgery–or soon after patients resumed full activity.

What led to re-injury? Patients who’d had problems in both shoulders were at greater risk. So were those with more looseness and those who had poor tissue quality at the time of surgery. The authors think that playing collision sports may put patients at risk for another dislocation. But since all of the patients who had surgery returned to sports, this could not be evaluated.

Of the six patients who chose not to have surgery, only two had stable shoulders at follow-up. The other four had problems within a year and a half of treatment. Three of them wound up having surgery.

The arthroscopic procedure seems to be a safe, effective treatment for young athletes. The authors feel that arthroscopic treatment reduces the chance of re-injury compared to other kinds of surgery or no surgery at all.

Scoping Out Surgery for Torn Rotator Cuff Tendons

The shoulder is now recognized as one of the most common places for injury. Sports activities, work-related events, arthritis, and the wear and tear that comes with age can cause shoulder problems. One particular injury is a torn tendon in the rotator cuff. Tendons connect muscles to bones. By pulling on the tendon, muscles are able to make bones move.

The rotator cuff is made up of four muscles. The tendons of the rotator cuff encircle the shoulder joint the way the cuff of a shirtsleeve circles the wrist. The rotator cuff holds the upper arm bone into the joint socket and turns the arm in and out. When one of the tendons in the rotator cuff is injured, torn, or damaged, pain and loss of motion occur.

Surgery is sometimes required to repair the torn tendon. The surgeon makes an incision into the shoulder to find and repair the torn tendon. A second way to reach the muscle is with an arthroscope, a small TV camera that allows the doctor to look inside the joint without cutting open the shoulder. The exact method used to repair the torn tendon depends on the shape of the tear.

Doctors doing this type of shoulder repair with an arthroscope would like to know: how good are the results? Does it matter how large the tear is or how long ago the muscle was injured? By reviewing 59 cases of arthroscopic rotator cuff repair, one physician was able to report good results. The results were measured by decreased pain and increased shoulder motion, especially the ability to use the arm overhead.

More than half of the people in this study had large or very large tears. No matter the size of the tear, almost everyone (95 percent) reported good to excellent improvement by the end of four months. In fact, even massive tears fared better with the arthroscope compared to past studies using “open” methods of surgery. (Open surgery requires the surgeon to make a large incision through skin and muscle to operate on the torn rotator cuff tendon.)

Arthroscopic repair can be successfully used with rotator cuff tears of all sizes and shapes–even tears from several years ago!

Reaching toward Effective Treatments for “Frozen Shoulder”

Talk to patients who’ve had one, and they’ll tell you it was no fun at all. Frozen shoulder, medically termed adhesive capsulitis, causes the shoulder joint to tighten up and become severely painful, making it difficult if not impossible to complete daily tasks.

Physical therapy treatments and in some cases injections into the shoulder joint help, but getting patients back to full function often takes weeks, even months. Doctors may recommend a more aggressive and immediate form of treatment that often provides prompt results. Manipulation under anesthesia, abbreviated MUA, is done by forcefully stretching the tight shoulder of a patient who’s asleep from anesthesia.

Which treatment for frozen shoulder works best? Or could the right combination of proven treatments work even better? Faster? To get to the bottom of these queries, researchers compared two ways of performing MUA for frozen shoulder. They tested whether MUA could be improved by first injecting a steroid medication into the shoulder joint.

Twenty-four patients underwent MUA and participated in the follow-up. Just over half had gotten the manipulation plus the steroid shot; the other group had the manipulation procedure without the shot.

Manipulation improved shoulder motion within one day in all but two patients. Four months later, all but three patients’ symptoms resolved. The profound improvements from the procedure led the authors to herald that “manipulation under anesthesia is a useful way to treat frozen shoulder.”

Interestingly, there were no major differences in results between those who’d gotten the shot and those who hadn’t. The shot simply didn’t add any measurable benefit. Thus, the authors recommend that these shots not be used in conjunction with the manipulation procedure.

Will Rotator Cuff Surgery Give You the Cold Shoulder? A Ten-Year Check-Up

Rotator cuff tears are commonly repaired with surgery. Short-term results are good, but few studies have looked at how people fare years after surgery. These authors wanted to know whether patients who had rotator cuff surgery still had good results ten years later, and how the results changed over time.

Thirty-three patients had surgery for rotator cuff tears. All of them had tried other kinds of treatment such as rest, physical therapy, and anti-inflammatory drugs before they had surgery. Their average age at the time of surgery was 55 years. Most of the patients were men.

Before surgery, patients filled out questionnaires about their pain and ability to do daily activities. They did these same questionnaires two and ten years later. Their shoulder strength was also measured. From this information, the authors gave each patient a “grade” before surgery and at each of the follow-ups. In addition, patients were asked about their activity levels. They were given a “disability rating,” which specifically described their ability to do daily tasks.  

Taking into account the effects of aging, patients’ grades for pain and function were even better at ten years than at two. At two years, 88 percent of them got good or excellent grades. The same was true for 91 percent at ten-year follow-up.

Patients generally felt they had good results. Most of them said their shoulders were “nearly normal” two years after surgery. This did not change at ten years.

In spite of this, patients were generally less active over time. At two years, ten of them had very low activity levels. By ten years, this number had gone up to 18. Many of the patients had reached the age of retirement by this point. Twelve of them had the same jobs they’d had at the two-year follow-up, but 19 had retired. Only two patients had to retire because of shoulder problems, though.

Patients had less disability with time. At two years, eight patients were unable to do normal activities, whereas this was only true of one patient at ten-year follow-up. This could be because patients became less active in later years, meaning fewer demands were placed on their shoulders.

Only three patients had unsatisfactory results from surgery, but all three started out with massive rotator cuff tears. Patients with small or medium tears had excellent results ten years later. The authors conclude that the results of rotator cuff surgery do not worsen over time. For patients close to retirement, the results may even get better.

Good News for Shoulder Arthroplasty Patients: A Bone Graft May Help

Total shoulder replacement generally has a good rate of overall success. However, if a problem develops with the replacement shoulder, it is usually because the glenoid, or socket, component has failed. The glenoid part of an artificial shoulder prosthesis loosens in about 10 percent of cases. Sometimes the natural socket wears away so significantly or unevenly that there isn’t enough bone to keep the artificial shoulder in place or placed correctly. 

In a recent study, two doctors tracked the success of glenoid bone grafting as part of total shoulder arthroplasty. They wanted to determine whether adding bone to the glenoid and securing the graft with screws could lead to a better result for some patients.

Out of 132 total shoulder arthroplasties, 21 patients received a large bone graft to correct a problem with the glenoid. The need for a bone graft was determined by two factors: (1) if there wasn’t enough bone present to securely attach the prosthesis and (2) if an unevenly worn glenoid would leave the component improperly aligned. This was determined by X-rays or computerized tomography (CT) before surgery.

In most cases, the surgeon took the bone graft from the part of the patient’s own humerus (upper arm bone) that was removed to insert the ball portion of the new shoulder joint. 

Sixteen patients (17 shoulder arthroplasties) were studied afterwards (nine men and seven women). The average age of the patients was 56 years old. All the patients had some shoulder instability before the operation. Thirteen of the shoulders were studied for an average of 70 months.

Five of the arthroplasties failed, including two in a patient who had both shoulder joints replaced. In all five cases, the glenoid component loosened. However, the other 12 patients reported significant pain relief as a result of the procedure. All 12 reported satisfaction with the surgery. Nine of the 12 patients also had good stability between the glenoid and the humerus. Fourteen of the 17 bone grafts healed in the correct position. In all, nine of the 17 shoulders showed good function.

The researchers concluded that although the glenoid bone grafting procedure is a difficult one, it holds the potential to improve the outcome of total shoulder arthroplasties. The procedure can increase the amount of bone in the socket and allow for a more natural position of the glenoid component.

Shoulder Dislocation: Surgery or Sling?

You don’t have to dislocate your shoulder to sense how much it would hurt. The ball of the upper arm bone, the humerus, gets pulled out of the socket, the glenoid. An injury like this can end up stretching and possibly even tearing important shoulder structures. 

Doctors will often put the shoulder back in place, then have the patient wear a shoulder sling for a few weeks. Unfortunately, the shoulder often dislocates again. The chance of dislocation is generally higher for younger patients and those participating in sports. Shoulders tend to dislocate again because the shoulder “anchors” have been stretched and damaged from the initial injury. 

Some orthopedic surgeons questioned whether the traditional way of dealing with dislocated shoulders (using a sling) was good enough. They wanted to know whether repairing the injured tissue by arthroscopic surgery would be more helpful.
 
Over a period of eight years, these surgeons worked with 46 people under age 30 who had dislocated their shoulder playing a sport. The average age was 21, and the most common sport was rugby. The surgeons provided the traditional option of wearing a sling after the shoulder was put back in place. The other option was surgery, along with a shoulder sling. Both groups received the same intensive physical therapy and rehab program after surgery.
 
The result was startling. Of the 28 who had surgery, 25 had an “excellent” outcome. This meant they had full shoulder motion, no pain, and a stable shoulder. The other three in the surgery group had a “good” outcome. In the years after surgery, only one person in the surgical group went on to dislocate the shoulder again.

Of the 18 patients who opted for the traditional approach, only one had a “good” outcome. Seventeen ended up dislocating the same shoulder again within about one year (six months average). If other studies have similar results, surgery will likely replace the sling as the gold standard for treating a dislocated shoulder.

Rotator Cuff Surgery Not a Handicap for Golfers

Golf often results in rotator cuff injuries. Aging is also related to rotator cuff injures. The result is that many rotator cuff tears happen in recreational golfers. There have been studies to determine how effectively baseball pitchers or tennis players can return to competition after surgery to repair rotator cuff tears. But so far, there has been little information on recreational golfers.

The authors of this study set out to correct that. They checked in with 29 recreational golfers who had undergone surgery to repair full-thickness rotator cuff tears. Most had moderate-sized tears. All the patients had also undergone acriomioplasty, which involves removing a small piece from the top edge of the shoulder blade. Acromioplasty is commonly performed during rotator cuff repairs. All of the golfers had been forced to stop playing golf because of their shoulder pain. The average age of the golfers was 60. The surgeries were almost equally divided between open surgery, done by cutting through the muscles, and arthroscopic surgery. Arthroscopic surgery uses a tiny TV camera to show the surgeon the inside of the joint, which allows for smaller incisions.

The authors interviewed the golfers an average of three years after surgery. All patients reported being satisfied with surgery. Physical testing showed 87 percent excellent and 10 percent fair results. A whopping 90 percent of the patients had returned to playing golf, and 88 percent of them felt they were playing at their former competitive level. Neither of the patients with massive tears had returned to playing golf. However, of the three patients who no longer played golf, one had been in a car accident and re-injured the shoulder, one had stopped playing for other reasons, and one had developed chronic shoulder problems unrelated to surgery. The authors didn’t see any significant differences between golfers who had injuries to the lead shoulder or those who had injured the back shoulder.

This study shows that golfers are more likely to be able to return to their pre-injury competitive level than pitchers or tennis players. The authors attribute such success to three factors. First, the athletes they studied were recreational athletes, not the high-level athletes commonly included in many other studies. Recreational golfers put much less stress on their shoulders than professional golfers. Second, in all cases the surgeons could reattach the tears to bone in the correct position. Third, most of the patients really wanted to golf and be active again.

These players followed their rehabilitation plan closely, which included wearing a sling at first and doing passive motion exercises right away. Active exercises began from four to six weeks after surgery, and resistance exercises 10 to 12 weeks after surgery. Patients weren’t allowed even to try chipping and putting until three months after surgery, and driving was allowed only four to five months after surgery.

It may not seem overly important to make sure that older people can continue to golf after rotator cuff surgery. But, as the authors conclude, golf is an enjoyable way for many people of all ages to socialize and stay fit. In many countries, 10 to 20 percent of the population plays golf. Not being able to play golf after rotator cuff surgery would be a major handicap to a lot of folks.

One Plus One Equals Relief of Shoulder Pain

Some patients with shoulder problems end up needing two different procedures to relieve their pain and return their range of motion. Arthroscopic subacromial decompression involves relieving pressure underneath the acromion (the top part of the shoulder blade). Arthroscopic resection of the clavicle (collarbone) involves taking off the end of the clavicle to relieve pain in the acromioclavicular (AC) joint. The AC joint is where the clavicle and acromion meet.

Both procedures have been proven effective when they are done separately. These authors did both procedures at the same time. They performed 32 surgeries in 31 patients. The authors followed up with the patients an average of five years after surgery. All patients were satisfied with their surgery. Only five patients had even mild or occasional pain, and that was only with strenuous overhead activities. Strength and motion tests showed no significant difference between the patients’ healthy shoulders and the shoulders that had surgery.

Before their injuries, 25 of the patients had been involved in sports, including four professional athletes. Significantly, 22 of the 25 returned to their previous level of play, including the four professionals.

The authors conclude that the two procedures are safe and effective when done together. And results using the arthroscope were as good as surgeries using an open approach. That’s good news for the group of patients that need both procedures to return their shoulders to full strength. Arthroscopic surgery is done using a small fiber-optic TV camera so surgeons can see the area they are working on. The arthroscope allows much smaller incisions. An open approach requires a longer incision and tends to disrupt the muscles around the shoulder.

A+ Results Long after Rotator Cuff Repair

Doctors and researchers know a lot about the short-term benefits of repairing rotator cuff tears. But how do these repairs hold up over time?

The authors followed up on 105 surgeries done between 1975 and 1983. All the surgeries repaired a full-thickness rotator cuff tear. All the patients also had an acromioplasty, which involves removing a part of the acromion (top edge) of the shoulder blade. The authors found that the surgeries successfully eased pain and greatly improved shoulder range of motion and strength in most cases. Overall, about 80% of the shoulders had an outcome rated excellent or satisfactory an average of 13 years after surgery.

When the authors analyzed the patient information, they discovered that large tears had worse outcomes than medium or small tears.
Patients with small tears had 94% excellent or satisfactory results. Patients with medium tears had 85% excellent or satisfactory results. This compares to 74% of patients with large tears and only 27% of patients with massive tears. In general, older patients had larger tears. For some reason, women also had somewhat worse results than men overall.

The authors give rotator cuff surgery an “A” on the test of time. They suggest that new technology and surgical methods should focus on better repair of large rotator cuff tears.

Rotator Cuff Surgery Passes the Test of Time

Repairing rotator cuff tears can give patients relief and return motion to their shoulders. But how well do these repairs hold up over time? These researchers looked at how a certain type of arthroscopic repair held up over the years. The mini-deltoid splitting method of repairing the rotator cuff involves slightly extending the incision on the point of the shoulder. In this way, the surgeon can separate the deltoid muscle to see and repair the torn rotator cuff.

The authors followed up on 60 rotator cuff repairs an average of two years and an average of five years after surgery. Subjects were asked a standard set of questions about shoulder pain and function. The results were compared to answers to the same questions before surgery. In all cases, the results were markedly better on the first follow-up than before surgery. And these good results held up. At the second follow-up, the subjects showed results that were just as good. Both follow-ups showed 80% good or excellent results from surgery.

The patients who had unsatisfactory outcomes were more likely to have had a massive tendon tear. They were also more likely to have already had shoulder surgery, including rotator cuff repairs. Eight patients developed complications. All but one of the complications developed in the first eight months.

This is good news for those who have had–or who are going to have–arthroscopic rotator cuff repair with the mini-deltoid splitting procedure used in this study. Based on this research, the chances are high you’ll end up with good to excellent results.

Ultrasound Gaining Acceptance in Diagnosing Shoulder Problems

A wide variety of tools are available to a physician to determine the extent of a serious shoulder injury. This is especially true for injuries to the rotator cuff muscles of the shoulder. The rotator cuff muscles consist of a small group of four muscles surrounding the shoulder. These muscles aren’t responsible for forceful movements. Instead, they guide the movements of the shoulder.

High-resolution ultrasound has recently become popular as a tool to help diagnose the extent of tears to the rotator cuff following shoulder injury. This recent study determined that ultrasound is a very effective way to help diagnose the extent of rotator cuff tears. In fact, with complete tears to the rotator cuff, ultrasound accurately diagnosed the problem 100% of the time. Ultrasound also helped correctly identify tears to the biceps tendon approximately 60% of the time and shoulder dislocations over 90% of the time.

Doctors may still try conservative measures such as medication, physical therapy, and time to help heal a shoulder injury. But ultrasound has been proven a very effective tool to help doctors diagnose the nature and extent of shoulder injuries, especially rotator cuff tears.

Acute Surgical Stabilization for First-Time Shoulder Dislocation

The military is a good place to study injuries in young athletes. The need to return soldiers to their line of duty sometimes means they are treated more aggressively than is common in the civilian population. In this study, a group of 48 soldiers were treated surgically for a first-time anterior (forward) shoulder dislocation. The long-term results of this approach are investigated.

First-time shoulder dislocations are often treated conservatively without surgery. A rehab program of exercises to strengthen and stabilize the shoulder is recommended. Soldiers (and athletes) get back into action after several weeks to months. But there’s always the risk of another shoulder dislocation. Recurrent dislocations occur most often with extreme activity such as volleyball, football, water skiing, and military training.

First-time dislocations with severe damage to the shoulder are more likely to be repaired surgically. This is often the case when there has been a capsulolabral avulsion. This type of injury refers to the fact that the labrum has pulled away from the bone. The labrum is a dense ring of fibrous cartilage around the shoulder socket. It gives the shoulder socket some depth and provides the shoulder with increased stability.

If the labral tear extends up far enough, it will even pull some of the biceps tendon away from where it inserts into the labrum. The surgical procedure used most often to treat this type of injury is called the Bankart repair. During the procedure, the surgeon repairs each of the soft tissues damaged by the dislocation. Suture anchors are used to hold the biceps in place.

Studies show that early results of surgical stabilization are excellent. This study attempted to report on the long-term results. They followed their patients for at least nine years (some as long as 14 years). They used patient questionnaires to ask about shoulder/arm function, pain levels, and patient satisfaction with the results.

Because this was mostly a military group, return to athletic activity and physical conditioning (such as doing push-ups) were also monitored. Only one person left the military for medical reasons and that was not for a shoulder problem. About 40 per cent of the group had recurring instability (partial or complete dislocation). A small number of these patients went on to have a second (revision) surgery to stabilize the shoulder.

Good shoulder function was reported for all patients in the study — even those who had recurrent dislocations. Good shoulder function means they returned to unrestricted physical activity required by their jobs and daily activities. That was important as this group of patients had a vested interest in returning to active duty status or returning to military academy in order to graduate.

The authors acknowledge this treatment of surgical stabilization for first-time acute anterior shoulder dislocation is considered too aggressive by some experts. But they defend this practice because their studies and records show very poor results for soldiers with conservative care for this injury. They make note of the fact that this population is unique in that they cannot modify their activities.

This more aggressive approach made it possible for military patients to resume full activities and complete their military obligation. Long-term follow-up revealed the patients were satisfied with the results. Most of them said they would do it over again the same way if given the choice.

The authors also note that the system used in a Bankart repair for these patients treated in the mid-1990s was a tack system (Suretac device), which has since been replaced by the suture anchors used today. It’s unknown how the long-term results compare between the tack system and suture anchors.

Putting the Squeeze on the Rotator Cuff

The action of throwing requires an athlete throwing overhand to “cock” the shoulder back. When this motion is repeated, soft tissues can get squeezed between the bones of the shoulder, causing the underside of the rotator cuff tendon to rub. When this happens, the athlete may begin to feel stiffness in the shoulder, even after a good warm up. The shoulder pain is usually vague at first but is pinpointed to the back part of the shoulder as the problem gets worse. Pain is most noticeable as the arm is cocked back to throw and when the arm starts to come forward.

The same pain can be reproduced when an examiner puts the shoulder into the cocked position. Other tests, such as MRI scan, may also be required to see if the rotator cuff is rubbing. If the problem is detected early, the athlete is treated by resting the shoulder for one month and then starting a strengthening program for the rotator cuff and the muscles around the shoulder blade. Shoulder surgery may be needed if the athlete has had the problem for a while, shows a positive MRI, and has not gotten better with rest and exercise.

Honey, I Shrunk the Joint Capsule

When a joint is unstable, surgeons sometimes tighten the joint by sewing the tissues of the joint capsule together. The joint capsule is a watertight sac that holds fluids that lubricate the joint. Now doctors have another way to tighten the joint capsule. The procedure is done using a laser beam.

A major benefit of using the laser for this surgery is that the surgery can be done using an arthroscope. An arthroscope is a tiny TV camera that is inserted into the joint through a very small incision. This allows the surgeon to watch what he or she is doing on a TV screen during surgery. The small incision allows quicker healing times.

Multidirectional instability (MDI) of the shoulder is a common and serious type of joint instability. In this study, researchers followed up with patients who had been treated for shoulder MDI by using lasers to shrink the joint capsules.

All 26 patients in this study had tried conservative treatments and physical therapy before getting surgery. Because one patient had surgery on both shoulders, the study actually followed 27 surgeries. Of these, 26 were stable and showed no symptoms at least two years after surgery. Fourteen of the patients had been athletes before surgery, and 12 of them were eventually able to return to their sports at the same level.

The authors conclude that laser shrinkage can be an effective treatment for MDI. However, they point out that certain parts of the capsule resist shrinking with the laser. This means that some sutures may still be necessary, even when the laser is used. The authors say that more long-term studies are needed. They are continuing to follow the original patients and plan to report on how these patients are doing four to six years after having surgery.