News Category: Shoulder

The acromioclavicular (AC) joint has come back into sharp focus in recent days. Because of changes in surgical technology, new advances have been made in the surgical treatment of this problem. You might know this condition by its more commonly used name: shoulder separation.

A shoulder separation is a fairly common injury, especially in certain sports. Most shoulder separations are actually injuries to the acromioclavicular (AC) joint. The AC joint is the connection between the scapula (shoulder blade) and the clavicle (collarbone). Shoulder dislocations and AC joint separations are often mistaken for each other. But they are very different injuries.

For more complete information on AC joint separation, see A Patient’s Guide to Acromioclavicular Joint Separation.

AC joint separations are graded from mild to severe, depending on which ligaments are sprained or torn. The mildest type of injury is a simple sprain of the AC ligaments. Physicians call this a grade one injury. A grade two AC separation involves a tear of the AC ligaments and a sprain of the coracoclavicular ligaments. A complete tear of the AC ligaments and the coracoclavicular ligaments is a grade three AC separation. This injury results in the obvious bump on the shoulder.

Treatment for a grade one or grade two separation usually consists of pain medications and a short period of rest using a shoulder sling. The rehabilitation program may be directed by a physical or occupational therapist. The treatment of grade three AC separations is more controversial as there is no “gold standard” or best known approach to the problem of an unstable AC joint.

One of the reasons why it is difficult to identify a gold standard in the surgical treatment of grade three AC separations is the wide variation in the pattern of injuries. The anatomic complexity of the joint is another reason why treatment is not straight forward or cut and dry. For example, with all of the ligaments connecting everything together, injury to even one ligament shifts the load and strain on the joint. In turn, the rest of the soft tissues surrounding the AC joint are adversely affected by these changes.

With all of these factors and variables in mind, let’s take a look at what is happening in the surgical treatment of grade three AC joint separations. The advancement of arthroscopic techniques has made it possible to repair or reconstruct this joint without making a large incision to expose the joint and its soft tissue attachments.

Surgeons have found that the separated joint can be held together with a graft (ligamentous tissues taken from some other part of the body or from a donor bank). Efforts to develop a synthetic (manmade) graft substitute have failed so far. Surgeons have returned to natural graft sources taken from tendons in the patient’s forearm.

They have also tried different suture techniques (e.g., suture sling fixation, cortical buttons, flip-button suture device) when putting the joint back together. Keeping the AC joint stable with load, movement, and activity is a challenge. For chronically dislocating AC joints, special “hook plates” have been devised to hold the widely separated joint together until soft tissue healing can take place.

The availability of these new graft and suturing techniques has made it possible for surgeons to refine their surgical technique. The treatment of chronic AC joint dislocation after failed conservative care is now possible with new hardware technology.

Complications previously reported such as button suture migration (movement) and osteolysis (bone absorption) are greatly reduced now. These new fixation practices made possible by the use of arthroscopy has made the difference. In places where extreme trauma has resulted in an injured ligament that is not expected to heal, the combined use of new graft, suturing, and fixation techniques may make reconstruction successful now.

The open-incision surgical technique is still used by many surgeons. In fact, the surgeon who reviewed all the surgical methods available and wrote this review article prefers the open technique. It makes the use of allograft tendon easier to reproduce anatomically correct ligaments for AC joint stability.

The conclusion of this article is that the surgical management of acromioclavicular joint dislocations (shoulder separation) has been updated in the last few years. New techniques, improved fixation hardware, and the study of the biomechanics behind these injuries has led to better surgical treatment of these complex AC joint injuries.

More study is still needed to report on complications with various reconstruction strategies. Comparison of results between the open surgical treatment of AC joint injuries and partially open or closed (arthroscopic) procedures is also needed.

Dr. William J. Robertson of Massachusetts General Hospital in Boston offers the results of his own study of surgery for acromioclavicular (AC) joint pain. Comparisons were made in terms of results (shoulder function, patient satisfaction, pain) between two groups. The first group had an open incision approach for this procedure. The second group had all all-arthroscopic approach with very small puncture holes to insert the arthroscope rather than full sized incisions.

The acromioclavicular joint is located in the front of the shoulder where the acromion meets the clavicle (collar bone). The acromion is a curved piece of bone that comes from the back of the scapula (shoulder blade). It forms a little bony “roof” over the shoulder joint.

Sometimes the end of the clavicle that meets the acromion becomes degenerated and very painful. Conservative (nonoperative) care usually takes care of the problem. The patient takes antiinflammatory medications and works with a physical therapist. Treatment extends over a period of three to six months. The goal is to reduce pain, restore normal posture and alignment, and improve motion and function.

If the patient does not achieve a satisfactory response from this approach, steroid injections (up to three spread out over three to six weeks) may be tried. When all else fails, then surgery becomes a consideration.

In the case of the 48 patients in this study, all had failed at least six months of conservative care. Surgery to remove the distal end of the clavicle was performed by Dr. Robertson. In 32 of the shoulders, arthroscopic surgery was performed. In 17 shoulders, the open incision method was used. Dr. Robertson describes both of these procedures in detail in this article.

The pros and cons of both approaches are discussed. Briefly, open incision allows for direct visual inspection of the joint. The surgeon can remove exactly the amount of bone necessary to take care of the problem. But in order to do so, the surgeon must cut through the soft tissues, joint capsule, and ligaments supporting the acromioclavicular (AC) joint.

As you might guess, the arthroscopic procedure has just the opposite advantages and disadvantages. The surgeon does not make a large incision and therefore does not have a wide direct view of all the anatomic structures. But at the same time, none of the soft tissues are cut and therefore do not lose their integrity. Stability of the joint is maintained. And the surgeon can look around inside the joint to see if there are other areas of damage that need repair. That is a big advantage over the open incision approach.

So, how did the results of these two groups compare? The group who had arthroscopic surgery to remove the tip of the clavicle had less pain than the open incision group. But all other areas measured (satisfaction, shoulder function, willingness to have the surgery again) were pretty much the same between the two groups. Patients in both groups had other damage that was repaired (e.g., rotator cuff tears, biceps tendinopathy, labral tears).

Dr. Robertson concluded that for chronic acromioclavicular (AC) joint arthritic pain, either surgical method (arthroscopic or open incision) is equally effective in alleviating painful symptoms and restoring normal motion and function. Open incision is more invasive and has greater reports of pain after the procedure. But four to five years later, the final outcomes are the same.

Surgeons who are less experienced with arthroscopy may want to continue with open incision procedures. Patients with large bone spurs or cysts may also need the open incision approach. For the experienced surgeon (like Dr. Robertson), operative time is equal between these two techniques so there isn’t an advantage of one over the other from that perspective.

There were two caveats (“yes buts”) to this study. The first was the small size. With only 48 patients (a total of 49 procedures), the results may not apply to everyone. A larger sample size should be studied and compared.

The second point is that patients weren’t randomly assigned to one group or the other. They were given the choice of which approach they would prefer. The equal success between the two groups may be linked to the patient’s positive feelings about the technique used. Further studies should include not only a larger number of patients but also random selection of treatment for each one.

Having one shoulder dislocation is scary enough. But imagine having the shoulder pop out of the socket again — or again and again. Recurrent shoulder dislocations is the subject of this study. Orthopedic surgeons from the Netherlands add their efforts and expertise to many others looking for risk factors for recurrent shoulder dislocations.

Previous studies have pointed to young age, male sex, and long delay between injury and surgery as the main risk factors for recurrent shoulder dislocations. Other studies have suggested the number of preoperative dislocations as being another possible risk factor for future dislocations. Participation in contact sports may be a risk factor as well.

In this study, the role of suture anchors in recurrent shoulder dislocations is explored. Suture anchors are the type of “stitches” that are used to reattach the torn tendon and capsule back to the shoulder socket. There has been some awareness that a low number (less than three) of suture anchors used might contribute to an increased risk of recurrent shoulder dislocations.

In addition to looking at the number of suture anchors compared with shoulder dislocations, the authors also re-evaluated the other known risk factors (e.g., age, sex, more than six months between injury and surgery) for their patient population. There were 67 patients (mostly professional or recreational athletes) in the study. They were all treated by the same orthopedic surgeon.

Shoulder instability was caused by a traumatic event in all cases. Surgery to repair the damage was done for everyone arthroscopically using suture anchors. The suture anchors were absorbed by the body and therefore did not have to be removed. Details of the surgical procedure are provided in the article for surgeons interested in how the author performs his surgeries.

After surgery, everyone was placed in a sling to immobilize the shoulder for six weeks. Then they all participated in a rehab program directed by a physical therapist. Return to sports activities was allowed when the athletes were deemed “ready” by the surgeon and therapist (usually four months after surgery).

Telephone surveys and written questionnaires were used as the main tools to evaluate results. The main interest was if any (and how often) shoulder dislocations occurred after surgery. Overall shoulder function was also evaluated. The patients were followed-up for 10 years to give an idea of intermediate results.

Ten years after the surgery, more than one-third (35 per cent) of the group had at least one redislocation. The number of cases was divided equally over time (an equal number occurred during the first two years, two to five years after surgery, and more than five years after surgery).

Two factors showed as being possible risk factors but without statistical significance. These included using less than three suture anchors and the presence of damage to the labrum. The labrum is an extra layer of fibrous cartilage around the shoulder socket that helps keep the head of the humerus (upper arm bone) stable in the socket.

In the group who had a shoulder redislocation after surgery, two-thirds had been repaired with only two suture anchors. None of the other reported risk factors were found to be influential in this study. One other observation was noted: athletes involved in overhead sports actually had fewer shoulder redislocations compared to other sports participants. The authors suggest perhaps these athletes had better muscle control or proprioception (sense of joint position) to explain the difference.

Although many studies have been done looking at risk factors for recurrent shoulder dislocation, this may be the first long-term (10 years or more) study to report on the role of suture anchors. The results confirm what surgeons know now that they didn’t know 10 years ago: two (or less) suture anchors simply aren’t enough to hold the shoulder. The need for at least three suture anchors is confirmed by the results of this study.

Two other comments of interest were made by the authors. First, as might be expected, patients who do not ever redislocate have better shoulder function compared with those who do experience a redislocation. And second, redislocation doesn’t always occur right away. More than half in this study didn’t happen until at least two years had passed since the surgery. Continued study is needed to better understand this second phenomenon.

Shoulder problems are common with a wide range of symptoms and treatments. One diagnosis that continues to challenge orthopedic surgeons is called multidirectional instability. This diagnosis is defined by instability of the shoulder in two (or more) directions. That sounds simple enough but there are shades of instability. And instability must be separated out from laxity (natural looseness of the ligaments).

In this article, three surgeons from three separate educational programs combine their expertise to review the problem and management of multidirectional instability (MDI). They define MDI as instability in two or more directions that presents with bothersome symptoms. There may or may not be hyperlaxity present.

The shoulder is a very complex structure. Stability depends on many different soft tissues including muscles, ligaments, tendons, joint capsule, and the labrum. The labrum is a special rim of fibrous tissue around the shoulder socket to give it greater depth.

Some structures function to dynamically stabilize (hold) the shoulder in place. Muscles and tendons are dynamic stabilizers. Other soft tissues are more static, providing a steady holding power instead. Ligaments, capsule, bone, and labrum are more static in their function.

When any of the stabilizing soft tissues are torn, damaged, or not functioning properly, other structures try to compensate. Now they must do their own job as well as the work of the deficient soft tissues. They can’t keep this up forever. Eventually the compensatory mechanisms fail and problems develop. Multidirectional instability is often one of those resultant problems.

Treatment of any orthopedic problem is best approached using a classification system. For example, in the case of shoulder instability, if the surgeon can identify the direction of instability, severity of instability, and presence of hyperlaxity, then a specific plan of treatment can be developed.

Having a classification system that includes whether there is dynamic versus static instability would be helpful in determining the most optimal treatment plan for each patient. But such a guiding classification system for multidirectional instability (MDI) is not available yet.

The authors suggest different classifications of MDI would respond differently to conservative (nonoperative) versus surgical intervention. For example, someone with a shallow glenoid cavity (shoulder socket) may benefit from rehab to strengthen the muscles around the shoulder.

Rotator cuff strengthening often increases the ability of the humeral head to stay compressed inside the socket. A strong rotator cuff also helps the shoulder resist translational (shear) forces. Restoring normal proprioception (joint sense of its own position) has been shown to improve motor control, thus increasing dynamic stabilization.

In recent years, the important role of the scapula (shoulder blade) in shoulder motion has been recognized. The scapula and shoulder must move together in harmony and with just the right rhythm and flow. Without this dynamic dance, a condition called scapular dyskinesia can develop resulting in shoulder problems and contributing to the instability.

The rehab program must address strength, endurance, proprioception, motor control, and coordination of the entire shoulder complex (including the scapula). Such a program is directed and supervised by a physical therapist. Patients must be advised to plan on at least a six month trial of concentrated efforts in rehab with a lifelong maintenance plan urged.

Some patients with shoulder instability may also do well with a rehab program while others will eventually require surgery. Sometimes recovery of stabilizing motor activity isn’t possible without shifting the capsule or repairing the rotator cuff. Other reconstructive techniques may be needed to fix the anatomic cause of shoulder instability.

The authors offer a detailed discussion of the various surgical interventions that can be used to halt debilitating symptoms of shoulder instability. They include techniques such as open inferior capsular repair, thermal capsulorrhaphy, arthroscopic capsular plication, and rotator interval closure procedures. Drawings, arthroscopic photos, and verbal descriptions of each are provided.

Each of these procedures must be followed by postoperative rehabilitation. The surgeon and physical therapist work closely to develop a specific program for each patient. The therapist works with the patient prescribing exercises based on the direction of the primary (main) instability and type of surgical repair performed. The ultimate goal is to restore normal shoulder motion, preventing stiffness, and helping the patient regain full activity.

Despite all that is known about multidirectional instability (MDI) of the shoulder, there remains much yet to be discovered. For example, the authors point out the need for a classification system to direct and guide treatment. Having a way to identify patients who would have the best outcomes with rehab versus surgery would be helpful.

Likewise, research is needed to develop some criteria for determining who should have each one of the possible surgical options based on best outcomes. There may be other (better) reconstructive techniques waiting to be discovered. Studies comparing results among all the various treatment options are helping surgeons make decisions but the authors say that more information is still needed.

Surgeons around the world are trying to solve the mystery of rotator cuff tear failure after surgical repair. In this study, researchers at the Seoul National University College of Medicine in Korea join the search.

Multiple studies have shown that the failure rate after rotator cuff repair ranges from 20 to 94 per cent. Although there are many potential risk factors, the authors of this study were looking for prognostic factors. Prognostic factors are patient characteristics that when present predict a failed result.

In order to pinpoint the specific prognostic factors, the authors cast a wide net so-to-speak. In other words, they analyzed the effects on results of many variables including patient age, sex (male versus female), symptom duration, size of the tear, smoking, and repair technique used.

They also considered the amount of fat that had filled in the tear as a possible risk factor. This attempt at healing is called fatty infiltration. Presence of other medical problems such as diabetes, high blood pressure, osteoporosis, and heart disease were assessed as prognostic factors as well.

After examining the medical records of 272 patients who had a rotator cuff repair, there were three significant prognostic factors for failed healing: 1) low bone mineral density (BMD), 2) fatty infiltration, and 3) tendon retraction. Let’s take a look at each of these predictors and see what clinical implications there are. Low bone mineral density (BMD) is the hallmark finding in osteoporosis (brittle bones).

Without good, solid bone structure, the suture anchors used in the repair loosen and pull out before tendon healing occurs. Suture anchors are used to reattach the torn tendon to the bone. Statistical analysis showed that patients with low bone mineral density had 7.25 times more chance of failed rotator cuff tear surgery compared with patients who had normal bone.

The second prognostic factor (fatty infiltration) was found to be an independent risk factor for failed rotator cuff repairs. Patients with higher amounts of fatty infiltration were more likely to have unhealed responses. Of the four tendons that make up the rotator cuff, fatty infiltration of the infraspinatus tendon was the most significant prognostic factor.

The third and final factor was tendon retraction. The further the tendon pulls away from the bone, the greater the risk of tendon repair failure. There isn’t anything the patient can do to change fatty infiltration or tendon retraction. The surgeon can use specific surgical techniques to work with the soft tissues for the best results.

The real benefit of this study was in recognizing the role of osteoporosis in rotator cuff tear healing. By measuring bone mineral density before surgery, patients at increased risk for failed tendon healing can be identified. With careful management of low bone mineral density it may be possible to improve the healing rate of surgically repaired rotator cuff tears.

How can this be done? Patients can decrease use of tobacco and alcohol while increasing their calcium and vitamin D intake. Proper exercise and medications (e.g., hormone therapy) are also known to increase bone mineral density level. Since osteoporosis and rotator cuff tears are both common in older adults (especially postmenopausal women), efforts must continue to educate everyone of the importance of osteoporosis prevention.

In this way, the success of tendon healing may be improved. Further studies are needed to verify the possible cause and effect of osteoporosis prevention with improved rotator cuff tear healing rates (and reduced failure rates after rotator cuff repair surgery). The authors suggest a well-organized, randomized study to confirm the link between bone mineral density and tendon healing.

Austrian surgeons lend their expertise to the question of why there is such a high failure rate after rotator cuff surgery. In an analysis of 95 patients over an 11 year period of time, they found an overall failure rate of 33 per cent. Most of those weren’t really retears but rather a failure to heal. Their observations as reported in this article are very similar to what other surgeons are finding in other locations.

Each one of the patients in this study was treated with a mini-open arthroscopic repair. The torn tendon was cleaned up if the edges were ragged. Any other damage to the soft tissues around the shoulder were repaired. The tendon was then reattached using a transosseous technique. This method requires drilling holes (tunnels) through the bone and sutures attached to the torn tendon threaded through the tunnels to secure the tendon to the bone.

They were also followed closely with physician examinations and ultrasound images taken every three months for the first year. Pain, range-of-motion, strength, and function were also evaluated. They used the American Shoulder and Elbow Surgeons (ASES) and Constant scores to assess these results. They also took a look at recreational and sports activity levels.

Continued follow-up was done in the same way every year. In this way, the surgeons were able to see at what point a prognosis or prediction could be made about the final results. One MRI was done about five years after the surgery.

MRI results were compared with ultrasound images to confirm ultrasound findings. These imaging studies showed the presence of a tear, size, depth (partial- or full-thickness, and location). The authors report that ultrasound for evaluating rotator cuff repairs and tears is a very reliable tool.

Other than the reruptures, the only other complications or problems reported were a few cases of shoulder stiffness and impingement. One patient had a stroke affecting the involved arm but the stroke was not related to the shoulder surgery.

In addition to the high failure rate, the surgeons could see that patients with the larger tears were more likely to be in the rerupture group. And as expected, there was a direct relationship between retears and scores on the functional tests.

The question is raised: with continued high rates of retears, should rotator cuff repairs be done? The authors conclude Yes because the majority (two-thirds) of all patients have a successful repair. They get significant pain relief and return of motion, strength, and function.

For those patients who had a failed result, this study supports the idea that it’s because the repair didn’t heal. And those reruptures don’t heal on their own. Small tears have a chance of self-healing but most retears tend to get larger over time. For patients who have a successful healing in the first six months, the long-term results are excellent.

In cases of retears that are asymptomatic (no pain or other symptoms), patients eventually start to lose strength. If the tears that develop in the first six months are less than two centimeters in size, the shoulder still functions fairly well. These patients report pain from time-to-time and loss of strength with shoulder abduction (moving the arm out to the side away from the body).

Patients with large tears (more than two centimeters in size) can expect persistent pain and loss of motion, strength, and function. Thus, the authors conclude the timing (early) and size of tear do predict final clinical outcomes. The task remains to find ways to perform the surgery so that everyone has an excellent result and retears are eliminated (or at least decreased considerably).

Surgeons everywhere are grappling with the fact that rotator cuff repairs aren’t always successful. In this review article, surgeons from the well-known San Antonio Orthopaedic Group in Texas discuss the causes of arthroscopic rotator cuff repair failure and how to decide when revision surgery is advised.

Using drawings, patient photos, written descriptions, and arthroscopic views, the authors cover a wide range of information about arthroscopic rotator cuff repair revision procedures. They include a discussion of intrinsic (patient-related) and extrinsic (surgeon-controlled) causes of failure. They also offer ways to evaluate patients in making the decision to do a revision repair. A detailed description of the arthroscopic technique they use is provided.

Most patients suffering from a rotator cuff repair failure want to know why this happened to them. Let’s take a look at causes of failure from both the patient and surgeon side of the equation. The two top factors that put patients at increased risk of rotator cuff repair failure are age and tear size.

Increasing age starting at age 55 has been shown to be a key factor in repair re-tears. Studies show that the rate of healing in patients younger than 55 years of age is around 95 per cent. This declines to 75 per cent for patients between the ages of 55 and 64. The rate of healing takes another nose dive down to 43 per cent in patients 65 and older.

Tear size can also be matched with risk of retear centimeter by centimeter. For example, for every one centimeter increase in tear size, the risk of rotator cuff failure goes up more than two times. With more than one tendon involved, the risk of retear increases nine times.

Other patient-related factors include poor quality of tendon or muscle, smoking, and the patient’s overall health. Patients with chronic systemic conditions like rheumatoid arthritis, heart disease, or diabetes are more likely to experience re-tear after rotator cuff repair.

The role of the surgeon in rotator cuff success is important, too. Low volume (i.e., the surgeon doesn’t do very many of these procedures) has been linked with a higher failure rate. Studies place the number performed to qualify for low volume as fewer than three rotator cuff repairs per months. High volume (the surgeon performs more than three rotator cuff tear repairs each month) increases the likelihood of a good result.

Surgical technique is also important. The surgeon must accurately assess each patient for the best repair approach. The technique selected depends on whether the repair is for a single tendon (versus multiple tendons), full-thickness versus partial-thickness tears, and tear pattern. Tear pattern refers to the shape of the tear (U-shaped or L-shaped).

Then there is the decision to repair a rotator cuff failed surgery. Not everyone with a re-tear even knows the tendon has come undone. Sometimes the patient is completely asymptomatic (without symptoms). There is no pain and weakness or loss of function are not significant enough to report.

And the presence of pain and loss of motion doesn’t always signal a failed surgery. There could be some other complication such as infection or systemic disease referring pain to the shoulder. A careful evaluation is needed to sort out the cause of shoulder pain and need for further surgery. The surgeon performs various clinical tests, orders imaging studies, and considers the need for electrodiagnostic testing.

Revision surgery is only needed when the patient continues to have chronic pain months to years after the original surgery and the problem has been diagnosed as rotator cuff repair failure. All efforts to treat the problem conservatively (without surgery) have failed to change the picture for the patient. And (very importantly), the patient does not have multiple risk factors for failure.

Patients should be counseled before having a revision surgery for failed rotator cuff repair. They should be told that the results are likely not going to be as good as with a successful first repair procedure. But the improvements in pain, motion, and function will probably be better than without the revision surgery. Recovery and rehabilitation are likely going to take longer after a revision surgery compared with the primary (first) repair.

This information is based on evidence from many studies reporting final outcomes following rotator cuff revision surgery. Surgeons report a 64 per cent good-to-excellent result with a 93 per cent patient satisfaction rate following arthroscopic revision rotator cuff repairs.

All is not lost if a patient experiences a poor or failed result after rotator cuff repair surgery. Massive tears with poor recovery may be treated with a shoulder replacement procedure. But the hope and goal of primary and/or revision rotator cuff repair surgery is to preserve the patient’s natural anatomy and function.

The list of things that can cause mechanical shoulder pain is long and getting longer. By mechanical we mean anatomic factors such as compression or degeneration. The term mechanical shoulder pain leaves out problems like infection, tumors, or other systemic causes.

One of the most common causes of mechanical shoulder pain is a problem labeled subacromial impingement syndrome or SIS. The term impingement tells us something is getting pinched. Subacromial impingement syndrome occurs when the rotator cuff tendons rub against the roof of the shoulder, the acromion.

Although SIS is one term, it actually represents a wide range of underlying pathologies. There could be a bursitis, rotator cuff tendinopathy, fracture, calcific tendinitis, or other change in the local anatomy contributing to the problem.

There are many factors that when present combine together to result in subacromial impingement syndrome. Aging with its many degenerative processes isn’t always very kind to the shoulder. Bone spurs form, the rotator cuff and other soft tissues fray and wear thin, and trauma all add to the development of mechanical shoulder pain. Loss of blood supply to the area is another reason why these problems occur.

Subacromial impingement syndrome and rotator cuff degeneration go hand-in-hand together. Much debate and controversy exist over the connection between these two conditions. Which comes first? Does the impingement cause tearing of the rotator cuff? Or does the rotator cuff degenerate and weaken over time resulting in impingement?

Orthopedic surgeons have looked carefully for an exact source of external compression. They have tried removing different parts of the bone around the shoulder in an effort to stop acute bursitis and the impingement process. Studies have been done using cadavers (human bodies preserved after death) to try and solve the question of cause and effect. The effects of age and shape of the acromion have been examined as possible contributing factors.

There’s been an effort to find outside (referred to as extrinsic) factors for the rotator cuff degeneration and subacromial impingement. Low blood supply to the supraspinatus tendon of the rotator cuff has been blamed for tendon degeneration. But some experts suggest just the opposite — the impaired blood flow to the tendon may develop because the tendon has been damaged first.

What does all this mean for patients? Well, whenever possible, treatment should be based on the cause rather than the effect in order to correct the problem. No one wants to have surgery that doesn’t work in the end because it didn’t really address the root cause.

At the moment, there is agreement that more studies are needed to sort this all out. But in the meantime, patients should be directed first to a nonsurgical management of the shoulder problem. However, we run into another road block here because it’s not clear what treatment works best. Currently the choices are steroid (antiinflammatory) or lidocaine (numbing agent) injection, physical therapy, chiropractic care, and other alternative approaches.

If the patient can find no pain relief with conservative care, then surgery may be needed. Here again, there is no simple answer to the question. “What’s the best surgical approach?” Removing bone spurs or rough edges along the acromion is the general direction of surgical intervention.

Although the results are generally good, there are still some patients who end up needing further surgery. In some cases, the end of the acromion bone (including the bursa) is removed entirely. It’s still not clear whether this type of decompression is required along with rotator cuff repair. Some surgeons choose to make some adjustments to the acromion by shaving bone off and/or repairing the rotator cuff without doing a full decompression.

In summary, the authors of this review of subacromial impingement syndrome suggest that the problem is really multifactorial. Each patient will have his or her own unique combination of reasons why they developed an impingement syndrome. Until high-quality research answers all the questions of what and why, it is suggested that nonsurgical management has good overall results and should be the way to go. Surgery can be equally successful in the hands of an experienced surgeon but should be reserved as the last resort.

When is surgery indicated for a rotator cuff tear? Usually surgery is scheduled when the patient has completed a rehab program and is still experiencing significant pain and loss of motion. If loss of motion (and therefore function) depends on the size of the tear, what is the critical tear stage that just won’t respond to rehab and requires surgery?

That is the focus of this cadaver study from the Orthopaedic Biomechanics Laboratory in California. They started with the hypothesis that there is a critical point at which a rotator cuff tear is large enough to cause abnormal joint biomechanics.

When that happens, the head of the humerus (upper arm bone) no longer drops down in the glenoid fossa (shoulder socket) during arm motions. As a result, the arm loses it full ability to abduct (move away from the body out to the side). Other muscles (e.g., latissimus dorsi, pectoralis major, deltoid) start to contract to help stabilize the shoulder. These muscles around the scapula (shoulder blade) are referred to as parascapular muscles.

This study was done in order to identify stages of rotator cuff tears that signal the need for surgery. The researchers used a custom-built shoulder testing system to measure the effects of varying loads placed on the muscles of the rotator cuff and parascapular muscles.

They loaded the muscles under three separate conditions: 1) rotator cuff only, 2) rotator cuff muscles with deltoid muscle, and 3) rotator cuff, deltoid, pectoralis major, and latissimus dorsi muscles. They used the traditional staging for rotator cuff tears based on footprint anatomy (that’s where the muscle inserts on the bone).

Stage I was a tear of the front or anterior portion of the supraspinatus tendon (one of the four tendons of the rotator cuff). Stage II represented a complete tear of the supraspinatus tendon insertion. Stage III was a complete tear of the supraspinatus and half of the infraspinatus (another of the four tendons of the rotator cuff). And finally, Stage IV was defined as a complete tear of both the supraspinatus and infraspinatus tendons.

Using the shoulder testing system, the authors were able to study the movements of the shoulder joint (called kinematics). They measured the differences in shoulder arthrokinematics (movement) between normal shoulders (no rotator cuff tears) and shoulders with all four stages of rotator cuff tears.

They found changes in muscle loading during shoulder external rotation with Stage II (supraspinatus) tears and during internal rotation after a Stage IV tear (full tears of both supraspinatus and infraspinatus).

The ability of the deltoid muscle to stabilize the shoulder during abduction movement was compromised right away with a Stage I tear. The whole humeral head shifted posteriorly (backwards) with a Stage III tear — this change in alignment significantly affected shoulder biomechanics.

Testing also showed that normal shoulder motion is limited when suprascapular muscles are holding to stabilize the shoulder and no longer able to do their own regular jobs. This is another key reason why shoulder motion can be so compromised with larger rotator cuff tears.

What did the researchers conclude from this information about the critical stage when surgery is needed for rotator cuff tears? Stage II tears signal a change in shoulder external rotation and abduction. Progression to Stage III and Stage IV result in biomechanical changes in the humeral head in relation to the shoulder socket (also affecting motion).

Rehab early on is still recommended as the first line of treatment. The goal is to prevent progression of the tear while restoring normal shoulder joint kinematics. Strengthening the suprascapular muscles is equally important during conservative care (rehab). By strengthening the pectoralis major, latissimus dorsi, and deltoid muscles, it may be possible to restore normal joint movement, reduce pain, and eliminate the need for surgery.

Every year more than 35,000 people in the United States have a total shoulder replacement (TSR) for painful, limiting osteoarthritis. What are these patients’ expectations? Are they satisfied after surgery? And are their expectations linked with their satisfaction? These are the questions surgeons at the Hospital for Special Surgery in New York City asked 98 of their total shoulder patients.

It might seem obvious that expectations of a shoulder replacement would range from relief of pain, better sleep, improved motion, and return of daily function (e.g., ability to reach, self-care, put on a seatbelt and drive).

But with more and more younger people having this procedure, those expectations have broadened. Now expectations include ability to participate in recreational or sports activities, carry heavy objects, and full restoration of motion and function.

How well were these expectations met in this group? To find out, each patient filled out a number of different surveys measuring expectations regarding pain, motion, fatigue, general health (physical, emotional, and mental), and their goals for surgery. Demographic information about each patient was also collected including age, education level, history of previous joint replacements, and presence of other diseases, illnesses, or health problems.

As it turned out, younger patients did have higher expectations in general but especially as it concerned returning to their previous level of activity (including work) and sports. Women were more concerned about keeping the shoulder from clicking or dislocating.

Everyone expected pain relief (day and night) and improved range-of-motion. Lower physical function before surgery was also linked with greater expectations for improvements after surgery in all ages and for both sexes (men and women).

What’s the benefit of this kind of information about pre-operative patient expectations of total shoulder replacement? Knowing what patients expect from this surgery gives the surgeon a chance to gear preoperative counseling toward reasonable outcomes.

Knowing that younger people expect more gives the surgeon an opportunity to address patient goals, especially as these might relate to sports activities. This finding also alerts surgeons to the fact that younger, more active patients may put greater demands on the shoulder implant. With older adults being much more active these days, patient and surgeon can discuss reasonable goals and expectations for recreational and leisure time activities.

One thing this study did not assess and that was the effect of surgeon interaction and discussion with patients. It is possible that how and what the surgeon says to the patient before surgery about the expected results could influence final outcomes and patient satisfaction. The authors suggest that further study of this factor may be helpful.

Tendon healing after rotator cuff repairs is a slow process. After surgery, patients are in a special abduction sling (looks like a square-shaped pillow under the arm). They have to wear this contraption for four to six weeks.

Some passive movements are allowed while wearing the brace but not all. It isn’t until the patient is weaned off the sling that active motion can begin. Then it takes another four to six weeks before strengthening exercises can begin. And finally, for those who are engaged in recreational or sports activities, return to these activities is allowed six to nine months after surgery.

The question often comes up (especially in sports athletes): is there any way to speed up recovery time? Surgeons are aware that the retear rate of repaired rotator cuffs is pretty high during those first three months. That’s why patients are put in an immobilizer and only allowed to do some passive motion. No tension is allowed on the surgically sutured tendon. Without some outside agent to help accelerate healing, the answer to the question is “no.”

That’s where this study comes in. There is one biologic product called platelet-rich plasma (PRP) that has been used to speed up tendon healing in other areas (e.g., elbows). Orthopedic surgeons from Seoul, Korea compared two groups of patients with full-thickness rotator cuff tears.

One group (19 patients) was treated with platelet-rich plasma (PRP). The second group (23 patients) had the repair surgery without the PRP. The patients in the two groups were very similar in age, sex (males and females), size of the tear, length of time between tear and surgical repair, and hand dominance.

Platelet-rich plasma (PRP) is the portion of your blood that contains the clear fluid and extra platelets. The platelets are the part of the red blood that contain growth factors known to accelerate or speed up healing. Studies show that PRP helps many types of tissue regenerate such as bone, ligament, cartilage, muscle, and of course, tendon.

The way they inserted the platelet-rich plasma (PRP) was to thread tiny gel packs filled with the fluid onto the sutures. Then they reattached the torn tendon to the bone with the PRP gel packs between the repaired tendon and the bone. The gel packs disintegrated leaving the PRP in place where it could release the growth factors to aid the healing tissue.

In this study, they compared the results between the two groups by measuring pain, range-of-motion, strength, function, and overall satisfaction. All measures were taken before surgery and again at regular intervals for at least 16 months. An MRI was also taken after surgery to get a look at the condition of the repaired tendon.

Despite their hypothesis that the platelet-rich plasma group would have better results, there were no clear differences in any of the measured outcomes between the two groups. In fact, at the three-month mark, the group without platelet-rich plasma (PRP) had slightly better results. Over time, the differences evened out.

Pain relief and improved motion was similar in both groups. The persistent loss of external shoulder rotation was also similar between the two groups. Muscle strength improved equally in both groups. In fact, patients were equally satisfied with results in both groups. And there weren’t any harmful effects of using the PRP gels.

It’s tempting to ask, “What went wrong?” The expectation was for better results in the platelet-rich plasma (PRP) group and that isn’t what happened. Maybe nothing went wrong. The authors suggested that maybe there weren’t enough patients in the study to really measure differences in clinical results. The research term for that phenomenon is to say that the study was underpowered.

Other reasons for the initial delay in healing in the PRP group included the fact that this group did have more patients with larger tears and rehab was started slightly later than in the conventional group (group without PRP).

The authors also suggested that the dose of PRP they used wasn’t enough or that the placement of the gel packs could be a factor. It’s also possible that the way the arthroscopic surgery must be done (running fluid through the joint) could wash away too much of the PRP to make a difference. Swelling after surgery is another potential factor.

This was the first study to look at the use of platelet-rich plasma (PRP) in arthroscopic rotator cuff repairs. There is a need for further study in this area before concluding that PRP doesn’t work or isn’t effective in accelerating healing of surgically repaired full-thickness rotator cuff tears. Maybe it would work better in partial-thickness rotator cuff tears. There were fewer retears after surgery in the PRP group so that’s something that needs to be investigated further as well.

Surgeons know that massive (very large) rotator cuff tears are at great risk of retears. Studies show a retear rate as high as 94 per cent. Not all of those retears are symptomatic but that is still not a very successful outcome. What can be done to improve the results of surgery for large rotator cuff tears?

In this study, surgeons take a look at the timing of the tears. They hoped to see if the timing of the tears might offer some clues as to the reason for the tears. Tears that occur early after surgery might be an indicator of a mechanical failure of the surgery itself.

Perhaps the type of sutures used or the way the stitches are put in place contributes to mechanical failure. Some studies have pointed to the way the soft tissue attachment is prepared at the start of surgery. This area is called the footprint — the place where the rotator cuff pulls away from the bone.

Another thought about the timing of tears has to do with biologic failure. This has more to do with the tendon healing where it is repaired or reattached to the bone. There is some thought that if the healing tendon can be protected long enough from stress, strain, and overload, then the patient is much less likely to retear the repair.

In addition to looking at the timing of rotator cuff repair tears, the authors also examined the clinical outcomes (motion, strength, function). They wanted to see if retears were somehow linked with decreased function after recovery.

In fact what they found with this study was a high rate of early ruptures. The tears occurred while the patients were still in a sling. They had not even started moving the arm or seeing the physical therapist yet. This points to the strong possibility of the repair itself being the problem (a mechanical failure where the suture and tendon interface).

There weren’t any tears after six months, which supports the idea that once the repair is healed, unless there is a biologic weakness in the repair, the surgery should hold up quite well. Using serial ultrasound studies, the surgeons could see how the tendons were healing for each of the patients in the study.

This study confirmed what other studies have shown and that is the strength of the repair is superior when surgeons used suture anchors with a double-row fixation technique. The suspicion that where the tendon is stitched back to the bone (tendon-bone interface) is part of the problem or the “weak link” was also investigated.

Ultrasound images showed sutures in the gap between the tendon and the bone. This is an indication that the tendon has pulled away from the bone leaving the suture behind. The fact that the suture anchor is still in place and hasn’t shifted further confirms mechanical failure as the cause of early retears.

In cases where the failure didn’t occur until three months after rotator cuff repair, there was a different story. There simply wasn’t enough tendon-bone healing to hold the repair. This is more of a biologic failure. And that raises a whole new set of questions.

For example, are there some other biologic or patient factors to explain this result? Does it have to do with the patient’s age, general health, medications being taken, or the presence of other problems (e.g., diabetes, heart disease, cancer)? Some other studies have shown that the use of antiinflammatory drugs may have a negative impact on where the tendon is reattached to the bone.

How does this new information on the timing of massive rotator cuff repair tears help surgeons? The authors of this study suggest two things. First, it may not be necessary to follow patients past the six-month anniversary of their surgery. If there haven’t been any problems, it’s not likely any will develop.

And second, with most of the retears early after surgery, surgeons must investigate ways to improve the surgical technique. It’s possible the sutures are too tight or the way the tendon is prepared before applying sutures makes a difference. At this point, all we really know is that there are some mechanical issues related to the surgical procedure that must be investigated further.

Shoulder problems labeled shoulder impingement syndrome often make it difficult to raise the arm overhead. Patients are able to raise the arm forward or out to the side to a certain point. But then the arm won’t go any further without help from the other hand lifting it up.

Another sign of shoulder impingement is pain that occurs when raising the arm from about 90 degrees until the person gets the arm up to around 120 degrees of motion. Then the arm continues on its merry way to the top, no problem. Pain often occurs when bringing the arm back down — and usually in the same place: when the arm is about 120 degrees away from the body moving back down to around 90 degrees. From 90 degrees down to the side is usually painfree.

This type of clinical presentation has been referred to as an impingement syndrome since the early 1970s when the term was first used. But better diagnostic tests such as MRIs, ultrasound, and arthroscopic exam are making it possible to clearly define the problem. And that may mean the term ‘impingement syndrome’ is out-of-date.

To make a case for clearer diagnostic categories for impingement syndrome, researchers from the University of Washington in Seattle conducted a systematic review. They looked at all the published studies on impingement syndrome and evaluated five specific topics:

1) the reliability of using clinical signs and tests to make the diagnosis of impingement
2) the idea that pressure on the rotator cuff by the acromion (bone across the top of the shoulder) causes impingement
3) evidence that contact with the coracocromial arch does not occur in normal shoulders, thus confirming this pressure as the real cause of the impingement
4) data to support the idea that bone spurs under the acromion can cause impingement and represent another reason to remove the acromion
5) evidence to support the idea that the best way to treat any impingement problem with the acromion or coracoacromial arch is with surgery to modify the anatomy (and take pressure off the rotator cuff tendons);the procedure to remove the bone is called an acromioplasty

Based on analysis of the hundreds of articles reviewed, the authors found it is possible to identify the underlying cause of impingement. But clinical tests and X-rays can be misleading. Clinical tests currently used to diagnose a rotator cuff problem (such as the Neer test or Hawkins sign) just aren’t reliable. Advanced imaging with ultrasound, MRIs, or arthroscopy are really needed to reach a clear and accurate diagnosis.

The most likely causes of impingement are rotator cuff tendinosis, partial-thickness tear, full-thickness tear, bursitis, or tight posterior capsule. Any of these conditions can cause the clinical presentation of pain and limited motion we still refer to as impingement.

This information points to the need to change billing codes from the nonspecific terminology associated with ‘impingement’ to more accurate categories. Once that step has been taken, then it will be possible to conduct further research. Surgeons and physical therapists will be able to compare treatments for each specific diagnostic category and truly find out what works best for each one.

The authors concluded that using the term ‘impingement syndrome’ to describe this shoulder condition and to direct surgical treatment (acromioplasty) is not supported by evidence reported over the last 40 years. From what we can see now, there are patients who get better without acromioplasty when they are treated conservatively with steroid injection, anti-inflammatory medications, and physical therapy. And there are patients who do not get relief from their painful symptoms after acromioplasty.

This study supports the idea that rotator cuff impairment is the root cause of the so-called ‘impingement’ problem. The authors further suggest that conservative care to rehabilitate the rotator cuff muscles will, in many cases, restore a more normal shoulder alignment and function, thus stopping the impingement and avoiding the need for surgery.

Where does that leave us? Who are the patients who can benefit from nonoperative treatment? And what works best for each one? These are the questions that yet remain and require further investigation. With more accurate diagnostic codes, this type of research can be conducted with meaningful answers obtained to these questions.

Shoulder replacements (called shoulder arthroplasty) are not done as often as hip and knee replacements. But more and more older adults are taking advantage of this available surgery. As with any joint replacement, complications and problems can arise. One of those problems is deep joint infection. Treatment for this complication is the subject of a study at Massachusetts General Hospital in Boston.

The authors (three highly experienced fellowship-trained orthopedic surgeons) took a look back at their records and found 28 patients who developed a deep infection. Results of treatment with a special implant made of antibiotic powder and cement were reported. The patients were between the ages of 31 and 82. Everyone was followed for at least one year. Some patients were followed for as long as five years.

Deep joint infection can crop up any time after the initial shoulder arthroplasty. In their group of 28 patients, one person developed an infection within two weeks of the first surgery. Others did not become symptomatic for almost three years (30 months).

Before we discuss the results, let’s take a closer look at the treatment itself. The implant referred to as a Prosthesis of Antibiotic-Loaded Acrylic Cement or PROSTALAC was used to replace the first (infected) prosthesis. Prosthesis is another word for the implant used to replace the joint. The authors think this may be the largest series of its kind reporting on the results of the PROSTALAC.

The PROSTALAC is made by the surgeon for each individual patient. It is shaped just like the stem and round head at the top of the natural femur (thigh bone). There are different ways to create the mold for the PROSTALAC implant.

In most cases, the surgeon used a tubular-shaped plate or flat dynamic compression plate and the formed the PROSTALAC implant around the tube or plate. Either of these approaches gives the spacer more support. In a smaller number of patients, no internal support beam or scaffold was used.

The infected implant is removed and the PROSTALAC implant put in place instead. In some patients, this device is considered a spacer — in other words, it holds the place of the femoral side of the joint until the infection is cleared up and a new prosthesis can replace it. Other patients elect to keep the PROSTALAC spacer as their permanent implant. Keeping the PROSTALAC spacer as the permanent implant avoids another (revision) surgery.

Previous studies have shown that deep joint infections do not always respond well to debridement and irrigation procedures (cutting out the infection and cleansing the joint with fluid). Just cutting out the infected implant isn’t a very good option either because that leaves the patient with loss of hip motion and difficulty weight-bearing.

That’s why this idea of a spacer was introduced. But how well does it work? That’s the focus of this study. The surgeons followed patients to see if the infection was truly gone or if there were other complications that developed later. Pain, motion, and function (e.g., walking, climbing stairs, recreational activities) were also measured.

They found that infection was eliminated by using the PROSTALAC implant for 82 per cent of the group (that was 23 of the 28 patients). Twelve of those patients kept the PROSTALAC and did not have another surgery. Pain was decreased but not gone for everyone. Thirteen patients still had moderate-to-severe pain.

Based on their results, the authors suggest the use of a spacer like the PROSTALAC can be very helpful in treating deep joint infections after shoulder replacement. The implant can stabilize the joint, provide pain relief, and restore some shoulder function. But it’s not without its problems. For example, complications such as a second (recurrent) infection, dislocation, or fracture of the PROSTALAC affected nine patients (about one-third of the group).

Prevention of deep joint infections is the key to avoiding these additional surgeries. But the cause of infection isn’t always obvious. Some of the patients had other comorbidities (other health problems) such as diabetes, alcohol abuse, and rheumatoid arthritis. A previous history of knee infection following a knee replacement was also reported by one patient. More research is needed in this area to reduce the incidence of infections and determine the ideal treatment approach.

Adhesive capsulitis, sometimes called a “frozen shoulder” still baffles physicians and scientists alike. No one knows what really causes it — or how to treat it. Women, age over 40, and shoulder injuries (trauma) head the list of possible risk factors.

But adults of both sexes (male and female) who have serious health problems such as diabetes, heart disease, stroke, or thyroid conditions have a higher incidence of adhesive capsulitis than the general adult population.

The problem comes on gradually causing pain, loss of shoulder motion, and decreased function. It disrupts the person’s life during the “frozen” stage. And then the problem goes away as mysteriously as it came on. These three stages (freezing, frozen, and thawing) can last anywhere from months to years. In the end, most people come out okay without any major long-lasting effects.

But, in the meantime, the painful symptoms, difficulty sleeping at night, and loss of shoulder function during the day can be very disabling. The patient’s quality of life suffers. What can be done to help the patient during these three stages? There are four main treatment methods: 1) antiinflammatory medications, 2) physical therapy, 3) steroid injections, and 4) surgical manipulation.

Which treatment works best? What order should the different options be used? These are questions for which we still don’t have certain answers. In this report, surgeons from Ohio State Medical Center take a look back at all the published data on steroid injections for adhesive capsulitis. They provide us an updated comparison of steroid injection to other forms of treatment for this condition.

They confined their analysis to studies of patients with primary adhesive capsulitis. Follow-up for more than six months was also required. Primary adhesive capsulitis leaves out patients who have a frozen shoulder because of some other medical condition (as mentioned such as diabetes, heart attack, stroke, thyroid disease). Only studies of adhesive capsulitis of unknown cause (also referred to as idiopathic adhesive capsulitis) were included in this review.

In the end, there were eight studies included that met all the qualifications for high-quality (level I or II) research. A combined total of 409 shoulders from the eight studies were evaluated. Treatment alternatives to steroid injections included ice pack treatment, no treatment, or placebo injection with saline (salt) solution instead of steroid medication.

The authors report that patients got better (pain relief) no matter what treatment was given. Using a special tool called the Shoulder Pain and Disability Index (SPADI), even greater improvements were made when steroid injection was paired with physical therapy. That particular combination worked better than steroid injection alone, saline solution injection alone, or saline injection with physical therapy. Taking a closer look at the overall (long-term) results, any advantage the steroid injections provided was short-term. With longer follow-up, all treatments had an equal effect.

In summary, Level I and Level II (high-quality) studies support the use of steroid injections for fast pain relief from adhesive capsulitis. However, the effects don’t last and steroid injections don’t give a better final result. But patient satisfaction is improved when pain can be targetted early on in the course of this condition.

Compared with no treatment, joint injection also improved shoulder motion sooner. But again, in the long-term, shoulder motion was restored in all patients regardless of the treatment used (including no treatment). Those findings bring out the question: should treatment even be applied if it’s all the same in the end?

The current thinking is ‘yes,’ treatment helps patients with the pain and may possibly speed up the healing process. But more studies are needed to show what works best to improve symptoms, motion, and function during the three phases of this condition.

The authors found from reviewing these eight studies that there is a need for better research. For starters, they suggest that studies should be conducted using the same outcome measures, the same number of patients in each treatment group, and better statistical analysis of the data collected.

More adults staying active and working longer before retiring can mean a greater risk of rotator cuff (RTC) disease and tears. Improved technology and surgical tools have led to an increased number of rotator cuff surgeries being done arthroscopically. This article was written in order to help surgeons keep up with all the changes.

The four tendons of the rotator cuff attach to the deep rotator cuff muscles. This group of muscles lies just outside the shoulder joint. These muscles help raise the arm from the side and rotate the shoulder in all directions. They are involved in many day-to-day activities. The rotator cuff muscles and tendons also help keep the shoulder joint stable by holding the humeral head in the glenoid socket.

Degenerative changes due to the aging process are the most common cause of rotator cuff tears in older adults. Studies show that once the rotator cuff starts to tear, the tear will continue to get worse and increase in size over time. These tears are divided into two basic groups based on severity: partial-thickness and full-thickness tears. As the names suggest, how far down the tear goes through the tissues determines the category.

It’s possible to have a rotator cuff tear without pain. But most acute and chronic tears that get worse tend to cause pain and loss of motion. It’s only a matter of time before weakness develops and then loss of function when trying to perform daily tasks.

The tendon tries to heal itself but often ends up just filling in the gap caused by the tear. Fat cells form the filler, but these are not structurally strong. This in-fill process is called fatty infiltration. Fatty infiltration does not improve shoulder motion, strength, or function.

Surgery may be needed but before subjecting patients to this type of invasive procedure, conservative (nonoperative) care is usually recommended first. Temporarily delaying surgical repair in favor of physical therapy does not seem to put the patient back in any way.

The therapist assists each patient by creating an individualized treatment program that addresses posture and alignment factors first. Then restoring motion and strength are next. The therapist always keeps the patient’s goal, activity level, lifestyle, and general health in mind. For those individuals who are still out in the work force, specific work requirements are determined as well.

Patients who either have failed to improve with conservative care or who have massive tears unlikely to respond to a nonoperative approach, may need surgery. Here’s where the surgeon must make some key decisions that require keeping up with current evidence-based research results.

For example, results are improved with partial tears if the surgeon cuts through the remaining tendon and makes a full-thickness repair (instead of sewing the torn tendon back together). Surgeons are also taking a closer look at which side of the tendon the tear is located (top next to the bursa or bottom next to the joint). Treatment can be more aggressive with bursal-sided tears (e.g., debridement, repair of tendon, and decompression). Decompression refers to shaving or cutting away bone that might be pressing against the tendon.

Sometimes the surgical approach taken depends on which of the rotator cuff tendons has been torn. Another deciding factor is whether the tear is closer to the tendon-bone interface or closer to the tendon-muscle connection.

Some muscles work together so closely with other muscles (such as the subscapularis and biceps tendon match) that a tear in one requires treatment of both. Full-thickness rotator cuff tears almost always involve both the infraspinatus and supraspinatus muscles.

In the case of full-thickness tears (tears that go all the way through the tissue), the surgeon then looks to see how far back the tendon has retracted (pulled back away from the bone). Here it will be necessary to decide on the best surgical technique to use to make the repair (e.g., single-row versus double or dual-row sutures, use of suture-bridging techniques).

Newer concepts in rotator cuff surgery include biologic augmentation of the repair. Graft material (either from a harvested tendon or grown in the lab from donor cells) is used to improve healing and support the repair site. Studies support the use of autografts (tissue taken from the patient) over allografts (donor tissue from another person) for the best results.

The final factor for consideration with today’s modern arthroscopic rotator cuff repairs is the area of complications that arise after surgery. Shoulder stiffness is no longer much of a problem with arthroscopic procedures. Instead, infection and nerve injury top the list of potential problems. The newer approach of using an intra-articular (inside the joint) pain pump is losing favor due to high levels of chondrolysis (destruction of joint surface).

In summary, surgical treatment of rotator cuff tears is performed arthroscopically more often than not. With an increased number of older adults suffering rotator cuff tears, rotator cuff disease has become a focus of research and attention. Surgeons who want to review the most current concepts for the treatment of rotator cuff tears will find this article informative and up-to-date.

The debate over whether arthroscopic surgery is superior to open incision for the shoulder continues. In this fresh look, records from the American Board of Orthopaedic Surgery (ABOS) were used to look for trends in surgeon practice. Starting in 2003 and going through 2008, data was analyzed to compare these two approaches when doing a procedure called the Bankart Repair for shoulder instability.

Shoulder instability means that the shoulder joint is too loose and is able to slide around too much in the socket. In some cases, the unstable shoulder actually slips out of the socket. If the shoulder slips completely out of the socket, it has become dislocated. If not treated, instability can lead to arthritis of the shoulder joint.

The most common method for surgically stabilizing a shoulder that is prone to anterior dislocations is the Bankart repair. In the past, the Bankart repair was done through a large incision made in the front (anterior) shoulder joint. This required damage to a great deal of normal tissue in order for the surgeon to be able to see the damaged portion of the joint capsule. The procedure was difficult and usually involved an attempt to sew or staple the ligaments on the front side of the joint back into their original position.

The arthroscope has changed all that. This special surgical tool gives the surgeon the ability to see inside the joint. The surgeon can then place other instruments into the joint and perform surgery while watching what is happening on the TV screen.

The arthroscope lets the surgeon work in the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery. If the surgery is done with the arthroscope, patients often go home the same day. Complications such as nerve damage or recurrent dislocation can still occur despite the method of repair. But the rate of problems is reportedly lower with arthroscopy compared with open incision.

Using the data from the American Board of Orthopaedic Surgeons (ABOS), over 4500 patients were evaluated. The number of arthroscopic versus open Bankart procedures was compared. Number and type of complications were available. Even the surgeon’s training and experience were scrutinized.

The reason for looking at the surgeon’s information was to evaluate trends in education and practice. For example, some orthopedic programs don’t even teach open repair techniques. The newer, more modern arthroscopic approaches have become standard. And as arthroscopic surgery has become more mainstream, more non-fellowship trained surgeons are performing these procedures.

What did the ABOS records reveal? First, of all the shoulder surgeries reported in the ABOS database, 8.6 per cent were Bankart repairs. Second, more arthroscopic Bankart procedures are being done compared with open Bankart repairs. Starting in 2003 (earliest time when records of this type were available), there was almost a 3:1 ratio between arthroscopic versus open Bankart technique.

Over time (from 2003 to 2008), the number of arthroscopic Bankart procedures continued to go up until there was a 90 per cent incidence of arthroscopic Bankart surgeries. And in that same time period the number of nonfellowship and nonspecialized surgeons performing arthroscopic Bankart procedures also increased significantly.

The authors conclude that their belief at the start of the study (that the majority of Bankart procedures are being done arthroscopically now) was confirmed. This trend is understandable given the improved surgical techniques available with arthroscopy.

At the same time, studies have shown improved outcomes for patients having arthroscopic Bankart repairs compared with open repairs. They reported less pain, reduced deformities, improved function, and excellent patient satisfaction with the results.

And there were fewer complications with arthroscopic Bankart procedures. For example, the rate of postoperative dislocations was 0.4 per cent for arthroscopic surgery compared with 1.2 per cent for open incision repairs. The rate of nerve injuries was 0.3 per cent for arthroscopic Bankart repairs compared with 2.2 per cent with open repairs.

What are the implications of these findings? Orthopedic fellowship and residency programs may want to review the way they are training surgeons. Those that are still teaching only open Bankart procedures may want to shift to arthroscopic training. And it may be necessary to create a means of recertifying surgeons who use arthroscopic techniques.

Orthopedic surgeons from around the world continue to look for ways to improve results of surgery for rotator cuff tears (RCTs) of the shoulder. Of special interest are the results of surgery for massive RCT tears.

The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. The rotator cuff connects the humerus to the scapula. The rotator cuff helps raise and rotate the arm.

The typical patient with a rotator cuff tear is in late middle age and has had problems with the shoulder for some time. This patient then lifts a load or suffers an injury that tears the tendon. After the injury, the patient is unable to raise the arm. However, these injuries also occur in young people. Overuse or injury at any age can cause rotator cuff tears.

This article addresses the question of what surgical treatment works best: complete repair, partial repair, or just debridement. Debridement refers to a surgical procedure in which the surgeon cleans the area of debris and torn fragments. The rotator cuff is then left to heal on its own. There are pros and cons to each technique. Sometimes working backwards is the most accurate way to know which way to go.

And that’s what they did in this study. The surgeons reviewed the cases of 72 patients who all had massive (complete rupture) of the rotator cuff. They were divided into three separate treatment groups based on the type of surgery (complete repair, partial repair, debridement).

The type of procedure was decided during surgery when the surgeon could see the location and severity of the lesion (tear). Partial-thickness tears and full-thickness tears can often be repaired if the damage isn’t too much. But massive, full-thickness tears may be too much to allow for any kind of repair. That’s when debridement is done instead.

The results (joint motion, function) from this study were obtained by measuring and comparing outcomes before and after surgery. The good news is that everyone in all three groups improved. They had less pain after surgery, more motion, and could use the arm more.

A closer look at the data showed that the patients in the complete repair group had the best results. They seemed to gain more active (patient-controlled) shoulder motion afterwards. And more motion translated into better daily function.
Taking a look at the results for partial repair versus debridement, there was no difference between those two groups.

The results of this study are important when considering treatment of a complete rupture of the rotator cuff. Other studies have shown that tears can be so massive that surgery won’t help. Re-rupture after rotator cuff repair is fairly common. No one wants to go through major surgery and a long rehab program only to retear the cuff.

Knowing that a complete repair yields the best results helps guide the surgeon when selecting the right course of action for each patient. It is still true that the best results occur with repair of small or moderate tears of the rotator cuff. The size of the tear really does predict the final outcome.

The larger tears tend to fill in with fat and scar tissue making surgical repair more difficult. The tendon can retract (pull away) so far that it cannot be restored to its correct anatomical insertion. Poor quality of the torn rotator cuff is another factor the surgeon considers when deciding what type of surgery to perform.

It should be noted that there was no control group in this study. In other words, they did not compare results with patients with massive rotator cuff tear who did not have surgery. Future studies may need to include this group to get a complete picture of results between these three types of surgery and conservative care.

The authors did recommend complete repair of massive rotator cuff tears. But they also said that the differences between results for the three groups (though measurable) were not large enough to be statistically significant.

When choosing between repair and debridement, there was a general trend for better results after debridement. It is a less invasive and less expensive procedure with fewer complications. Patients can have the surgery as an out-patient, they still get pain relief, and the rehab period is much shorter. For older adults, that’s a recipe for success in getting back motion and function.

The term frozen shoulder has been around since the early 1930s. But recent research has been able to show that every stiff, painful shoulder isn’t necessarily a true “frozen shoulder.”

Perhaps you’ve heard the alternate term for this problem: adhesive capsulitis. According to the authors of this review, frozen shoulder and adhesive capsulitis are not the same things. What’s the difference?

Frozen shoulder is a vague term similar to saying something like you have a limp when you walk. That doesn’t tell you very much about the problem, the cause of the problem, or how to treat it.

At best, a frozen shoulder describes spasming of the short rotator muscles of the shoulder or tiny adhesions around the joint or bursae. That’s the actual physical condition behind the shoulder pain and stiffness. Many conditions (not just one) can actually lead to this state of affairs.

On the other hand, adhesive capsulitis is a single problem of chronic inflammation of the joint capsule. The shoulder capsule is a covering of connective tissue interconnected with shoulder ligaments and tendons. They all help hold the head of the humerus (upper arm bone) in the shoulder socket.

The inflammatory process causes the capsule to thicken and tighten to the point that the extra fold of capsular tissue gets stuck to itself. There is a loss of normal synovial fluid in the joint.

When this happens, the shoulder can no longer slide and glide smoothly through its full range-of-motion. The capsule looses its ability to stretch. The result is the shoulder gets stuck and becomes stiff and painful just like a frozen shoulder. In chronic cases, inflammation is gone but it was the first step that got the process started. Treatment is still directed at the joint capsule.

Capsular restriction is the one factor that defines adhesive capsulitis separately from other conditions that can cause shoulder stiffness. Other problems like rotator cuff tears, tendinitis, shoulder arthritis, or nerve impingement can also cause loss of motion that looks just like adhesive capsulitis.

But in each of those other conditions, the motion loss is the result of multiple factors (not just one factor). Treatment focuses on the specific cause of the stiffness and that often has nothing to do with the shoulder joint capsule.

But if both conditions (frozen shoulder and adhesive capsulitis) look the same on the outside (stiff, painful shoulder), then how can the physician tell what’s causing the problem or how to treat it effectively?

A careful history and review of what has happened over the course of time helps. Patient characteristics can also point to the correct diagnosis. For example, adhesive capsulitis is seen most often in women between the ages of 40 and 60 who are sedentary (not manual laborers or actively engaged in exercise). And there is often a history of some other serious health problem (e.g., heart attack, stroke, diabetes, breast cancer, thyroid disease).

X-rays aren’t usually very helpful in distinguishing a frozen shoulder from adhesive capsulitis. They do help rule out fractures, arthritis, bone spurs, and osteopenia (decreased bone density). MRIs with dye injected into the joint (called magnetic resonance arthrography or MRA) will show changes in the joint capsule typical of adhesive capsulitis.

There is one clinical test the physician can perform that is very diagnostic. And that’s moving the arm passively without the patient’s help. If the shoulder resists movement into external (outward) rotation with the arm down at the side, it’s likely adhesive capsulitis. There’s no pain involved keeping the arm from moving (as there would be with a frozen shoulder). It’s more of a mechanical hold from a sticky/stuck capsule that’s keeping the joint from moving.

Once the diagnosis of adhesive capsulitis has been made, it’s important to move quickly into treatment. Physical therapy is the first step toward improving motion and reducing painful symptoms. The therapist will use a variety of difference tools including deep heat, electrical therapy, stretching of the soft tissues, and mobilization of the joint.

Surgery is an option but usually only if a good six months’ effort at physical therapy doesn’t yield the hoped for or intended results. Sometimes patients get worse in spite of treatment (not because of it). They are likely candidates for surgery as well.

The surgeon has several procedures to choose from. Manipulation (moving the joint through its full motion) while the patient is under anesthesia (asleep) is one method. An even better approach is to perform an arthroscopic exam to see exactly what’s going on. If necessary, the capsule can be cut or even partially removed to free up motion. Where and how much of the capsule to release is a matter of debate that requires further study.

Following surgery, the authors suggest aggressive motion-preserving therapy. The patient’s arm is held in a position of 90-degrees of elbow flexion and shoulder abduction (arm out to the side 90-degrees from the body) whenever resting or sleeping.

In fact, the patient eats, walks, goes to the bathroom, and does everything with the hand on top of the head in order to maintain this position. Physical therapy continues until the shoulder has its full motion once again. The approach is consistent stretching and motion without aggravating the tissues. Strengthening is added later.

In summary, adhesive capsulitis is a cause of shoulder pain and dysfunction that is separate from frozen shoulder. Best results are obtained when an early, accurate diagnosis is made and treatment started for either condition. For surgeons treating adhesive capsulitis, the authors provide an in-depth, detailed description of diagnosis, treatment, and surgery.

Shoulder dislocations are not uncommon. Most dislocate forward (called an anterior dislocation). Less often are the posterior shoulder dislocations. As the name suggests, a posterior shoulder dislocation occurs when the head of the humerus (upper arm bone) pops backwards out of the shoulder socket.

What causes posterior shoulder dislocation and who is affected most often? How is it treated and what are the results? These are the questions answered by this study.

Orthopedic surgeons from The Shoulder Injury Clinic in England took the time to look back at their medical records to find 112 patients with posterior shoulder dislocations. By reviewing the charts, they were able to put together a picture of what those patients looked like (called patient demographics). By analyzing the data collected, they were able to identify predictive factors for high- and low-risk of complications.

The most common complication following posterior shoulder dislocation was recurrent instability. Recurrent instability means the shoulder dislocated a second time or the shoulder could slip in and out of the joint (called subluxation). They found that when the force of the first dislocation was enough to damage the head of the humerus, the risk of a second dislocation (or recurrent subluxation) went up dramatically.

Other risk factors for recurrent dislocations were age (younger age — less than 40) and seizure as a cause of the first dislocation. In more than half the cases of recurrence in this group, the second dislocation also occurred during a seizure. Evidently, the force of shoulder muscle contractions during the seizure is enough to pull the shoulder out of joint.

Patients least likely to suffer a second (recurrent) posterior shoulder dislocation were older, suffered a traumatic first dislocation, and had only a small defect or lesion of the humeral head from that first injury. Traumatic injuries were linked with car accidents, falls, and in a few cases, sports injuries.

This picture of the patient at risk for future posterior shoulder dislocations is new. Because of the size of this study (112 patients with 120 dislocations), the authors were able to create a more complete picture of patient demographics never before realized. And they were able to show long-term outcomes for patients who were treated but who still developed recurrent instability.

Let’s take a look at the type of treatment and treatment results reported in this study. First of all, the patients included in the study had an acute posterior dislocation. That means they were evaluated within the first 10 days after the first dislocation occurred.

All shoulders were reduced (relocated or put back in the socket) in one of three ways. One-third (33 per cent) were reset using sedation (to relax the patient) and traction (pulling the arm down). If that didn’t work, then gentle manipulation was used by raising the arm to 90 degrees of flexion, inwardly rotating the shoulder, and moving the arm toward the body. In a small number of patients (five total), general anesthesia was needed. Once the patient was asleep, full muscle relaxation made it possible to reduce the shoulder.

Follow-up treatment consisted of wearing a sling for four weeks along with gentle movement exercises. Once the sling was removed, then the patients went to physical therapy for a 12-week program of joint motion and strengthening exercises. If the shoulder dislocated again, then a longer physical therapy program was needed. In some cases, surgery to repair the torn soft-tissues and bone lesions was needed to restore shoulder stability.

What were the final results? Patients were followed at regular intervals for up to two years. They were tested and retested using valid and reliable tools such as the Western Ontario Shoulder Instability Index (WOSI), Disabilities of the Arm, Shoulder, and Hand Score (DASH), and the Short Form-36 (SF-36).

Even with treatment, all patients still showed loss of normal shoulder movement and function two years after the injury. The authors commented that it may be the case that all posterior shoulder dislocations would do better with surgery rather than conservative care. They are investigating this theory.

In general, posterior shoulder dislocation is a rare type of injury and must be studied more closely. With more information, it may be possible to prevent such injuries (and certainly recurrent dislocations) by recognizing and reducing risk factors whenever possible.

For those patients who are not at risk of recurrent dislocation, mild deficits in function may be acceptable. They may be able to get along just fine without surgery to repair damage done to the shoulder as a result of the dislocation. Those individuals who are at risk for another dislocation may do better with early surgical intervention. Future studies are needed to prove or disprove that idea.