News Category: Shoulder

Have you ever heard of scapular winging? If not, you might recognize it if you saw it — it’s the way the shoulder blade sticks out when it’s not where it’s supposed to be. And it’s supposed to lie flat against the back while gliding up and down/in and out with arm movements.

Sometimes you see scapular winging in young children. They haven’t developed the full strength of the arms and upper back yet. If they are skinny and all arms and legs, you might not think twice about the scapulae (plural for scapula and a scapula is the same as shoulder blade) sticking out.

But in adults, scapular winging (especially when it’s only present on one side) isn’t normal and can have some serious consequences. Without proper scapular positioning and movement, the arm doesn’t move normally. Lifting the arm overhead and then lowering it back down can become painful, difficult, and even impossible.

What causes this problem and what can be done about it? That’s the focus of this article written by three orthopedic surgeons from the University of Illinois Medical Center in Chicago. They review the anatomy and biomechanics of the scapula along with the 17 muscles that attach to the scapula.

Causes of scapular winging are broken down into two groups: primary and secondary. Primary scapular winging occurs when one of the main muscles that hold the scapula steady stops working as it should.

Injury to the nerve controlling scapular muscles is one cause of primary scapular winging. Athletes are at greatest risk for nerve paralysis causing primary scapular winging. Whether an athlete, homemaker, industrial worker or other individual who suffers a fall, collision, or repetitive motion, you could develop this problem.

Secondary scapular winging is the result of a problem somewhere else in the shoulder complex. That other problem could be a rotator cuff tear, shoulder bursitis, shoulder dislocation, or a frozen shoulder. Osteochondroma (bone tumors) can also cause secondary scapular winging. With osteochondromas, there is usually a “clunk” that can be felt and heard as the arm moves away from the side.

Any injury or condition that can alter the way the muscles fire or cause muscular fatigue can result in impairment of the scapular rhythm needed for normal arm movement. Likewise, anything that changes the alignment of the scapula can have the same effects on scapular position and movement.

How can the physician tell what’s causing the problem? That’s a good question — it isn’t always an easy task. Oh, it’s easy to see there is a problem because the scapula is clearly either sticking out away from the body or not where it’s supposed to be in the middle of the back next to the spine. But whether that’s a primary or secondary scapular winging and what’s causing it can be much more difficult to sort out.

Diagnosis will require a careful evaluation of the patient. A physical exam will be necessary to look at the scapula and watch how it moves during arm motions. Testing of the individual muscles will help identify weakness. Nerve conduction velocity tests along with electromyography of the muscles may be needed to look for nerve palsy.

Imaging studies such as X-rays, MRIs, and CT scans each have their place in the diagnostic process. Once the diagnosis has been made, then treatment can begin. Conservative (nonoperative) care is advised first. If there’s nerve damage, the process of healing and recovery can take many months up to two years.

A physical therapist will conduct a movement system analysis. From this information, a program of movements, activities, postures, and exercises will be set up to help restore normal motion of the scapular-shoulder complex. When indicated, electrical stimulation may be used to retrain muscles that have lost the normal nerve signals telling them when to contract and when to relax.

Sometimes surgery is needed. There are a number of different surgical procedures for this problem depending on the underlying cause. Tendon or nerve grafts, muscle transfers, or neurolysis can be done. Neurolysis refers to using heat to destroy the sensory nerve fibers that carry pain messages to the brain. The treatment doesn’t affect motor function, just puts an end to the pain.

For surgeons interested in an update on the surgical treatment of scapular winging, this article provides tips from the authors as well as a description of their preferred treatment. Drawings and photos taken during surgery are provided along with step-by-step instructions for several surgical procedures.

Shoulder joint replacement surgery (also called shoulder arthroplasty) is a great treatment for many people with shoulder pain from arthritis. But patients who don’t have enough muscle function to stabilize the joint may not be able to benefit from the traditional implant design — one that mimics the normal anatomic shoulder.

Instead, a different type of shoulder replacement, called reverse shoulder replacement has been developed. And it has worked so well, surgeons have expanded the number and types of patients who can qualify for this type. The reverse shoulder replacement does exactly as the name suggests: reverses the socket and the ball, placing the ball portion of the shoulder where the socket used to be and putting the socket where the ball or humeral head would normally be.

This new design gives a much more stable shoulder joint that can function without an intact rotator cuff. The artificial joint itself provides more stability by creating a deeper socket that prevents the ball from sliding up and down as the shoulder is raised. Shear forces are transformed into compressive forces. This simple change allows the large deltoid muscle that covers the shoulder to lift the arm. The result is a shoulder that functions better, is less painful, and can last for years without loosening.

That’s the positive side of things. There are some problems that are unique to the reverse total shoulder replacement. The three most common problems with reverse shoulder replacements are neurologic injury, bone fracture around the implant, and hematoma (pocket of blood or other fluid trapped inside the joint). Other reported problems include infection, dislocation, baseplate failure, and fracture of the acromion (piece of bone from the shoulder blade that curves over the top of the shoulder).

The best way to handle these problems (referred to by surgeons as best practice) has not yet been determined. Likewise, the long-term results in patients who have a reverse shoulder arthroplasty are not available yet. For now, it seems an understanding of implant design, shoulder anatomy, and common complications will help the surgeon avoid problems and avoid failed surgeries.

Let’s take a closer look at some of the more common problems. The first and potentially most damaging is neurologic injury. Cutting or pulling (traction) on the nerves to the arm can cause loss of sensation of the arm, hand, and/or fingers. Sometimes the reverse shoulder implant puts strain on the group of nerves to the arm called the brachial plexus. In other cases, the implant can displace (push aside) the nerve plexus creating loss of sensory and/or motor function of the arm. One other cause of nerve damage is scar tissue that can press (compress or impinge) nerves of the brachial plexus causing similar problems with sensation and movement.

Periprosthetic fracture is a break in the bone around the implant. Most of these fractures occur during the surgical procedure as the surgeon prepares the bone to receive the implant. The surgeon must be very familiar with the implant itself, its design and how it’s supposed to work, as well as the best way to hold the implant in place. The surgeon must be careful when handling the patient’s arm during the procedure. Extreme shoulder positions in a patient with weak or brittle bones can contribute to bone fractures.

Hematoma (blood trapped in the joint) is another common complication that doesn’t have a single cause but many possible causes. Proper placement of the implant is necessary to avoid fluid collection in empty areas or what are called dead spaces. Sometimes patients develop pathways of drainage called sinus tracts at the incision site where blood and fluid can pool causing a hematoma. Studies have also shown that infection and hematoma are linked.

Up to 10 per cent of all patients receiving a reverse shoulder arthroplasty develop a serious infection. Risk factors include multiple previous surgeries, a large-sized dead space, poor sterile technique, and revision (second) surgeries on the reverse implant. Surgeons use two methods of prevention for infections. One is to give the patient antibiotics just before the procedure. The other is to use cement that has antibiotic in it.

When these efforts fail and the patient develops an infection, then antibiotics specifically for the bacteria present are the treatment of choice. Infections that do not clear up with antibiotics may have to be treated surgically. The surgeon rinses the joint thoroughly with a saline (salt-based) solution and scrapes away any visible infection. This procedure is called irrigation and debridement. Sometimes it is necessary to remove part of the implant called the liner and replace it with a new one.

The simple act of reaching behind to scratch the middle of your back or (for women) undoing a bra-strap can dislocate a reverse shoulder implant. This action places the arm in a position of extension, adduction (arm close to the body), and internal rotation.

Any imbalance in the muscle tension around the shoulder or unusual shape of the shoulder socket can contribute to a dislocation with this motion. Placing the wrong sized socket or wrong sized round head that fits in the socket (or a mismatch of the two components) are additional reasons why dislocation can occur. Revision surgery may be the only way to treat this problem. But first, the surgeon will try putting the shoulder back in the socket and then placing the patient in a sling for three to six weeks. Patients are cautioned to avoid shoulder extension, adduction, and internal rotation (those motions that can flip the shoulder out of joint) until fully healed.

Finally, baseplate failure is a design problem that surgeons and manufacturers of reverse shoulder implants are working on. The baseplate is part of the round component that attaches to the shoulder where the socket used to be. If the patient’s bone doesn’t grow in and around the baseplate, the shoulder joint may not be secure or stable.

Makers of the implants have provided locking screws that can be angled into the denser bone to help prevent the problem of baseplate failure. A central screw (right through the middle of the bone) also helps anchor the humeral prosthesis in place. Other design features under investigation include using thicker screws, a tilted baseplate, and offsetting the center of rotation.

In summary, reverse shoulder arthroplasty has been around now for the last 10 – 12 years. They have worked well enough that surgeons now use them more routinely with a wider range of patients. The main use of reverse shoulder arthroplasty is for older adults with large rotator cuff tears. Fractures and failed traditional shoulder replacements are two other reasons why reverse shoulder arthroplasty might be used.

As with any surgery (and especially joint replacement procedures), there are potential problems and complications that can develop. Surgeons who know the possible pitfalls can take measures to prevent them whenever possible. Changes in implant design will continue to improve outcomes. We are all waiting for long-term results to be reported. Studies following patients over 10, 15, and 20 years will give us the kind of feedback needed to improve survival rates and prevent problems associated with this procedure.

If the shoulder dislocates one time, it may be possible to rehab the muscles and regain normal motion and strength with no further problems. But a second or third (or more) dislocation leads to an unstable joint (also known as shoulder instability).

At that point, there can be (and there often is) damage to the bone forming the joint. The defect may be in the head of the humerus (upper arm bone) or the glenoid (socket side of the joint). In traumatic dislocations, damage may occur in both places.

The exact lesion differs from patient-to-patient. There could be a fracture in the bone or a piece of cartilage (called the labrum) pulled away from the joint. With an anterior (forward) dislocating shoulder, the fibrous capsule covering the joint can get sheared right off. Sometimes, patients experience a combination of two or more of these injuries contributing to their unstable shoulder joint.

Large bony defects of this type can’t be treated conservatively (i.e., without surgery). The surgeon may be able to perform the procedure arthroscopically but many times the surgical technique is very challenging and requires an open-incision approach.

Best results from surgery require a very careful pre-operative examination. The patient’s history, clinical presentation (signs and symptoms), and imaging studies are all necessary parts of the evaluation.

With the information obtained from the assessment, the surgeon can make an accurate diagnosis. Then he or she can plan the most effective and comprehensive surgical procedure required for the best results. Repairing one defect without addressing all aspects of the shoulder instability is a recipe for treatment failure.

As you might expect, the specific surgical treatment needed varies depending on which side of the joint is affected. The surgeon must also take into consideration the exact location, type, and size of the lesion. Then the decision is made whether to perform the procedure arthroscopically or with an open incision.

Large defects on the glenoid (socket) side of the joint usually require an open procedure for the best results. This is especially true if there is a fracture of the glenoid rim and/or when there is a significant amount of bone loss.

Large defects (holes) must be filled in. The surgeon has a choice of fill-in materials including bone graft material, folded over tendon material, or a bone transfer (e.g., from the tip of the coracoid, another bone in the shoulder complex).

Small defects on the humeral head can be managed arthroscopically. A new procedure called Remplissage has made it possible to treat more humeral head defects arthroscopically than ever before. Remplissage is a French word that means “to fill.” As with glenoid defects, the surgeon can stuff part of a shoulder tendon into the hole using sutures to hold it in place.

Open approaches to humeral head defects are still much more common than arthroscopic procedures. Again bone grafting may be used to fill in the defect. The surgeon can also smooth the humeral head, a procedure called resurfacing. If that doesn’t work, then a partial (one-sided) shoulder replacement called hemiarthroplasty may be the next step. Just the side with the defect (humeral or glenoid) is removed and replaced.

In summary, large defects in the shoulder joint affecting the bone on either side can occur with traumatic shoulder dislocation. These bony defects can also contribute to chronic, recurring shoulder dislocations. The only solution may have to be surgery but the choices of surgical approach, method, and techniques used are complex and challenging.

Exactly which way to go isn’t always clear cut. More research is needed to track cases and report on outcomes. This type of information could potentially help surgeons make the necessary treatment decisions on a case-by-case basis with a little more certainty.

In this study, orthopedic surgeons from Germany take a closer look at an unusual rotator cuff tear. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. Most of the time, the supraspinatus and/or infraspinatus are affected by a rotator cuff tear. Much less often, the teres minor and subscapularis are torn.

An isolated tear of the subscapularis tendon in 21 patients treated with arthroscopic surgery is the focus of this report. The rotator cuff tendons are key to the healthy functioning of the shoulder. They are subject to a lot of wear and tear, or degeneration, as we use our arms.

Tearing of the rotator cuff tendons is an especially painful injury. A torn rotator cuff creates a very weak shoulder. A strong subscapularis tendon/muscle unit is needed to hold the head of the humerus (upper arm bone) in the center of the shoulder socket.

Normal shoulder joint biomechanics and kinematics (movement) depend on an intact subscapularis muscle. Without a normal, healthy (strong) subscapularis muscle/tendon unit, the risk increases for shoulder subluxation (partial dislocation) or full dislocation.

And just as the expression “use it or lose it” suggests, a torn rotator cuff tendon that is no longer connected to the joint becomes atrophied (wasting away). The damaged area starts to fill in with fat cells, a process called fatty infiltration. Over time, the result of muscle atrophy and fatty infiltration is weakness or insufficiency.

The question this study attempts to answer is what are the results of surgical treatment for an isolated subscapularis tendon tear? Isolated means the subscapularis is the only part of the rotator cuff that is torn — not the usual infraspinatus or supraspinatus but just the subscapularis.

Shoulder function was assessed after arthroscopic surgery and MRIs taken to capture the state of the healing tendon. Two clinical signs used to test the integrity of the subscapularis muscle (the lift-off and belly-press tests) were also compared from before to after surgery.

The surprising finding from this study was that although 20 of the 21 patients had an intact repair and improved strength, one-fourth of those same patients had atrophy (wasting) of the upper portion of the subscapularis muscle. The second half of the surprise was that none of these patients had any functional losses because of the muscle weakness.

Only one patient had a re-rupture, which could be seen on an MRI as a fluid-filled gap between the end of the tendon (called the tendon stump) and the bone where it should normally attach. And despite the rerupture, this patient was satisfied with the results of surgery.

Anyone with a positive belly-press test had subscapularis muscle atrophy. The belly press test was measured by having the patient press the hand of the affected arm against his or her abdomen. A special electronic plate placed against the belly could measure the amount of pressure applied by the hand and determine whether or not there was subscapularis weakness or insufficiency.

The authors concluded that the severity of subscapularis tears was not as predictive of outcomes as the time between trauma and surgery. The longer the wait between subscapularis tears and repair, the greater likelihood of less optimal results. A bigger gap between injury and surgery gives more time for the body to fill in with fatty infiltration.

They also suggested that arthroscopic surgery for this group of patients yielded good early results. A longer follow-up period will show whether or not reruptures are common after arthroscopic repair of isolated subscapularis tendons. Other future studies are needed to compare the results of isolated subscapularis tendons between arthroscopic versus open incision repairs.

In this article, a surgeon from the University of Michigan Medical School presents a review of a shoulder condition known as posterior instability. The term posterior instability tells us the shoulder has too much slide, glide, or movement backwards. Subluxation (partial dislocation) and even complete dislocation are often the end results of posterior instability.

Another name for this condition is glenohumeral instability. Glenohumeral refers to the shoulder joint where the round head at the top of the humerus (upper arm bone) inserts into the glenoid fossa or shoulder socket.

Incidence, cause, evaluation, diagnosis, and treatment of posterior glenohumeral (shoulder) instability are the main topics. Specific clinical and imaging tests are discussed. Conservative care and surgical management are also included.

The basis for this information comes from 107 studies on the topic published between 1950 and 2010. Shoulder instability is a fairly common problem, especially among athletes but also in the general population. Most of the time, the shoulder moves too much forward (anterior instability). Posterior instability is much less common accounting for only up to 10 per cent of all shoulder instabilities.

The main cause of posterior shoulder instability is overuse or trauma (fall, injury). Repeated motions in athletes who participate in overhead throwing actions, swim, or lift weights commonly contribute to posterior shoulder instability. Volleyball players, football players, and tennis players are also at increased risk for this problem.

Damage to the soft tissue around the shoulder (e.g., capsule, ligaments, rotator cuff, labrum) contributes to the problem. And it doesn’t take much to create instability since the shoulder socket is shallow enough to allow for all the movement we need to move the arm around in a complete circle.

There are lots of ways to describe or classify posterior shoulder instability. Some of the different methods include by degree (mild to severe), direction (single or unidirectional versus multidirectional), mechanism of injury, and by timing (acute versus chronic).

Mechanism of instability tells us whether there was an injury or if the person might have had some abnormal anatomy contributing to the problem. Soft tissue laxity, unusual angle of the humeral head as it sits inside the fossa, or an excessively shallow socket may be factors leading up to the problem of instability.

How do you know if you have posterior shoulder instability? A very telling symptom is movement of the humeral head backwards either partially or fully out of the socket. Aching pain along the back of the shoulder is common.

But a true tell tale sign is the posterior drawer test. Pain and symptoms of instability are seen when the shoulder is flexed (bent forward), elbow bent to 90 degrees, and palm facing down. An examiner applies pressure over the shoulder in a downward motion to feel for any movement called translation which should not be present.

Follow-up imaging studies such as X-rays, CT scans, and MRIs may be ordered. Each one of these tests offers a little different piece of information. X-rays show the bone anatomy, any defects in the bone, and the condition of the joint space. Other types of imaging studies give the surgeon an idea of the size and shape of the shoulder socket as well as any disruption in the soft tissues.

Once the diagnosis has been made and all the information gathered about the instability, then treatment can be planned. Most of the time, conservative (nonoperative) care is tried first.

Three to six months of physical therapy (aided by a home exercise program) is the first-line of treatment. The therapist identifies which muscles to strengthen and helps the patient regain normal rhythm of motion and motor control. This is especially important with the coordination of movement between scapula (shoulder blade) and humerus (upper arm).

If the instability persists, then surgery may be needed. There are some cases where surgery is recommended right away. This plan of care is most likely when there has been a traumatic injury. Damage severe enough to alter the bone or pull the soft tissues away from the joint may require immediate surgical intervention.

The type of surgery done depends on all the factors reviewed when classifying the lesion. For example, the surgeon may repair a torn labrum (fibrous rim of cartilage around the shoulder socket). Or it may be necessary to reconstruct the head of the humerus. Bone grafting, tightening the posterior capsule, or wedge osteotomy (to change the angle of the humeral head or shoulder socket) are additional types of surgery performed for posterior shoulder instability.

Some patients just aren’t good candidates for surgery. This includes people with uncontrolled seizures (even with medication) and folks who don’t follow their physical therapist’s advice or who don’t do their exercises. The postoperative rehab program is long and requires daily attention.

After surgery, patients can expect six weeks in a sling and an exercise program no less than three months long. Athletes or patients with work duties that require specific arm motions can count on a full year of rehab.

There are many different causes of shoulder pain. Any problem inside or around the joint can create pain. One of the more common sources of shoulder pain occurs when there is some type of pathology of the long head of the biceps tendon (LHBT).

The biceps tendon attaches between the elbow and the shoulder. It helps you lift your arm straight up and bend the elbow. There are two parts: the short- and long-heads of the biceps. Each one attaches in a slightly different place on the arm. Pathology of the long-head of the biceps causing shoulder pain could be a partial tear of the tendon or tenosynovitis (inflammation of the sheath or lining around the tendon).

Another injury of the long head of the biceps causing shoulder pain could be a SLAP lesion. SLAP stands for superior labral tear from anterior to posterior (from front to back). The labrum is a rim of fibrous cartilage around the shoulder socket. The word “superior” tells us the injury is to the cartilage that covers the top part of the shoulder socket.

Treatment for any of these causes of biceps tendon problems may consist of surgery called a tenotomy. During a biceps tenotomy, the long-head of the biceps tendon is released from its attachment to the shoulder. Surgically cutting this portion of the tendon allows it to retract or move away from the shoulder. A tenotomy of this type removes the damaged, inflamed tissue from the joint. This particular tendon has a rich supply of pain nerve fibers so releasing it helps reduce shoulder pain.

Despite all good intentions in treating the shoulder pain by performing a tenotomy, sometimes after tenotomy surgery, the patient develops complications. The most common problems are a cramp-like arm pain, loss of normal elbow strength (flexion or bending), and a change in the shape of the upper arm. This altered appearance of the upper arm is called a Popeye deformity.

A Popeye deformity is usually pretty obvious. There’s a dip where the long head of the biceps tendon has been released and retracted from the shoulder. A large bump along the front of the upper arm (making the biceps muscle look extra large) occurs when the muscle belly (not just the tendon) retracts (pulls back).

This deformity is most obvious when the patient flexes the biceps muscle to bend the elbow. Picture the way Popeye (cartoon character) always showed off his bicep muscle after gaining strength from eating spinach. Only in the case of complications after tenotomy a “Popeye muscle” isn’t a sign of strength. Instead, there is muscle weakness.

Why do these complications occur after a simple biceps tenotomy for shoulder pain? Who is affected most often? These are the questions explored in this study. Gathering as much information as possible from patients who developed complications after arthroscopic tenotomy of the long head of the biceps tendon may provide a few answers.

This study included 132 patients with this complication. SLAP lesions as the source of biceps tendon pathology accounted for half of the group. Almost half (45 per cent) of all 132 patients who had a tenotomy ended up with the Popeye deformity. Three-fourths of these patients were men.

It turns out that male sex is actually the biggest risk factor and predictor of Popeye deformity as a complication of the biceps tenotomy. Age wasn’t a factor and neither was body mass index (BMI) or arm dominance (being right- or left-handed). The problem of a Popeye deformity is mostly one of cosmetic appearance. It can (but does not usually) result in a major loss of shoulder strength or function. Elbow strength is mildly affected.

The authors conclude that tenotomy of the biceps tendon is not for young, active patients or anyone with concerns about appearance. Age is not a factor in predicting who might experience this type of complication but being male is a strong predictor.

Therefore, men who are involved in work or recreational activities that require strong elbow flexion and forearm supination (turning the palm up towards the ceiling) should be forewarned that strength loss could affect them. This type of information may be of particular interest to carpenters, woodworkers, mechanics, gardeners and others who use their forearms and elbows repetitively to complete daily work tasks.

Trying to decide if you should have that rotator cuff surgery done? The findings from this study might help you. Many adults who have a rotator cuff tear consider waiting to see if the shoulder will heal on its own without surgery. The goal of this study was to observe over time what happens to full-thickness rotator cuff tears that are treated conservatively (nonoperative treatment).

There has always been a question whether rotator cuff tears can heal without surgery. It is clear that painful symptoms can be treated effectively without surgery. But does the torn tendon actually regenerate itself? And if the tear does heal (or at least decrease in size) — is the tissue quality of the healing site normal tendon tissue or scar tissue? This study does not look at the quality of tissue repair but does evaluate size of the tear over time.

Ultrasound imaging was used to diagnose 61 tears in 51 adults 60 years old and younger. Follow-up ultrasounds were taken two to three years later. Patient age, sex (male or female), size of the tear, and patient symptoms were compared with the results of the ultrasound.

They found that half of the tears got worse (larger in size) over time and that an increase in tear size was accompanied by increased shoulder pain. One-fourth of the total group developed a second full-thickness rotator cuff tear. The rest of the group (26 tears accounting for 43 per cent of the total) were unchanged (not better or worse).

Analysis of the data did not show any link between the change in tear size and patient age, trauma as a cause of the initial problem, or size of the original tear. There did not appear to be any correlation between new tears and sex or trauma as a cause of the first tear. There was a clear relationship between increasing shoulder pain and the original rotator cuff tear getting larger in size.

The authors suggest that based on their findings, it looks like rotator cuff tears can get better — but most do not. Younger, more active adults with rotator cuff tears may want to consider surgery early on for full-thickness tears.

Ultrasound images that show scar tissue rather than normal tendon tissue support a decision for surgery. Predicting who will recover and who will develop a worse tear (or additional tears) remains unknown.

Further study is needed to help sort out this aspect of recovery in the decision-making process. Anyone with a rotator cuff tear who develops increasing shoulder pain should consider having a repeat ultrasound done to see if the tear has increased in size or another tear has developed. Worsening of the rotator cuff problem (or a new tear) signals the need for surgical repair.

You’ve probably never heard of the biceps pulley system. But anyone who has had a rotator cuff tear or who has pain along the front of the shoulder may, in fact, have a lesion (tear or damage) of the biceps pulley.

What is this biceps pulley? The full name of the pulley mechanism is biceps reflection pulley. It is a sling of soft tissue fibers made from surrounding shoulder ligaments and tendons of the shoulder rotator cuff. The sling helps keep the biceps tendon inside a groove in the humerus (upper arm bone) along the front of the upper arm and shoulder.

Disruption of the biceps pulley (usually from a rotator cuff tear) allows the biceps tendon to sublux (partially shift out of the groove) or dislocate (pop out fully). The result can be anterior shoulder pain (along the front of the upper arm) and/or shoulder instability.

In this study, surgeons who were already performing arthroscopic examination and/or arthroscopic surgical repair of shoulders took a close look at the biceps pulley mechanism of each patient. The study included 229 patients who were treated for a variety of shoulder problems (e.g., rotator cuff tears, osteoarthritis, instability). Adults of all ages (ranging from 18 to 76 years) were included.

Everyone was examined by the surgeon in the clinic before surgery. Shoulder motion was evaluated. The presence, location, and intensity of pain were recorded with each shoulder motion and shoulder position tested. The results of these dynamic tests of shoulder function were later compared with arthroscopic findings. Making this type of comparison helps surgeons know which clinical tests are reliable.

They found that one-third of the group did, indeed, have a biceps pulley lesion. In most cases, the biceps pulley lesion was present when the patient had a rotator cuff tear and SLAP lesion.

SLAP refers to a superior labral anterior-posterior tear. The labrum is a rim of fibrous cartilage around the shoulder socket. This little extra lip helps keep the shoulder in the socket. The SLAP lesion refers to a labral tear at the top of the socket (that’s what superior means) that goes from the front (anterior) to the back (posterior) of the socket.

The biceps tendon is intimately linked with the labrum because it attaches along the upper front area of the socket. In some SLAP lesions, the biceps tendon is also pulled away from the bone. In this study, one third of the torn pulleys still had an intact (undamaged) biceps tendon. Almost 80 per cent of the entire group had a biceps pulley tear and a rotator cuff tear at the same time.

Another important (and surprising) finding in this study was the fact that dynamic shoulder tests with the arm positioned in 30 and 60-degrees of shoulder abduction and internal/external rotation were not needed to detect a pulley lesion. Testing the arm in a neutral position gave just as much and just as good of information as adding this extra test position.

The authors conclude that surgeons may not always be aware of the biceps pulley system. The loss of this restraining mechanism may contribute to continued shoulder pain after repair of a torn rotator cuff tendon. A proper inspection of the biceps pulley is advised. Repair of this anatomic feature may improve surgical outcomes.

Future study of this biceps pulley mechanism is needed to find out which comes first: degeneration and disruption of the pulley system or rotator cuff lesions? Since many of the biceps pulley lesions were in older adults, it may be that an injury to the biceps tendon leads to disruption of the pulley mechanism.

The end result may be weakening of the rotator cuff with eventual damage there as well. On the other hand, seniors are also at increased risk of rotator cuff tendon degeneration and disruption, which could create the chain of events that leads to biceps pulley lesions.

Surgeons have found that reducing pain after shoulder surgery helps speed up recovery. As a result, more aggressive pain control measures are now in use. One of those methods is to inject a local anesthetic (marcaine, lidocaine, bupivacaine) directly into the joint after surgery.

This study shows that the practice of postoperative infusion of marcaine actually contributes to the destruction of the joint surface. The result is a condition called chondrolysis. Chondrolysis is defined as a generalized (all over) loss of the articular (surface) cartilage of the joint.

The fact that the condition is generalized (rather than a local area of cartilage loss) shows that this is more than just a mechanical problem. If it were a suture rubbing away the surface cartilage, then only one or two bare spots would form.

But when the entire surface of the humeral head (round ball of bone at the top of the upper arm) and the inner layer of cartilage in the shoulder socket are missing, then it’s time to take a closer look.

In this study, 375 cases of shoulder arthroscopic surgery were reviewed. The procedures ranged from a simple debridement (cleaning the joint of infection, loose tissue, and smoothing rough edges) to repair of torn cartilage (called the labrum), capsular release, and rotator cuff repair.

Chondrolysis as a complication after arthroscopic surgery has been studied before. But this is the largest report of its kind and the first effort to figure out why this problem develops. By looking back at the records of these 375 cases, the authors found three main risk factors that may be the problem.

Most notably, it looks like injecting a specific numbing agent (marcaine) at a high enough dose (0.5 per cent) is the most significant risk factor. Pain and loss of shoulder motion were the first symptoms reported. The pain began within the first 18 months after shoulder surgery. In all cases, marcaine was injected into the joint after the procedure.

Anyone who had shoulder surgery without the use of an intra-articular (inside the joint) injection did NOT develop chondrolysis. Likewise, when a lower dose of marcaine (0.25 per cent) or a different drug (e.g., lidocaine) was used there were no reports of chondrolysis.

A couple other factors were identified as increasing the risk of chondrolysis after intra-articular injection of marcaine. The use of suture anchors in the glenoid (shallow groove, shoulder socket) was one risk factor.

Younger patients were also more likely to develop chondrolysis after intra-articular injection of marcaine following arthroscopic shoulder surgery. The link between age and chondrolysis isn’t clear.

Local anesthetics like lidocaine, bupivacaine, and marcaine are known to destroy chondrocytes (cartilage cells) in animal studies. The cytotoxic (cell killing) effects may be more common in younger age groups but more study is needed to find out what’s really happening. The fact that there were fewer cases of chondrolysis with lidocaine may suggest lidocaine is a weaker agent.

Now that we know 0.5 per cent marcaine injected into the joint after shoulder surgery can lead to joint surface destruction, it may be possible to prevent chondrolysis as a complication of arthroscopic procedures.

Avoiding postoperative infusion of this drug (or using a lower dose) may be all that’s required but there may also be combinations of risk factors at work, too. If that’s the case, then further research is needed to find out which risk factors or combination of risk factors are significant.

Raising your arm up over your head can be a piece of cake. Smooth, easy flow of motion is effortless. But to accomplish this movement, there is an entire shoulder and upper quadrant complex at work. The scapula (shoulder blade), clavicle (collar bone), and glenohumeral (shoulder joint) must slide and glide with just the right timing.

Part of the shoulder complex includes the soft tissue structures surrounding and attaching to various points on these bones. Any change in the anatomy, shape of the bones, or position of these structures can alter movement. One problem involving the coracoid process is the focus of this article.

The coracoid process is a small hook-like structure at the top front part of the scapula (shoulder blade). The coracoid process works together with the acromion to stabilize the shoulder joint

The acromion is a curved piece of bone that comes from the back of the shoulder blade around and over the top of the shoulder joint. Muscles and tendons of the rotator cuff slip underneath the coracoid and the acromion to attach to the humerus (upper arm bone). Some ligaments stretch between the coracoid process and the acromion.

Pinching of the soft tissue structures by the coracoid process is referred to as coracoid impingement. The patient’s first inkling that something is wrong is a dull, aching pain along the front of the shoulder. As the arm moves forward and up, across the chest, or internally rotates, the coracoid pinches against the subscapularis tendon, subcoracoid bursa, and/or the biceps tendon.

Coracoid impingement is an uncommon problem and rarely occurs alone without some other change in the nearby anatomic structures contributing to the problem. For example, rotator cuff tears or degeneration or an unusual shape or length of the coracoid bone can lead to coracoid impingement. Calcium build up in the subscapularis bone or the formation of a ganglion cyst can also cause impingement in this area.

Surgeons who are treating shoulder problems may find patients who still have shoulder pain after shoulder surgery to repair a torn rotator cuff or relieve pressure under the subacromion.

Coracoid impingement just doesn’t occur by itself. There is usually another reason why this additional problem has developed. It is up to the surgeon to search carefully for factors such as rotator cuff damage or degeneration, shoulder joint instability, or arthritis.

The patient’s history can offer helpful clues. There is often a previous history of fractures of the humerus, coracoid, or glenoid (shoulder socket). Prior shoulder surgery is another contributing factor.

The physician examines the shoulder and looks for tenderness over the coracoid process, pain when the arm is moved across the chest, and weakness of the subscapularis muscle. Other signs and symptoms may include shoulder instability, pain on testing the biceps tendon, and generalized weakness of the rotator cuff.

Experts don’t agree on whether CT scans or dynamic MRIs (taken while the patient is moving the arm) are helpful. The shape, size, length, and movement of the coracoid and the arch that it forms vary from patient to patient. Knowing what is “normal” and “abnormal” can be difficult to tell.

The radiologist looks for cystic changes, edema, and tears in the soft tissues. Imaging studies do help identify decreased space between bones where impingement might occur. Usually coracoid impingement has more than one anatomic feature contributing to the problem.

An arthroscopic examination (using a special scope to look inside the joint) is the best way to find out what’s causing the problem. Some cases can be cleared up surgically at the time of the arthroscopic exam. The surgeon may reshape or cut the tip of the coracoid process off. Tears in the rotator cuff may be repaired.

If there is a thickened bursa (pad of tissue to reduce friction between two surfaces), the surgeon can reduce the size or remove it entirely. Likewise, any thickened soft tissue or scar tissue causing narrowing of the space between the coracoid and the humerus can be removed.

The surgeon is careful not to cut into the supportive ligaments holding the shoulder complex together. Likewise, it is important to avoid cutting into nerves and blood vessels in the area. The effect of this type of surgery is to decompress the subcoracoid space.

Success is measured by pain relief and improvement of shoulder function. Joint motion isn’t usually affected by coracoid impingement, so there may not be any change before and after surgery in terms of shoulder joint range-of-motion.

Two other things you should know about coracoid impingement. First, conservative (nonoperative) care is possible. In fact, this is the first-line of treatment before doing surgery.

A physical therapist will work with you to restore normal posture and shoulder stability. This may involve a strengthening program for the rotator cuff, and taping of the scapula and shoulder (called kinesiotaping).

Kinesiotaping is used to place the shoulder in the right position and re-teach the muscles to hold and move properly. The result is to take pressure off the subcoracoid soft tissues and prevent impingement.

Any areas of scar tissue or tightness may be treated with manual therapy and stretching exercises. The therapist will evaluate how you move and any compensatory patterns of movement you may have developed as a result of anatomic changes or soft tissue injuries or degeneration. Activity modification may be required at home during daily activities, at work, and during recreational or sports activities.

If conservative care is unable to change the movement pattern and painful symptoms, then surgery is considered. Sometimes the surgeon is unable to accomplish what needs to be done with arthroscopic surgery. In such cases, open incision surgery may be required. The procedure is called an open coracoid decompression.

In summary, the problem of coracoid impingement is rare and even more unusual as an isolated problem (i.e., by itself without some other shoulder pathology contributing to it).

There aren’t very many studies reporting on the outcomes based on treatment. Conservative care is attempted followed by surgical repair and/or reconstruction if and when a nonoperative approach is unsuccessful in relieving pain. The author of this study provides a description, drawings, and intraarthroscopic photos of his preferred surgical techniques to handle this problem.

Normal shoulder movement and function requires that all parts of the rotator cuff are intact and working together. If even one of the four muscle/tendon units that make up the rotator cuff is damaged, there is an imbalance in the force and load placed on the joint. The result is abnormal joint biomechanics (movement).

The largest muscle in the rotator cuff is the subscapularis. This muscle helps rotate the shoulder and arm inward (internal rotation). The subscapularis helps stabilize the shoulder in the socket and prevent forceful anterior (forward) dislocations.

The subscapularis also helps balance the force applied on the shoulder from the posterior (back side of the) rotator cuff. The rotator cuff surrounds the entire shoulder joint like an envelope (front, back, side, and under the arm). Any weakness on one side from a tear or damage to the rotator cuff will affect how the rest of the cuff functions.

In this study, surgeons from Germany report on the results of open surgery to repair full-thickness subscapularis tears in athletes. Being the largest of the muscle/tendon units, it is also one of the strongest. But as the authors of this study point out, subscapularis tears occur more often than previously recognized.

The 30 patients in this study ranged in age from 15 to 64. The majority of the group was male who injured the arm during a sports activity. The mechanisms of injury were reported as 1) a fall backward on the outstretched arm, 2) a direct blow to the shoulder, 3) traumatic anterior (forward) shoulder dislocation, or 4) backward motion of the shoulder (extension) when the arm was in an abducted position. Shoulder abduction places the arm away from the body either out to the side or up over head as when throwing a ball forward.

In all patients, the subscapularis tendon was fully torn or ruptured. This is called a full-thickness tear. Some were severe enough to pull the tendon away from the bone. Severity of tear was also judged by how far the torn tendon retracted (pulled away) from the place where it was torn.

Treatment is usually surgical, especially for athletes who want to get back into action as soon as possible. In this study, open incision repair was done. Any other damage to the shoulder (muscles, ligaments, or joint) was also repaired at the same time.

Surgical techniques used differed depending on the location and severity of tendon tear/rupture. Type of sport the athlete was involved in was also considered when planning the specific surgical approach. Attention was paid both to functional demand and cosmetic appearance.

The authors described their operative technique for the subscapularis and for those athletes who also tore the long head of the biceps tendon. After surgery, shoulder motion into external (outward) rotation was restricted for six weeks.

A shoulder splint was worn for the first three weeks. No lifting and no vigorous activity were permitted for three months. Sports specific training helped the athletes return to their chosen sports six months after surgery.

A closer look at the results showed an 87 per cent satisfaction rate with the final outcomes. Motion, strength, and function improved with very few problems or complications. Two patients reported ongoing joint stiffness. There were no cases of infection or nerve damage following surgery.

The surgeons involved in this study took the opportunity to test the value of clinical tests used to evaluate patients before surgery (e.g., joint range-of-motion, muscle strength, arm lift-off test, belly press test). They were looking for pre-operative factors that might help predict post-operative results.

They found that putting off surgery after the initial injury was a risk factor for less than optimal results. The longer the damage goes unrepaired, the more likely the damaged area fills in with fat cells. The more fat infiltration present, the more likely it is that the surgical repair will fail (re-rupture).

The authors concluded that early repair of full thickness subscapularis muscle/tendon tears gives the best results. When the tendon is restored quickly, there is less chance for scar tissue or fat to fill in and greater likelihood that full function can be restored. Most athletes with subscapularis muscle/tendon tears do return to their pre-injury level of sports participation. And that’s the best news of all.

Athletes who injure their shoulders aren’t the only ones to have rotator cuff tears (RCTs). Age-related degeneration is also a factor, especially for adults over age 60. Researchers are trying to understand the pathogenesis (process of disease) behind rotator cuff degeneration.

In this report, orthopedic surgeons from the Philadelphia Hand Center use the case of a 63-year-old man with shoulder pain as a result of an injury to examine the current scientific evidence explaining shoulder rotator cuff tears.

Magnetic resonance imaging (MRI) studies have helped surgeons look at rotator cuff tendons and see what’s going on. MRIs taken over time show the degenerative process at the cellular level. MRIs of human tissue have been aided by cadaver studies (looking at tissues in humans after death) and by animal studies.

Taking a look at the tissues under a microscope has shown that the injured or degenerating rotator cuff tendon has disorganized tendon fibers, fewer normal cells, and quite a bit of fill-in by fat and scar tissue.

The cells that make up the collagen matrix (basic structure) of the rotator cuff are altered. As a result, the body’s effort to repair and remodel degenerating or defective tissue is unbalanced. The natural break down of tissue occurs without an equal amount of repair and remodeling. The result is a tearing of the rotator cuff tendon in the older adult.

There isn’t an inflammatory process like we would normally see with an acute injury. This ongoing process of unbalanced degeneration, repair, and remodeling results in a rotator cuff defect that is referred to as a tendinopathy. The literal translation of tendinopathy is “pathology (disease) of the tendon”.

Studies show that defects in the rotator cuff occur more often than we thought. Up to half of all adults over the age of 70 may have unknown rotator cuff defects. Because many people are asymptomatic (no symptoms and especially no pain), the presence of rotator cuff disease goes unnoticed. Why some people have symptoms while others do not (with equal rotator cuff disease) remains a mystery.

Some experts question the possibility that the mechanism of tendon changes might explain symptoms. For example, direct injury may create an early acute inflammatory response with pain while mechanical compression or overuse of the rotator cuff doesn’t generate an acute response so no pain or other immediate symptoms. When enough tissue breakdown occurs and the muscle can no longer contract fully, then loss of motion may be the first sign of a problem.

For some patients like the gentleman in this case example, the question becomes whether this new injury is really an acute rupture or merely the final result of an ongoing degenerative process. Under the stress of a load (e.g., trying to catch a suitcase falling out of an overhead bin on an airplane), the already degenerating tendon gives way. What was a chronic (but unknown) condition now becomes an acute (newly traumatic) problem.

Most of today’s theories about rotator cuff tendon degeneration are still based on observations of patients who have symptoms, not those who have rotator cuff tendinopathy but remain asymptomatic.

The authors conclude that age-related tendinopathy of the rotator cuff may put older adults at risk for tendon rupture. But this is still a theory and not fully supported by evidence or explained by imaging studies. Newly symptomatic, chronic degenerative defects may be treated differently than acute traumatic injuries.

Long-term studies of adults and the natural history (what happens over time) of rotator cuff tendons is needed. The information gained may help direct treatment by identifying the true underlying problem.

In this article, orthopedic surgeons from an orthopedic center and a university review the diagnosis and treatment of humeral avulsion glenohumeral ligament (HAGL) lesions. What are HAGL lesions, you say?

The word humeral tell us the shoulder is involved because the humerus is your upper arm bone. At the top of the humerus is the round ball that fits into your shoulder socket and makes all those circular arm movements possible. Avulsion of tendons or ligaments means there has been a tearing of the soft tissues — enough to pull away from the bone where it was attached.

The glenohumeral ligament is a band of tissue around the shoulder that provides the stability needed to keep the head of the humerus in the socket. Age-related degeneration and trauma (injuries) that damage this ligament can result in a chronically dislocating shoulder.

Recognizing that a patient has a humeral avulsion of glenohumeral ligaments (HAGL) is a key to successful treatment of shoulder instability. In many cases, a patient with a shoulder that frequently pops out of the joint has more than one type of damage to the soft tissue structures. If the HAGL lesion goes undetected, surgery to treat other problems may not be successful.

How does the surgeon diagnose the problem? There are several steps in the diagnostic process. First, the surgeon asks the patient all about how this happened, what the symptoms are, and what makes it better or worse. A very important piece of patient history is a prior failed shoulder surgery.

HAGL tears occur most often when the person has the arm in a position of abduction (away from the body) and external rotation (outward rotation). Think of a pitcher’s arm after the wind-up and just before releasing the ball or how you would hold your hand under your head when lying on the ground looking up at the stars. Force or trauma with the arm and hand in this position cause avulsion injuries of the soft tissues leading to dislocation.

Clinical tests are carried out to give the surgeon an idea of the joint motion and muscle strength (or weakness). The surgeon will challenge the shoulder in different positions and directions. These tests are called provocative maneuvers.

This step helps identify which muscles, tendons, and ligaments might be affected. The direction of instability is determined through these tests. The shoulder can have multidirectional instability meaning it is unstable (dislocates) in more than one direction — forward, backward, upward, and/or downward.

X-rays and other imaging studies such as MRI and magnetic resonance arthrography (dye injected into the joint before the MRI) are essential. These tests give the surgeon a look inside to see what is going on.

An even better diagnostic test is the arthroscopic exam where the surgeon inserts a long, thin needle into the joint. There’s a tiny TV camera at the end of the scope that gives an inside view of the joint. The surgeon can see where the ligament attaches and look for any places along the rim of the socket or joint capsule where the soft tissue has pulled away from the bone.

Because the glenohumeral ligament surrounds the joint, it can be damaged in the front of the shoulder (anterior), back of the shoulder (posterior) or above (superior) or below (inferior) the joint. Treatment (usually surgical repair) is based on the location, type, and extent of damage to this ligament.

Specifics of surgical repair are provided in this article. The surgeons describe the patient position used during surgery. They include the type of incisions made and offer a step-by-step approach to surgical stabilization for HAGL lesions. Photos are shown taken during the arthroscopic exam.

The actual surgical procedure may be done following the arthroscopic exam. Sometimes it is necessary to perform and open incision repair. The details of anatomy, repair of the lesion(s), and ways to avoid cutting the subscapularis tendon are also provided.

The authors conclude by saying that the most important aspect of diagnosing and treating shoulder instability is to make sure the surgeon looks for more than one area of damage or injury.

Humeral avulsion of glenohumeral ligaments (HAGL) can go undetected when the torn edge of the ligament scars down to the joint capsule. If this lesion isn’t repaired, the shoulder will remain unstable. Repeated dislocations even after surgery to correct some other problem (e.g., torn labrum, avulsion of tendon, rotator cuff tears) is an indication of an HAGL lesion.

It seems like everybody knows someone who has had a rotator cuff problem. With over half a million news rotator cuff injuries or tears each year, it’s highly likely you may find yourself in this same group. Older adults (65 years old and older) have the highest incidence of rotator cuff tears. Research shows that more than half of the adults in this age group have a rotator cuff tear — many without even knowing it!

With the aging of the many Baby Boomers (folks born between 1946 and 1964), it’s likely that the number of patients with rotator cuff disease showing up in the surgeon’s office will continue to increase. Surgeons are anticipating this problem by asking how to optimize treatment?

The answer isn’t straightforward (do this or do that) because there are so many issues that affect the decision-making process. For example, when should patients receive conservative (nonoperative) care and when should they have the tear repaired surgically? Should treatment vary depending on when the tear occurred (i.e., is the tear acute meaning it happened recently or is it chronic — it’s been there a long time).

Should everyone who is recommended to have surgery really go through with it? What if they have known risk factors that predict a poor result (like people who smoke or who have diabetes or other serious health concerns)? And what about surgery? Is there one procedure that works best for each type, size, shape, and location of tears? Does everyone benefit equally from the same rehab program (either when part of a conservative program or post-operatively after surgery)?

There are so many questions to consider, the American Academy of Orthopaedic Surgeons has published Clinical Practice Guidelines (CPGs) for the care and management of rotator cuff tears. The guidelines consist of 14 recommendations based on all available current (high-quality) evidence in the literature. The full guidelines are available on line at the American Academy of Orthopaedic Surgeons website (www.aaor.org/guidelines) but we will summarize them for you here.

First of all, there is agreement among all the physicians who came up with these guidelines that “if it’s not broke, don’t fix it.” In this case that means, if a person has a rotator cuff tear but it doesn’t hurt and doesn’t bother them, then don’t do surgery to repair it. Anyone who does have painful symptoms, loss of motion, decreased strength, and altered function should consider having surgery.

The evidence was inconclusive more often than not. Answers to many questions are lacking. Does exercise help? If so, what kind of exercise? Should you have the joint injected with a steroid and numbing agent? Does ice work better than heat? When would electrical stimulation be effective? When should you take a nonsteroidal antiinflammatory medication? These are questions that must be investigated further before any recommendations can be made.

And that’s just on the side of conservative care. When it comes to recommendations about surgery, the waters get even murkier. Should the surgeon use suture anchors to reattach the torn tendon to the bone or is it better to drill a tunnel through the bone and thread the tendon through to anchor it down? Should the surgeon perform the surgery using an open incision, arthroscopic repair, or the more recently develop mini-open approach? Once again, the evidence is inconclusive on these points.

Okay, so how about after rotator cuff surgery? Do patients really need to wear those slings and pillows that hold the arm away from the body? When should range-of-motion exercises be started after surgery? How quickly can motion and exercise be progressed? What’s the best way to manage pain during all this treatment? Don’t know, don’t know, don’t know.

What did the evidence support? There was weak support for doing surgery to repair chronic, full-thickness rotator cuff tears that cause pain and other disabling symptoms. Early surgery following the acute tear may have better outcomes than waiting until the problem becomes chronic. If the tear is only a partial one and doesn’t go all the way through the tendon, then conservative care with inflammatory meds and physical therapy may really be acceptable choices.

As for negative predictive risk factors (e.g., smoking, diabetes, infection) the panel could not tell surgeons they should or shouldn’t advise against surgery unless the MRI showed a significant tear, the patient was elderly, or the patient had a Worker’s Compensation claim. And these risk factors did not predict a poor outcome 100 per cent of the time.

The panel concluded there is a definite lack of strong evidence to help guide surgeons. The path in choosing the best treatment for optimal outcomes in patients with rotator cuff tears isn’t clear. Every patient deserves an individual evaluation with all factors and variables taken into consideration.

Clearly, there is a need for future research — and as this summary shows, scientists can choose almost any aspect of the management of rotator cuff tears to investigate at this point. Acute tears must be studied as well as chronic tears. The effects of conservative care versus surgical should be explored for all types of tears. And what type of surgery is advised for acute, chronic, partial thickness, and full-thickness tears would be helpful for patient and surgeon.

When the shoulder dislocates repeatedly, it’s time to get some serious help. That’s when the surgeon steps in and provides a stabilization procedure. Special suture anchors are used to repair damage to the soft tissue. The surgeon can use either an open incision approach or an arthroscopic method to accomplish the task.

Sometimes the stabilization doesn’t hold and the shoulder re-dislocates. Once again, the surgeon can go back in and use surgical means to restabilize the joint. Invariably, the question comes up whether it’s the way the surgery is done (open versus arthroscopically) that determines the rate of failure.

Various studies have been published on the rates of success/failure for arthroscopic versus open stabilization. The rates of failure requiring a revision operation are fairly even between the two different approaches. So the next question is: how do the results compare between the initial stabilization surgery and the revision (second) surgery?

In this study, this comparison is made just for patients who were treated using the arthroscopic approach. The same technique using suture anchors was used for both sets of patients for a clear comparison. And patients were “matched” between the groups so that their ages, sex (male versus female), and hand dominance (right-handed versus left-handed) were the same between the two groups.

There were 20 patients in each group (one woman and 19 men per group). They ranged in age from 16 up to 45 years old. Everyone had at least one dislocation, of course before having the first operation. Some patients had up to 60 recurrent dislocations.

The repair procedure was done for everyone under general anesthesia. Using an arthroscope, the surgeon looked inside each joint to determine the location and full extent of the damage. The damaged tissue around the joint was cleaned up and reattached. In the case of second (revision) surgeries, any loose sutures from the first operation were removed. Everyone was put in a sling for four weeks and then went to rehab afterwards for six weeks.

The results were compared between groups using X-rays and five standardized tests of shoulder function. The tests included the Rowe Score, Walch-Duplay Score, Melbourne Instability Shoulder Score, Western Ontario Shoulder Instability Index, and Subjective Shoulder Value. Each test measured a slightly different aspect of pain, motion, function, patient satisfaction, return to sports/recreation/work, and stability (physical and emotional).

Everyone was followed for at least two years so the data collected reflect mid-range results. Patients will be followed further in order to gather long-term results as well. But for now, here’s what they found. First of all, the patients who had a longer period of time with more recurrent dislocations before the initial stabilization surgery were the most likely to require further surgical procedures.

Four other differences were seen from the revision group when compared to the group who only had the initial stabilization procedure. Shoulder function was reduced in the revision group. Return to sport or work at the same level as before the first surgery was a bigger problem for the revision group. Many had to reduce their work/play, change sport, or even quit sports involvement.

Shoulder fatigue with everyday activities like writing or raising the arms overhead was reported more often in the revision group. A sudden, unguarded movement (e.g., losing balance) requiring the arms to respond quickly created problems for the revision group. The revision group was afraid of falling, especially if it meant a fall onto the involved shoulder. And finally, the revision group was unable to maintain their preferred level of fitness.

You probably get the picture the surgeons saw: outcomes after revision (salvage) surgery for recurrent shoulder instability just aren’t as good as results for patients who only need one stabilization procedure. What’s the benefit of a study like this?

Well, knowing that results of revision surgery are not optimal, surgeons can investigate two things: 1) are there risk factors that might be able to predict who will have a failed first stabilization procedure and 2) what can be done to prevent this from happening?

Is it a matter of finding the right surgical technique for each patient based on his or her specific injury, number of dislocations before surgery, length of time between first dislocation and surgery, or some other variable? The authors suggested perhaps there’s an emotional element connected with the experience of a failed surgery.

In summary, arthroscopic surgery to stabilize the shoulder is an effective and reliable procedure for most patients. But for those who have a failed response with further subluxations (partial dislocation) or full dislocation, a second (revision) surgery may be needed. Results of revision stabilization surgery are often disappointing with reduced function and inability to return to sports or work at the desired level. Studies like this one will aid future efforts to improve the results — both for the initial (first) surgery and for a revision procedure when one is needed.

The place where your collarbone meets the breast bone is called the sternoclavicular (SC) joint. Another name for the breast bone is the sternum. The anatomical term for the collarbone is clavicle, hence the name for the joint between these two bones: sternoclavicular or SC joint.

Injuries to the SC joint are rare but when they do occur, the results can be very serious. The close proximity of structures such as the trachea, esophagus, lungs, blood vessels, and nerves to the arms makes this injury the cause of problems that can be life-threatening.

In this article, orthopedic surgeons review the cause of this injury, diagnosis, and treatment. Discussion of special considerations related to the patient’s age is included. Patients in their early-to-mid-20s (and younger) may not have completed growth. The growing ends of the bones in this area may not be complete. The bones are not fully ossified.

Traumatic injuries to the SC joint are rare because the supportive soft tissue structures in this area are so strong. It takes a great force to overcome resistance and stability provided by the shape, size, and strength of the ligaments.

Car accidents and sports injuries account for most of the reasons why the SC joint might dislocate. And even athletic events have to be pretty extreme to dislodge this joint. For example, dislocation can occur to a player lying on the field who is then subjected to the force of another player falling or jumping on his or her clavicle. Or taking a direct hit or kick to the clavicle can also dislodge the SC joint.

Injuries of the SC joint can be classified as mild-to-severe. A mild injury means there’s pain and even swelling but the ligaments aren’t torn or damaged so the joint is still stable. If the ligaments stretch because of severe swelling, the joint can get partially separated, a condition called subluxation. Subluxation is considered a moderate injury. The most serious injury is a dislocation.

The swelling can prevent the surgeon from being able to tell the direction of the dislocation (anterior or posterior). The patient’s symptoms are somewhat diagnostic. For example, difficulty breathing may point to a posterior dislocation affecting the trachea (windpipe) or lungs. Difficulty swallowing suggests injury to the esophagus.

Imaging studies such as X-rays, MRIs, and CT scans are usually needed to make the final diagnosis and help the surgeon plan the best course of treatment. Mild injuries may respond well to conservative (nonoperative) care. Ice and pain relievers relieve symptoms (pain and swelling) and positioning with a sling helps protect the area while it is healing.

There are two ways to reduce (realign) a SC joint that is dislocated: closed or open reduction. Anterior dislocations are treated most often with closed reduction. Closed means the surgeon does not make an incision to gain access to the joint. Instead with the patient asleep (under anesthesia), pressure is applied to the collarbone to push it back in place. The joint will probably still be unstable until healing is completed, so the joint is supported and protected for a few weeks.

Posterior dislocations of the SC joint can also be treated with closed reduction. Again, the patient must be sedated. The surgeon uses positioning and traction of the arm while an assistant applies pressure to the clavicle to shift it back in place. X-rays are taken to confirm successful closed reduction of anterior or posterior dislocations treated in this fashion.

When the surgical team is unable to use closed reduction, an open procedure is done. The clavicle is manually reduced and stability of the joint assessed. Reconstructive surgery using a tendon graft to replace the ruptured ligaments may be needed to restore joint stability.

In some cases, the surgeon removes part of the clavicle (portion nearest the sternum). Then the rest of the clavicle is reattached to the first rib. The authors offer details on the surgical technique they use for this procedure.

After surgery, patients must be watched carefully. They are still at risk for infection, failure to maintain the reduction, and breakage of pins and plates used to hold everything together. Pins and wires can also migrate or shift and pierce the heart or nearby blood vessels. To avoid such serious complications, surgeons are advised never to use any wires, sutures, pins, or other fixation devices across the SC joint.

Later, arthritis can develop and the joint can even dislocate again. Patients must be monitored closely and told what to watch for. They must be instructed to return to their surgeon at the first sign of trouble. Early treatment helps prevent further complications and yields the best results.

Young, active adults with shoulder problems may not want a shoulder replacement as the solution to their pain and loss of motion. And, at the same time, they may not be a good candidate for such a procedure. The surgeon’s challenge is to find other ways to treat this problem called glenohumeral arthrosis.

The glenohumeral joint is what the lay person would call the shoulder joint. Arthrosis means damage has occurred to the joint surface. The first step in managing glenohumeral arthrosis requires a careful examination of the chondral (cartilage) surface and first layer of bone (the subchondral area).

Small, local lesions or defects of the cartilage are treated differently from large diffuse lesions. In this article, surgeons from the Center for Shoulder, Elbow, and Sports Medicine at Columbia University Medical Center in New York City review alternate treatment approaches for glenohumeral arthrosis. The term “alternate” refers to some other way to solve the problem without a shoulder replacement.

It may be possible to manage glenohumeral arthrosis without using surgery at all. The goal is to decrease pain and increase motion. Work and activity levels must be adjusted to protect the joint from further microtrauma. A physical therapist will guide patients through necessary lifestyle changes to accomplish this. At the same time, the therapist will prescribe an exercise program to improve strength, motion, and function.

Medications such as Tylenol, ibuprofen, and other nonsteroidal antiinflammatory drugs may be added to assist these nonoperative measures. Early reports support the use of hyaluronic acid injected into the joint. This treatment is used successfully for knee osteoarthritis and is being tried for patients with shoulder osteoarthritis.

When an adequate trial of conservative care fails to help, then surgery may be considered. There isn’t one “best” treatment that works for everyone. The surgeon re-evaluates the patient in order to identify the best treatment approach.

Two major factors affect this decision-making process. The first is patient-based. The surgeon takes into consideration all individual patient factors such as age, activity level, patient goals, and job requirements. The second is disease-based factors. The surgeon takes into account the cause of the problem, the size of the chondral (cartilage) defects, and how deep the lesion goes.

For any size chondral lesion, the first line of surgical treatment is an arthroscopic examination and debridement. Debridement refers to surgically cleaning out the area of any debris and pieces of cartilage or other fragments in the joint space. The surgeon smoothes any rough sports and removes bone spurs.

At the time of the arthroscopic exam, the surgeon looks to see what caused the arthrosis in the first place. There could be a rotator cuff tear, hole in the cartilage, or some abnormality of the surrounding soft tissue structures.

Chronic overhead motion with repetitive stress and load can put shear forces on the already compromised joint causing further damage and degeneration. If the player is to go back to active sports participation, the cause of the problem must be addressed because these repetitive motions are a necessary part of play. The player needs to be able to resume full action without return of painful symptoms and loss of function.

There are restorative procedures that can be done to help the joint cartilage heal and recover. Smaller lesions can be treated with abrasion, microfracture, and drilling techniques. Larger holes and defects may respond better to grafting procedures. Grafting uses cartilage and subchondral bone (first layer of bone under the cartilage) from the patient or from a donor to fill in the hole and stimulate bone and chondral growth around the defect.

The decision about which restorative approach to use is very complex. All of the treatments mentioned for restorative care of the shoulder cartilage are being used and studied primarily in the knee. Their use for the shoulder is just beginning.

A different management approach already in use for a case of shoulder arthrosis that is not quite ready for replacement is called resurfacing. The damaged head of the humerus (upper arm bone) is shaved down and covered with a metal cap. This is similar to putting a cap on a tooth. Results of resurfacing in young, active patients have been very favorable so far. Loosening of the metal cap is the number one problem to develop.

For patients with large defects, another new idea is the focal humeral resurfacing implant. The device looks like a large screw with a smooth head. It is screwed into the head of the humerus and provides a smooth surface to slide and glide in the joint.

Resurfacing of the shoulder joint can be done without a metal cap or implant. Surgeons are experimenting with various soft tissues to use as a covering. This technique is referred to as biologic interposition. The Achilles tendon from behind the heel is the most popular graft tissue for this treatment but others are being tried.

The use of knee cartilage (called the meniscus) to cover chondral defects in the shoulder has moved from cadaver studies to live humans. The meniscus has the right shape (round) and is flexible enough to conform to the joint surface. Concerns about complications and lack of durability have delayed routine use of this procedure.

And finally, there is a movement in the scientific world to find a way to engineer chondral (cartilage) tissue. This technique is called regenerative tissue or biologic resurfacing. Some experts really see this as the future of medicine for worn out parts and places anywhere in the body, including the joint cartilage.

As you can see from this report, there are many treatment options for shoulder chondral lesions that are being developed and studied. Not all are currently available or available routinely. In time, researchers will sort out which patients are good candidates for each procedure. If and when restoration of the joint surface just isn’t possible, then a partial or complete joint replacement can be considered.

Along with hip and knee joint replacements, shoulder replacement has become increasingly popular for people with pain and loss of motion from arthritis. But the shoulder is a bit different from the hip and knee. A tear in the muscles around the shoulder (called the rotator cuff) can complicate things.

Replacing the joint without an intact, functioning rotator cuff may not improve the situation. Without the muscles to hold the joint in place and move the arm, the surgery may not be successful. Surgeons who recognized this problem designed a special replacement joint (implant) just for large rotator cuff tears that cannot be repaired.

The procedure is called a reverse shoulder arthroplasty. The round ball-shaped bone that normally fits into the shoulder socket is removed and replaced with an artificial cup. The anatomic socket is replaced with a titanium round head. The two parts of the shoulder (round head and socket) are reversed in location.

The indications for this surgery are pain, loss of shoulder motion, and failed conservative (nonoperative) care. A rotator cuff tear that is too large to repair is another criterion for the use of the reverse shoulder arthroplasty.

In this study, the surgeon who designed the reverse shoulder implant investigated the results of treatment with this implant. The focus was on patients who had a massive rotator cuff tear but no sign of shoulder joint arthritis. The study was done at the Foundation for Orthopaedic Research and Education in Tampa, Florida. It was funded by the company that manufactures the implants (Don Joy Orthopaedic Surgical company).

The authors make note that the definition of a massive or irreparable rotator cuff tear can be defined differently by various surgeons. In their study, the patients had damage of at least two of the four tendons that make up the rotator cuff. They used special X-ray criteria called the Hamada classification to determine whether or not there were arthritic changes in the joint.

Results were measured using patient report about pain, X-rays to look at the joint, and several tests of shoulder strength, motion, and function. There were two groups: those who had a previous shoulder surgery (usually a failed rotator cuff repair) and those who had never had shoulder surgery before. Results were compared between the two groups.

They found significant improvements in all areas measured for both groups. There were a few failed implants and 18 of the 60 patients said they wouldn’t have the surgery if they had it to do over again (unknown reasons why they felt that way). Two-thirds of the group had an excellent result and were very pleased.

The patients most likely to be disappointed with the results were those who had severe shoulder pain but fairly good motion (greater than 90-degrees). Sometimes after the reverse shoulder implant, their motion was less than before surgery.

When problems occurred with the reverse shoulder arthroplasty, it was usually because the implant came loose or broke. Other complications included fracture of a bone in the shoulder complex affecting the humerus (upper arm bone), clavicle (collar bone), or scapula (shoulder blade). Shoulder dislocation, deep infection, and hematoma (pocket of blood) were also reported in individual patients.

Each patient was followed for at least two years. Everyone will continue to be monitored and results measured at regular intervals. Later publications will report mid- to long-term results. These two-year results suggest that the reverse shoulder implant doesn’t last as long in patients with a previous failed rotator cuff repair.

In summary, the reverse shoulder arthroplasty is an effective treatment option for patients with irreparable rotator cuff tears who do not have arthritis. Other treatment may be considered (e.g., muscle transfer, arthroscopic debridement, partial rotator cuff repair) but these methods only treat the pain. The reverse shoulder implant can provide pain relief and restore joint stability and function.

The reverse shoulder arthroplasty is a new enough procedure that surgeons are still studying who would benefit from this implant. Although it was designed for patients with massive rotator cuff tears that cannot be repaired, it has also been used for patients with severe bone loss, failed shoulder replacement, and humeral fractures that did not heal.

It may not be the best choice for patients with pain but preserved motion (more than 90-degrees of shoulder elevation). The authors of this study suggest trying other options first for these patients. Rotator cuff repair or debridement should be considered. Continued improvements in the design of the reverse shoulder implant and in surgical techniques will likely yield improved outcomes and greater implant survival in years to come.

Why are some rotator cuff tears (RCTs) painful while others are not? And what makes them convert from a pain free (asymptomatic — without symptoms) to a symptomatic tear? If we knew the answers to these questions, we might be able to prevent rotator cuff tears from getting worse and becoming painful.

Identifying factors linked with pain development in previously asymptomatic rotator cuff tears is the subject of this article. It’s actually an early report on the work being done by a group of orthopedic surgeons. This preliminary report comes from the Washington University School of Medicine in St. Louis, Missouri.

The rotator cuff is a group of four muscles and their tendinous attachments that surround the shoulder in the socket. They provide both stability (to hold the head of the humerus in the socket) and strength for smooth and controlled movement.

The surgeons involved in this study found 195 patients with an asymptomatic rotator cuff tear. They followed these folks over a period of time to see what would happen. Eventually, the group formed two groups naturally. Patients who started to have pain were placed in one group. The patients who continued pain free were considered the second group.

By comparing the two groups, it was possible to see differences that might explain who develops a painful rotator cuff tear and why that happens in some people but not others. Data was collected using X-rays and ultrasound imaging of the shoulder joint.

Ultrasound studies are helpful because they show tear progression and fatty degeneration of the rotator cuff muscles. Tear progression refers to tears that go from being partial (not all the way through the tendon) to full-thickness (complete rupture).

Tear progression also describes tears that increase in length or width by more than five millimeters. Fatty degeneration refers to the body’s attempt to heal the tear by filling in with fat deposits.

Range-of-motion and muscle strength were also assessed. Shoulder function before and after was measured using a tool called the American Shoulder and Elbow Surgeons Score.

Everyone in both groups had a painful rotator cuff tear in one shoulder. A symptom-free tear was found in the other shoulder, which qualified them to be in this study. There was no known injury or trauma causing the tears. Most of the patients were older (over 60 years old) when the rotator cuff tears were diagnosed.

Everyone was followed for at least six months before these results were compiled and reported. For those who were in the study longer, measurements were taken every 12 months. Some patients were in the study for as much as five years. Everyone in the study was asked to report any time pain developed that was rated as three or more on a scale from zero (no pain) to 10 (worst pain) that lasted six weeks or more.

Taking everything into consideration, the authors made the following observations:

In this article, a medical student, chief resident (orthopedic surgeon), and associate professor of orthopedic surgery at Brown University team up. Together, they review the current evidence about treatment for chronic shoulder pain. Whether it’s from a rotator cuff tear, arthritis, a frozen shoulder, or a labral tear, the information in this update will guide those looking for a little help for their ongoing shoulder pain.

Of course, an accurate diagnosis is the first step. And that was the topic of a previous article in this journal back in August of 2010. Once a clear cause for the problem has been determined, then treatment can begin. Conservative (nonoperative) care is always first whenever possible.

Conservative care is made up of three things: physical therapy, medications (usually antiinflammatory drugs), and steroid or hyaluronic injections. We will summarize each of those areas for those who are not familiar with these options.

Physical therapy can help you regain lost shoulder motion while paying attention to your posture and alignment. Helping you change movement patterns and poor postural habits can also go a long way in preventing a relapse. You will be given a home program to follow. Cooperation with the exercises and activities recommended by the therapist will ensure a successful outcome.

Stretching exercises to increase flexibility will be followed by strengthening exercises to restore strength. The therapist will show you ways to move that will avoid impingement (pinching of the muscles and tendons around the joint).

Don’t be afraid to take the medications your orthopedic surgeon or primary care physician prescribes. A simple pain reliever like acetaminophen (Tylenol) may be all that’s needed to get you past the rough patch. Studies show that nonsteroidal antiinflammatory drugs (NSAIDs) can also be helpful in managing chronic shoulder pain.

Short-term use of antiinflammatories (NSAIDs) can relieve your pain without causing the terrible stomach upset and other GI problems that can occur with chronic use. Short-term refers to a couple of weeks up to a month (two to four weeks). If you do take antiinflammatories (NSAIDs) and experience any nausea, stomach pain, or other GI symptoms, tell your doctor right away. A different dose or even a different drug may be needed.

“Local therapy” is a term used to describe injections into the shoulder to reduce inflammation and pain. A numbing agent similar to novacaine combined with the steroid (antiinflammatory) can be very helpful. When local therapy is followed by physical therapy, this treatment may be just the ticket needed to avoid surgery. This is very helpful for those patients who can’t have surgery for some reason (age, poor health).

You may have heard of another type of local injection therapy called hyaluronan. These products have been used quite successfully with the knee and are being tried in the shoulder as well. The fluid that is injected into the joint helps restore the lubrication needed for smooth shoulder movement. The effect is to protect the joint surface and thereby reduce inflammation.

For some people, conservative care just doesn’t do the trick. The pain continues and surgery may be recommended. The type of procedure done will depend on the underlying problem. For osteoarthritis, arthroscopic debridement is often the first step before a shoulder replacement.

The surgeon can avoid making an open incision and cutting through tendons and muscles by inserting a long thin needle into the joint. A tiny TV camera on the end of the scope allows the surgeon to see (and work) inside the joint. Any scar tissue, tears, and bone spurs are gently scraped away to restore smooth joint motion.

If there is a rotator cuff tear or degeneration, the tissue can be repaired or if necessary, reconstructed with a tissue graft. Labral and biceps tears (either alone or with rotator cuff damage) can also be repaired. The labrum is a rim of fibrous cartilage around the shoulder socket to help give it greater depth and stability. Tears of this structure can be very painful and are often severe enough to pull away with the biceps tendon still attached. That’s why the repair procedure addressed both areas.

And finally, adhesive capsulitis, also known as a “frozen shoulder” — again, the surgeon can use the arthroscope to go in and release the tight tissue. Gentle release of the fibrous tissue can be less traumatic to the shoulder than manipulation under anesthesia (MUA). Manipulation refers to moving the shoulder through its full motion while stretching and tearing the tissues that have become bound down.

In summary, the results of conservative care for chronic shoulder pain from all causes are good in the majority of people. For those who try but fail to improve with nonoperative care, surgery may be needed. Outcomes from surgery are also good to excellent in 90 per cent of the patients who go this route.

Working with a team of health care professionals including your physician and physical therapist is your starting point. It’s best not to wait too long before seeking help for that painful shoulder. Turning an acute problem away from the path of chronic pain may be as simple as a pain reliever and a few exercises. Overcoming chronic shoulder pain may be a much longer process, but it is do-able!