News Category: Shoulder

The authors of this review on the shoulder took on a huge project with their research efforts with several goals in mind. First, they wanted to review and revise Codman’s table of shoulder abnormalities. Dr. Codman was the first to compile a list of signs and symptoms for each of over 25 possible conditions affecting the shoulder. Dr. Codman published this table in 1934 and it remains surprisingly accurate today. With the information collected at the Johns Hopkins Medical Center in Baltimore, Maryland, the authors were able to update the table and create a modern version of Codman’s table.

Second, they developed a database back in 1995 with information entered on all of their shoulder patients. The intent was to be able to compare results from before to after surgery. They also hoped to be able to study the data collected and look for patterns of clinical signs and symptoms that might help in diagnosing shoulder problems. They did this by comparing what they found during the preoperative history and exam with their actual findings at the time of the surgery. In this way, they could offer other orthopedic surgeons a summary of how useful are the various tests and measures in use today.

For the database, they collected measurements before, during, and after surgery. Some of the tests included joint range-of-motion, strength, information on general health, and specific provocative shoulder tests. Provocative tests apply load or force to various soft tissue structures of the shoulder to look for signs of damage or injury. Most of these tests are commonly used by orthopedic surgeons, physical therapists, and athletic trainers when assessing shoulder problems.

The reliability and validity of each test was measured for each of seven major conditions affecting the shoulder. The tests included range-of-motion, drop-arm sign, shoulder shrug sign, Neer Impingement sign, Hawkins-Kennedy sign, Speed test, Apprehension tests (anterior and posterior), compression test, lift-off test, painful arc sign, cross-body adduction test, resisted extension test, external rotation lag sign, and Whipple Test. So, you can see it was a very thorough collection of tests used in this field.

The authors provide five tables summarizing their findings for each of these tests. The tests were used with patients who had rotator cuff tears, shoulder arthritis, adhesive capsulitis (frozen shoulder), shoulder instability, labral tears, biceps disease, and arthritis of the acromioclavicular (AC) joint. The acromioclavicular joint is along the front of the shoulder where the clavicle (collar bone) meets the acromion. The acromion is a curved arch of bone over the top of the shoulder coming from the shoulder blade.

Third, they reviewed all the published studies on the shoulder including a wide range of diagnoses such as rotator cuff disease, tendon tears, shoulder instability, bursitis, labral tears, and joint abnormalities. Finally, they included a review of their own experiences examining, diagnosing, and treating complex and challenging shoulder problems. They offer the following observations:

The focus of this review article is a specific shoulder injury known as a SLAP tear. SLAP stands for superior labral anterior-posterior. It refers to an injury affecting the labrum, a fibrous rim of cartilage around the edge of the shoulder joint. Because the shoulder has such a wide range of motion, the shoulder socket can’t be too deep. But if it’s too shallow, there is an increased risk of shoulder dislocation. The labrum gives a little lip to the socket to help balance out the need for mobility with the need for stability.

Overhead throwing athletes such as volleyball players and baseball pitchers often develop SLAP tears requiring surgery. In a SLAP tear, the labrum pulls away from the acetabulum (shoulder socket) from the front (anterior) all the way to the back (posterior). It is classified into four groups or categories depending on severity and associated soft tissue injury. The most common SLAP injury is type II. This refers to a tear near the site where the biceps muscle inserts into the bone.

Diagnosing a SLAP tear can be quite a challenge — even with today’s improved methods of imaging. The injury may occur as a result of injury or chronic overuse, but it can also develop slowly and without apparent cause. There isn’t one test that is 100 per cent reliable. In fact, most of the clinical tests available and in use today lack the necessary statistical sensitivity and specificity to be relied upon. The surgeon uses the patient history, observation, and examination as a starting point to determine what’s wrong. Muscle weakness, muscle atrophy(wasting), and loss of throwing speed and/or loss of control while throwing offer clues to the underlying problem.

Location of the pain, patterns of instability, and impaired movement patterns are carefully considered. The physician often compares the healthy, uninvolved side with the injured, painful side to identify specific changes present. It’s not until the surgeon performs an arthroscopic exam or repair procedure that the final diagnosis is made. But compared to even just 10 years ago, surgeons are better able to identify and treat SLAP tears with good results. The goal is to return the player to full participation in his or her sport. Or for the older adult with degenerative changes requiring treatment, restore full function in daily activities.

New knowledge about the blood supply to the labrum, shape of the labrum, and function of the labrum has helped us understand this unique injury. For example, the inner portion of the labrum doesn’t have a blood supply. That’s why it can’t heal on its own without some kind of surgical intervention. The back and lower part of the labrum has a better blood supply than the front and top of the labrum.

Whether or not the biceps is torn away (type II injury) depends on where the tendon inserts into the joint. It’s not the same in everyone and sometimes the fibers are attached in more than one place. Sixty (60) per cent of all the tendon attaches to a bony bump called the supraglenoid tubercle. The rest of the tendon inserts directly into the labrum. Even the attachment to the labrum varies from person to person. Sometimes it’s more toward the front (anterior) labrum and sometimes it attaches more toward the back of the labrum (posterior anchor). Understanding these differences has helped surgeons find better ways to reattach the disrupted soft tissues and return normal motion without stiffness to the patient.

Understanding the anatomical details of the labrum is of great importance for the surgeon. In order to restore the patient’s normal biomechanical function (and throwing abilities), it is necessary to repair the damage in such a way that the patient isn’t left with loss of motion or function. Too tight of a repair will leave the person with a stiff shoulder. Too loose and the joint is no longer stable, but rather, at risk of dislocation. Without a fully intact labrum, there can be too much external rotation, which also increases the athlete’s risk of an anterior (forward) dislocation.

Anatomical and mechanical variations may explain why some overhead throwing athletes never have a problem while others develop SLAP lesions. The amount of natural shoulder rotation that is present as well as any retroversion (twist) of the bone can make a difference. Tightness or contractures of the ligaments or capsule can alter the way the shoulder moves, setting off a cascade of biomechanical events that leads to a SLAP injury.

Not everyone needs surgery for this condition. Some older adults develop thinning of the labrum with frayed edges that constitute a Type I SLAP but there are no symptoms. These types of degenerative labral tears don’t require repair. In other cases, minor tears with no damage to the biceps may not create any mechanical symptoms if the tear is small enough. Surgery can even make some people worse by increasing stiffness and making rehab much longer than it would have been without surgery.

Conservative care with physical therapy and rehab to restore normal flexibility, strength, and stability of the soft tissues around the shoulder joint may be all that’s needed. Rest, followed by a gradual return to throwing (or in the case of older adults, daily activities) is often part of the program. The therapist analyses the athlete’s throwing mechanics in order to alter any problematic patterns.

Most of the time, it’s painful and limited shoulder motion that brings the patient in for treatment. The painful symptoms are made worse by heavy lifting, pushing, or overhead motions. These are referred to as mechanical symptoms because they occur when the shoulder is in a certain position or trying to perform a task that requires movement.

Surgery may be as simple as shaving away the frayed edges of the damaged labrum. This procedure is called a debridement. For unstable tears, the surgeon clears away any fragments and reattaches the rest of the labrum to the acetabulum where it belongs. Reattachment of the soft tissues is called fixation and is accomplished using absorbable tacks, suture anchors, or stitches without knots. If the biceps tendon has pulled away, it must be repaired as well. Repair techniques vary depending on whether the tear is located more anterior or posterior. The author offers advice and suggestions on repair techniques, ways to make sutures, and when to use each method of fixation.

A final focus of this report was a summary of research results so far. For example, studies show more favorable results using suture anchors instead of bioabsorbable tacks. Patients treated with the tacks were more likely to experience ongoing night pain, limited return to sports participation, and low scores in function. No matter what type of fixation device is used, there still isn’t enough research to show which one is stronger and holds up better and which one results in better outcomes. It is clear that unstable SLAP tears need more than just debridement. Without fixation, the damaged area breaks down again two years after the surgery.

In summary, there’s more to SLAP tears than meets the eye. As more and more information is gathered and reported, surgeons will learn from one another and gain a better understanding of the anatomy, pathology, and risk factors behind SLAP tears. These injuries are difficult to diagnose quickly and accurately. Often there are other shoulder injuries present at the same time. There is no formula that can be used to predict who will need surgery or how their surgery will turn out. Each patient must be examined as an individual, carefully and completely, so as not to miss any additional problems that could compromise the treatment selected.

The shoulder is a joint that takes on a big burden. It needs to be able to take on a heavy load and still be able to move around freely as we need it to. When pain strikes the shoulder, however, it can become difficult to do some of the most minor of tasks. And shoulder pain is common. Slightly more than 33 percent of visits to doctors for complaints of muscle, joint, or bone pain are because of shoulder problems. The most common problem is subacromial impingement syndrome, a condition where a piece of bone that is the extension of the shoulder blade, the acromion presses down on the rotator cuff, tendons that raise and lower the arm, and rub together.

This injury can be seen as rotator cuff tendinosis, rotator cuff partial thickness tear, or bursitis. And, although researchers estimate that shoulder pain affects between seven and 27 percent of adults in the United States, with the most common diagnosis is subacromial impingement, there are no clear set criteria for its diagnosis, which means that treatment may be difficult to come by.

The authors of this study wanted to examine the effectiveness of screening for subacromial impingement in the hopes that this would help doctors better treat the disorder.

Researchers looked at 55 patients (47 men) who had shoulder pain for at least one week. The average amount of time, though, was almost two years. First, the researchers performed the Neer test. In this test, the doctor lifts the patient’s arm and tries to rotate it to see how the shoulder reacts. The Hawkins-Kennedy test is done by the doctor holding the patient’s shoulder and then moving the patient’s arm, bending the elbow, against the chest. The painful arc was also done. With this test, the patient moves his or her arm, using the shoulder, and reports any pain.

The empty can or the Jobe test was also performed. For this, the doctor lifts the patient’s arm to a 90 degree angle and the patient tries to move his arm as the doctor provides resistance. Finally, the external rotation resistance test also involves resistance. The patient’s arm is bent at the elbow and the doctor tries to push the arm outward.

After these tests, the patients underwent an arthroscopic examination of the shoulder. This involves making small incisions in the shoulder to allow the surgeon to insert a camera to look inside the joint. The goal was to see if there was impingement and if any of the first five tests had been able to detect it.

The researchers found that 16 of the patients did have impingement, as seen by the surgery. They also found that the painful arc, external rotation resistance and empty can tests were the most helpful in diagnosing the impingement. When using the five tests, the positive results of three of the tests would be a good indication of subacromial impingement, the authors of this article wrote.

Arthroscopic surgery, surgery where the doctor makes a few tiny incisions and uses long, narrow instruments to perform the surgery, is an increasingly popular option when it is possible. Shoulder surgery is one area where arthroscopic technique is frequently used. It is used often when a shoulder has been dislocated, leaving the joint unstable. Unfortunately, the surgery isn’t always successful over the long-term and the shoulder may dislocate again. In fact, with young adults, arthroscopic surgery doesn’t have the same success rate that traditional, open, surgery has. Despite this, it’s often the first choice because of the many advantages of arthroscopic surgery: quicker healing time, shorter hospital stay, and fewer complications.

The authors of this article wanted to identify risk factors that could contribute to the chances of redislocating the shoulder after arthroscopic surgery.

Researchers examined the progress of 385 patients (278 men) out of an original 422 at the start of the study. In 301 of the patients, it was their dominant shoulder that was affected. Ninety-two of the patients had experienced a first dislocation when they were 22 years old or younger, and there was an average of three months between injury and surgery for 97 patients, four to six months for 112 patients, seven to nine months for 95 patients and 10 to 12 months for the remaining 81. One hundred seventy six patients had experienced between one to three dislocations, 209 had four to six. After surgery, each patient received the same post-operative care and the same rehabilitation program. Follow up was done at three months, six months, one year, two years, and three years after surgery.

The researchers found that 31 patients (8.1 percent) had experienced another dislocation within three years of their surgery. Thirteen of these patients were those who had dislocated their shoulder their shoulder the first time before they were 22 years. The majority of those overall who redislocated were men (90.3 percent), and in 77.4 percent overall, it was their dominant shoulder.

The study authors concluded that it could be possible to identify patients who may be at higher risk of dislocating their shoulders again. However, they caution that their study was limited because it was retrospective (looked back) and did not have any protocols to be sure that all patients were on an equal basis. As well, they had no x-rays or other types of images that were taken after surgery to check if there was any damage that may only have been visible in that way.

What’s the best way to treat calcifying tendinitis of the shoulder that doesn’t respond to physical therapy, medications, or steroid injections? The authors of this systematic review report that the use of extracorporeal shockwave therapy (ESWT) has proven successful, though we still don’t know if it is the best treatment approach. That remains to be determined in future studies.

What is calcifying or calcific tendinitis? It’s a degenerative condition affecting the four tendons surrounding the shoulder called the rotator cuff. These include the supraspinatus, infraspinatus, teres minor, and subscapularis muscles. All four muscles can be affected, but usually it’s just one of the four. And the tendons are listed here in declining order of frequency (i.e., supraspinatus is affected most often and subscapularis least often).

Calcium crystals called calcium pyrophosphate are deposited in the tendons. No one knows where these crystals come from exactly. But once the tendons start to degenerate, the crystals are released into the soft tissues as the tendon fibrils break down. Research shows that the calcium crystals help the tendon degenerate. The tendons harden and symptoms of impingement can develop. With impingement, there is shoulder pain when the arm is raised overhead or to the side above shoulder level. The stiff tendon doesn’t move and glide as it should and it gets pinched between the bony structures of the shoulder. Sometimes the person with this problem can move the arm through the pain all the way overhead. But other people have limited motion that leads to decreased function.

By sorting through five years of data from recently published studies, researchers from the Department of Trauma and Orthopaedic Surgery in England were able to confirm that all studies showed improvement after treating calcifying tendinitis of the rotator cuff with extracorporeal shockwave therapy (ESWT). ESWT is the use of sound waves to create enough energy to disintegrate the calcium deposits. It has been used with good results for other problems like gallstones and kidney stones. Once the calcium crystals have been broken up, it appears that the body absorbs them because X-rays show they disappear.

Most of the studies included patients with Types I and II calcification. There are three types of calcifying tendinitis diagnosed by X-rays. Type I has deposits that have clear outlines. A line can be drawn around the dense deposits to show exactly where they are, their size, and their shape. Type II disease has a clear outline but tends to be spread out more through the tissue and harder to see as a distinct shape. Type III lesions look cloudy without a specific form, shape, or outline.

All studies used a scoring system called the Constant-Murley score to measure results before and after treatment. Having one test used by everyone made it possible to compare the outcomes from one study to the next — even when the studies weren’t all conducted exactly the same way. The authors point out that this advantage was also a disadvantage. With only one measure of results was used, it’s impossible to know if other test measures might have shown a different result (better or worse). They suggest that future studies use other scoring systems for a comparison.

But for now, it looks like extracorporeal shockwave therapy is safe and effective for this potentially disabling condition. Significant improvement in motion, pain, strength, and function was consistently reported in all studies included in the review. Improvements were reported using both high-energy and low-energy shockwave therapy but high-energy had the best results. Low-energy therapy was better than no treatment or sham (placebo) groups.

The scapula (shoulder blade) is an amazing anatomical structure. It is suspended over the ribs between the spine and the arm by only two ligaments. There isn’t a real joint between the scapula and the trunk. Three layers of muscle and bursae (plural for bursa) support this structure. The bursae are small fluid-filled sacs designed to reduce friction between muscle or tendon and bone. These layers (superficial, intermediate, and deep) form a smooth surface for the scapula to move, glide, and rotate over. Because there is movement but no actual joint, this connection is considered a pseudojoint.

The scapula gives the glenohumeral joint (shoulder) a stable base from which to operate (move). The scapula itself slides, glides, and rotates in a 2:1 ratio with the shoulder. This means that for every two degrees of shoulder motion (flexion or abduction), the scapula moves one degree over the thoracic wall. Scapulothoracic movement requires proper length-tension ratios between the scapular bone and all of the muscles around it. Any change in the glenohumeral-to-scapulothoracic ratio can result in altered or compromised shoulder motion. One particular problem called the snapping scapula syndrome is an example of what can happen when any one of these layers is disrupted for any reason.

The snapping scapula syndrome is characterized by a loud pop or crack when the arm is raised up overhead. The medical term for this sound is crepitus. The sound is made by some soft tissue rubbing between the scapula and the thoracic wall. The tissue caught between these two structures could be a bursa, tendon, or muscle. The person with this problem may or may not experience pain with the movement.

There isn’t one reason why someone develops snapping scapula syndrome. Studies show that sometimes there’s a change in the shape or curvature of the scapula. After years of movement, the repetitive motion eventually causes a wear pattern that results in the snapping scapula syndrome. When a bursa is involved, the snapping problem could start as an isolated injury or it could be the result of repetitive (abnormal) motions of the scapulothoracic joint.

A less common cause is the development of a benign tumor called an osteochondroma. Bone spurs, scapular or rib fractures, nerve injuries with muscle wasting and weakness, or other types of tumors have also been linked with the snapping syndrome. And any surgery to the upper quadrant (e.g., breast implants or other breast cosmetic procedures, removal of a rib pressing on a nerve) can result in muscular changes that contribute to the development of the scapular snapping syndrome.

No matter what the cause, the effect is a disturbance in the way the scapula moves over the thoracic wall. This altered movement pattern is called scapular dyskinesis or scapular dyskinesia. Diagnosing the problem can be difficult. There’s no one single test or imaging study that clearly shows what’s going on. Sometimes on visual exam, it’s possible to see some postural changes, asymmetry from one side to the other, or an obvious change in the normal scapulohumeral rhythm as the arm is raised up. The examiner also looks at range of motion, strength, and flexibility. If nerve damage is suspected, electrodiagnostic testing can be ordered.

X-rays, CT scans, MRIs, and ultrasound have all been used to diagnose scapular snapping syndrome. X-rays can show scapular angles, skeletal or rib abnormalities, or other bony deformities. Standard CT scans don’t offer much help. Three-dimensional CT scans may be more diagnostic but MRIs offer the best look at the soft tissues. When bursitis is part of the problem, ultrasound helps guide the physician inject the area. Otherwise, as an imaging modality, ultrasound isn’t used much for the diagnosis of the snapping scapular syndrome.

Once the diagnosis has been made, the physician’s attention turns to treatment. Much research and study has been directed at finding conservative (nonoperative) ways to successfully treat this syndrome. Physical therapists have taken front and center stage on this one. Different theories and different approaches have been tried and tested. Addressing any postural issues is considered the first step. Making sure the head, neck, and shoulders line up and work together in a coordinated way with the rest of the body is part of a rehab approach called the kinetic chain model.

Kinetic chain rehab is very much like the old song that says the neck bone’s connected to the shoulder bone and the shoulder bone’s connected to the elbow and so on. Each body part moves in relation to all the other body parts from head to toe. Creating a rehab program for scapular dyskinesia takes into account all postural components, not just around the head, neck, shoulder, or scapula. Core training as well as individual muscle strengthening progresses through a stepwise program over a period of 10 to 12 weeks. The patient is guided through the acute phase to recovery and beyond into a maintenance phase. The goal is to restore dynamic scapular control, muscle endurance, and a return to the normal 2:1 glenohumeral-to-scapulothoracic rhythm.

Physical therapy may be augmented by antiinflammatory medications and/or injections into troublesome bursae. The injections may be a steroid and/or a numbing agent to provide local anesthesia for pain relief. These treatment tools can aid in pain control and indirectly contribute to recovery from the poor motor control that is the center of scapular dyskinesia. Where there is pain, the can be altered movement. Reducing or eliminating that pain, can help muscles resume normal movement patterns. If these measures don’t achieve the desired results and especially if there are bone spurs or tumors involved, then surgery might be the next step.

Surgery is not advised in cases where there is not an identified lesion causing this syndrome. Surgery is considered first when the patient gets relief from the pain and snapping after a trial injection of local anesthetic provides pain relief. When surgery is called for, the surgeon may remove a portion of the scapula that is prominent and rubbing against the rib cage. This procedure is called scapular dissection. Other soft tissues might also be dissected such as the inflamed bursa, bone spurs, or fibrous tendons. Any surgery in this area comes with an increased risk of nerve damage, as there are several nerves there that can be very easily cut by accident during the procedure.

Surgery may be done with an open incision. This approach gives the surgeon a better chance to see the various structures affected and identify what’s going on. But more and more, arthroscopic surgery has replaced open treatment. Arthroscopy is less invasive, reduces the amount of cutting and disruption to the soft tissues, creates fewer cosmetic problems, and shortens hospital stays. In some cases, the surgeon may choose to use a combination of open and arthroscopic approaches. Studies show that the bursa is easily removed with arthroscopy but any bone removal may be better approached with an open incision.

Surgery is followed by immobilization in a sling for several weeks. This gives time for the soft tissues to recover, especially when the muscles have been cut away from the bone as part of the procedure. Rehab follows the period of immobility in order to restore motion, strength, and function.

The authors of this review article on the topic of snapping scapular syndrome conclude by saying that this problem has been around for a long time. In fact, the first case was reported in 1867 during the post-civil war era. This syndrome probably isn’t going to disappear overnight. Early identification of the syndrome may be able to address the motor component quickly and easily through an exercise program. The longer the condition persists, the more disharmony develops with postural and soft tissue factors contributing to an impaired movement pattern of the entire scapular-shoulder complex. Avoiding surgery is possible when there aren’t bone spurs or tumors contributing to the problem. Physical therapists must continue doing their homework and researching for the best, most effective way to treat this problem conservatively.

It’s very disturbing to have shoulder surgery and still end up with pain, stiffness, and a feeling that the shoulder just isn’t going to hold up. Sometimes it’s not just a bad feeling — the shoulder may be unstable enough to dislocate repeatedly. That’s a condition referred to as shoulder instability. When it occurs after surgery to repair a shoulder injury, then it’s considered a failed shoulder stabilization surgery.

In this article, surgeons who specialize in sports surgery present a review of all the factors to consider in failed shoulder stabilization surgery. They discuss diagnosis issues, technical errors during the initial repair surgery, and risk factors for repair failure. They also help surgeons identify complications and offer suggestions for ways to treat those problems.

The majority of failed shoulder surgeries are attributed to failure to diagnose the full extent of the problem. It’s not that the surgeon didn’t know what was wrong with the shoulder. In 84 per cent of all cases, there was more than one problem. And the additional problems weren’t recognized or repaired, leaving the shoulder at risk for failed surgery. The surgeon evaluating patients with shoulder instability following surgery must go back to the beginning. With a thorough history, physical exam, and review of risk factors, the full scope of problems can be identified. Then a treatment plan to address each one is developed.

Finding the source (or sources) of the failure is important before just going back in with more surgery. There are some routine questions that must be asked like what kind of surgery was done, did it have any effect, and was there another injury or athletic event that led up to a reinjury and now the current instability? The surgeon will also look for common risk factors such as the patient’s age, inappropriate activity level (too much, too soon), or inadequate rehab after surgery.

There’s always a list in the back of the surgeon’s mind of other risk factors out of the patient’s control. This could include poor quality of soft tissue or bone, damage to the joint cartilage, and technical problems from the surgery. A careful physical exam will show how much motion the athlete has, strength and function, as well as the degree of instability (mild-moderate-severe). By comparing the unstable side to the uninvolved, stable shoulder, it’s possible to get an idea of ligamentous integrity and just where the instability is coming from.

Loss of motion, too much motion, and/or loss of strength in any particular direction provides helpful information. For example, the patient who can externally rotate the arm past 90 degrees is showing some shoulder joint instability from lax or loose ligaments. If the shoulder capsule is stretched out too much, the patient will be able to move the arm away from the body (a motion called abduction) 20-degrees or more on the unstable side compared to the other (uninvolved) side.

Testing shoulder muscle strength is a good way to look for rotator cuff tears or nerve damage. Loss of normal muscle function from either of these problems can lead to biomechanical dysfunction. With as many as 30 per cent of shoulder surgery failure, it’s not uncommon to find both muscle and nerve injury or damage to more than one muscle.

Once the physical exam has been completed, the surgeon puts the whole picture together and decides what kind of imaging might be helpful. Sometimes the original misdiagnosis occurred because there was inadequate imaging. Certain X-ray view may be needed (e.g., West Point axillary view, Stryker Notch view, scapular-Y view) or a three-dimensional (3-D) CT scan to look for specific types of lesions. Bone loss, location (e.g., humeral head or glenoid fossa) of that bone loss, and extent of bone loss are all important variables to look for before attempting another operation.

The humeral head is the round ball of bone at the top of the humerus (upper arm bone). The glenoid fossa is the shoulder socket. It is usually very shallow and flat. Together, these two components make up the shoulder joint. Not only does the 3-D CT scan show the integrity of the bone, but it also shows the joint surface and any lesions that might be present there. CT scans also help the surgeon see if there were technical errors from the first operation. This could be the improper placement of suture anchors or not enough anchors to hold the soft-tissue repair in place until healing could take place.

Sometimes more than one imaging study is needed. Surgeons get different information from X-rays and CT scans than from MRIs. It may be that all three are ordered and reviewed. Whereas CT scans give some idea of the condition of the bone, MRIs provide a way to examine the soft tissues around the shoulder (e.g., capsule, rotator cuff, labrum or cartilage around the rim of the shoulder).

When all the pieces of the diagnostic puzzle are put together, then a treatment plan is defined. Each complication or problem calls for a different approach. The surgeon faces an even greater challenge when there is more than one pathology. The authors present some tips for some of the more common problems including bone loss, Hill-Sachs lesions, rotator cuff insufficiency, and capsular injury.

Bone loss is often unrecognized during the first surgery. Without full diagnostic imaging, the surgeon may not see how severe the condition is. If it’s bad enough, open surgery and bone grafting might be necessary. One way to give the shoulder more stability is to deepen the socket. This can be done by adding a rim of bone along the front edge of the glenoid fossa. That will help keep the humeral head in the socket and prevent it from popping out anteriorly (forward direction). Another way to prevent chronic anterior dislocations is to join two tendons together that can resist forward movement of the humerus during motions that can push the head out of the socket.

With repeated dislocations, damage can occur to the head of the humerus. The smooth surface of the humerus hits against the bony edge of the glenoid (socket). The collision causes a dent in the bone of the humerus called a Hill-Sachs lesion. The presence of a Hill-Sachs lesion increases the risk of shoulder redislocation and instability. The defect will have to be filled in either with a bone graft, synthetic plug, or tendon transfer.

Rotator cuff injuries are often missed at the time of diagnosis of the original shoulder instability. One (or more) of the four tendons that make up the rotator cuff (and usually the subscapularis muscle/tendon) may be partially or completely torn. Without the proper pull, support, and coordinated control that the rotator cuff provides, the repaired shoulder can become unstable again. As with the Hill-Sachs bony lesion, this soft tissue lesion can be repaired or reconstructed. The surgeon makes the decision based on all of the factors discussed so far.

And then there’s the management of capsular injuries. The shoulder joint is surrounded by a watertight sac called the joint capsule. The joint capsule holds fluids that lubricate the joint. The walls of the joint capsule are made up of ligaments. Ligaments are connective tissues that attach bones to bones. The joint capsule has a considerable amount of slack, loose tissue, so that the shoulder is unrestricted as it moves through its large range of motion.

The shoulder joint relies on the ability of these ligamentous tissues to hold the shoulder in place. Damage to the capsule or too much laxity can contribute to shoulder instability. Surgical repair is possible by harvesting ligamentous tissue from elsewhere and transferring it to the area of capsular deficiency.

The surgeons’ decision about the best way to approach failed surgery for shoulder instability is not over yet. Knowing what tissues are involved and to what extent is just the starting point. Now, the method of operation must be considered. Is an open incision required or can this be done arthroscopically? This is a decision that is made on a patient-by-patient and surgeon-by-surgeon basis.

Studies show that the results are fairly comparable for shoulder revision surgeries between arthroscopic and open-incision approaches. Some repairs are just easier to make one way versus the other. Open-incision is preferred when there are multiple areas of damage that require attention and especially when there is severe bone loss. Surgeons are aware of the fact that when successful, a revision surgery won’t yield the same positive results as the initial repair.

And finally, as mentioned briefly before, there are decisions to be made about what and how much hardware to use (e.g., anchors) to hold it all together (not to mention where to place the anchors). The wrong placement can result in bone wearing, soft tissue fraying, and subsequent osteoarthritis. That just adds one more problem to the list of things that could go wrong after surgery for shoulder instability.

Hopefully, you can see from this long list of problems just why it is that there’s a 30 per cent failure rate for surgical procedures designed to restore shoulder stability. Between patient factors (things that can and cannot be controlled), incomplete diagnosis, and surgical technical errors, there’s plenty of room for failure and loss of function as well as performance.

For athletes interested in getting back into action as soon as possible, the decision treatment that yields optimal results may not be simple or quick. The careful surgeon will take his or her time to get to the bottom of the problem(s) and solve them. That can take time but the favorable results desired are worth the time and effort it takes to thoroughly evaluate the case and carry out the treatment plan.

Repeated shoulder dislocations are referred to as chronic shoulder instability. Throwing athletes are the most likely group to suffer this problem. Microtrauma from overuse or acute trauma are two common causes. The dislocation is usually in the anterior (forward) direction. There are many factors that contribute to this type of dislocation. In this article, physicians specializing in sports medicine take a look at the role of the glenoid (shoulder socket) in this chronic instability.

The shoulder joint called the glenohumeral joint is made up of two main parts. On one side is the humerus (the upper arm bone). At the top of the humerus is a round ball-shaped bone that fits into a shallow socket of the scapula (shoulder blade). This shallow socket is called the glenoid fossa or just glenoid. Movement of the head of the humerus in the glenoid is what gives us our shoulder movements of flexion, extension, abduction (arm away from the body), and rotation (internal and external).

Any damage to the already very shallow glenoid can contribute to shoulder instability. Defects in the rim around the glenoid and bone loss within the socket are two ways the glenohumeral contact can be affected, adding to the problem of chronic dislocations. Sometimes these defects occur because the shoulder dislocates in a traumatic event. Bone is actually fractured and a fragment of the rim breaks off. In other cases, the bone just wears away from constant contact and compression. Remember, these are athletes who are practice and perform overhead throwing motions 100s and even 1000s of times each season.

Other athletes such as football, volleyball, or soccer players may suffer a traumatic injury with damage to the ligaments attached to the glenoid rim. Without that little rim of fibrocartilage around the joint, it’s much easier for the shoulder to pop out of the socket and dislocate again and again. And sometimes a small instability changes the biomechanics of the shoulder complex enough that over time, the bone wears away unevenly. In either case, rim defects get larger over time. The result is a worsening of the instability.

And so the vicious cycle gets set up and continues. Changes in the joint structure cause biomechanical alterations (i.e., the way the shoulder moves in the socket). Changes in the arc of shoulder motion wear the joint surface unevenly. This, in turn, alters forces within the glenohumeral joint, wearing the glenoid bone unevenly, and the cycle continues. This is how even a small defect can ultimately lead to chronic instability.

What can be done about it? Well, the first thing is that the problem has to be identified and recognized for what it is. Surgery will fail if the full extent of the injury isn’t treated. The patient’s history, a physical examination, and appropriate imaging tests are all used to define the problem. X-rays can show bone loss, MRIs show how much bone loss is present, and CT scans detect rim fractures.

From this information, it is possible to calculate how much of the humeral head is actually in contact with the glenoid surface. The surgeon then uses the arthroscopic exam to look at the bare spot on the glenoid and finish the exact measurements of the defects. The authors provide detailed formulas and examples of calculations to help surgeons compute the percent of bone loss.

Treatment is based on the percentage of bone loss. What is considered an insignificant amount (less than 15 per cent of the surface area) may respond to conservative (nonoperative) care. Bracing, strengthening exercises, and modifying activity level may work well for athletes who are not involved in overhead sports. Rehab supervised by a physical therapist helps the patients understand which movements should be avoided in order to prevent another dislocation from occurring.

If this approach fails to restore motion and function, then surgery to repair the damage and/or reconstruct the shoulder may be required. Anyone with moderate bone loss (15 to 25 per cent) or severe bone loss (25 to 30 per cent or more) will need surgery. The exact surgery planned depends on what type of damage is involved (e.g., bone factures with fragments, labral (rim) tears, amount and location of bone loss, or other defects). Sometimes the surgeon is able to piece the bone fragments back together. This is most likely when the defects are small — limited in number and size and providing that the bone fragments can be found.

Surgical treatment becomes more complex when bone loss affects one-fourth (or more) of the joint surface. In such cases, the surgeon must look at the patient’s activity level, how long it’s been since the injury, the condition of the surrounding soft tissues, number of bone fragments, and potential for healing. To aid in this process, the authors provide a treatment decision-tree (flow chart), which incorporates all of these considerations. Research shows that whenever possible, any bone fragments should be reattached. The risk of failure goes down for patients who are treated in this way.

There are numerous options to choose from including transfer of bone from some other area of the shoulder to make up for defects in the rim. This procedure is called a glenoid augmentation. Several ways to do this are described (e.g., the Latarjet procedure; the Bristow procedure, the Eden-Hubbinette procedure). Drawings to illustrate the procedures are also provided. The surgeon tries to match the bone graft to the contoured (curved) surface of the glenoid. Screws are used to hold the graft in place.

It’s not enough to just wire bone fragments together and reattach them. The surgeon must pay attention to the biomechanics of the shoulder as well. Restoring the normal bony arc of motion is essential for stability. Does the patient want to return to everyday activity and function? Or is he or she expecting to return-to-play? This is a key determining factor in patient satisfaction. Surgeons are still looking for the best way to restore the joint to near normal. They can’t always guarantee 100 per cent recovery and return to sports at a preinjury level.

Sometimes surgery fails to correct the problem. The patient continues to experience symptoms of pain and repeat dislocations. A second (
revision) surgery is needed. The biggest predictor of failed surgery the first time is just how much bone loss is present because it’s this bone loss that results in a failed stabilization. The more bone loss, the greater the risk of a failed repair.

In summary, chronic shoulder dislocations with moderate to severe bone loss of the glenoid fossa or glenoid rim must be repaired surgically to restore shoulder stability. It is possible for high-demand contact athletes engaged in overhead throwing motions to regain shoulder stability and function. The surgeon must pay close attention to the socket side of the shoulder joint and repair any damage to the rim that holds the humeral head in place. There are ways to do this, but finding the best approach for optimal results remains an area of research right now.

Osteoarthritis of the shoulder isn’t always something older people experience. Sometimes younger adults (ages 20 to 50) develop pain, stiffness, and loss of motion and function from arthritic changes in the joint. Although the effects are the same, the causes often differ between young and old. Older adults tend to develop arthritis as a result of aging and joint degeneration from many, many years of use.

Younger adults are more likely to have had an injury earlier in life that has now resulted in trauma-induced arthritis. Infections, repetitive motions that cause microtrauma, and chondrolysis following arthroscopic shoulder surgery are other reasons why the joint cartilage wears away and arthritis sets in. Chondrolysis is the medical term for destruction of articular cartilage. That’s the cartilage that lines the joints and makes smooth motion possible.

No one is quite sure why chondrolysis develops in some people after arthroscopic procedures. It happens after all kinds of arthroscopic operations — not just for one type of problem. It happens in patients who have had thermal devices, suture anchors, and pain pumps put in the joint. But not everyone who have those implants develop chondrolysis, so there probably isn’t just one single reason for this rapid destruction of the joint cartilage.

What can be done for the person with early onset of shoulder arthritis? Some time ago, artificial shoulder joint replacements were made available to younger patients with arthritis. But enough time has passed that we now know from short- to mid-range follow-up studies that this isn’t always the perfect solution. The implant can wear out or loosen. Then it has to be replaced. That can mean a second surgery, loss of bone, further complications, and a major set back in motion and function.

Likewise, for hemiarthroplasties (replacing just one side of the joint), the side that isn’t replaced eventually wears out, too. Or the side with the replacement implant develops problems with loosening or biomechanical wear and tear. That means more surgery for those patients as well. What’s the answer to this dilemma? The evidence supports delaying joint replacement by pursuing conservative (nonoperative) care for as long as possible.

Okay, so, what works in that department? Patients have a few choices. Physical therapy to build up strength around the shoulder and minimize stress or overload on the joint is one approach. Acupuncture, transcutaneous nerve stimulation (TNS), and nonsteroidal antiinflammatories (NSAIDs) may be helpful. Like any medication, NSAIDs have the potential to create adverse reactions. The physician and the patient must weigh the benefits against the potential side effects when choosing these drugs. They may reduce painful inflammation and improve movement, but they can cause significant gastrointestinal (GI) complications and therefore, must be taken with another drug to protect the GI tract.

Injections of a visco-supplement or steroid may provide some relief of pain compared with placebo (pretend injections of just saline, a salt solution). The visco-supplement is a fluid that helps restore pain free movement in the joint. It has been shown to be more effective and longer lasting than the steroid injections with fewer side effects. Steroid injections reduce inflammation and usually have a numbing agent included that helps reduce pain. There aren’t very many studies of results from these two different types of injections. More information is needed about the short-term and long-term effects of both before shoulder injections can be routinely recommended.

When surgery is needed, it’s best to start with noninvasive (or the least invasive) procedures possible. Every effort should be made to stimulate a healing response and save the joint, rather than remove and replace it. Joint sparing is the name given this approach. There are several ways to do this. The first (and most commonly used) procedure is called debridement. The joint is shaved and smoothed down. Any debris or loose fragments of cartilage are removed. This helps restore smooth, pain free motion.

There are also various ways to repair and/or restore damaged cartilage. For example, autologous chondrocyte implantation (ACI) and osteochondral autologous transplant (OATS) are two restorative procedures. In these procedures, cartilage is placed inside the lesion in hopes of restoring the normal structure and function of the original cartilage. ACI is a new way to help restore the structural makeup of the articular cartilage. Surgeons may recommend this procedure for active, younger patients (20 to 50 years old) when the bone under the lesion hasn’t been badly damaged, and when the size of the lesion is small (less than four centimeters in diameter).

ACI is done in two parts. First, a short surgery is scheduled to allow the surgeon to take a few normal, healthy chondrocytes and use them to grow more in a laboratory. At a later date, the patient returns for a second surgery, at which time the surgeon implants the newly grown cartilage into the lesion and covers it with a small flap of tissue. The cover holds the cells in place while they attach themselves to the surrounding cartilage and begin to heal.

With the second restorative procedure, OATS, a plug of cartilage and the first layer of (subchondral) bone are removed from normal, healthy cartilage and transferred to the site of the cartilage defect. This can be done all in one procedure and does not require two operations like the ACI.

If conservative care and minimally invasive restorative procedures fail to bring the relief patients need, then joint replacement may be the next step. The surgeon assesses the joint surface and surrounding soft tissues to determine which approach is best. The patient’s age, activity level, goals, and bone density are all taken into consideration when choosing the best surgical approach for each patient. Hemiarthroplasty works well for younger patients but the benefits are only short- to mid-term. In the end, these patients often develop pain from continued degeneration of the joint and require a total joint replacement. But the hemiarthroplasty might buy them some time and allow them to function pain free for several years.

Some surgeons have tried using a hemiarthroplasty (replacing the head of the humerus) while resurfacing the socket side of the joint called the glenoid. Resurfacing means lining the glenoid with cartilage, ligament, or connective tissue harvested from some other part of the body. The results of studies so far haven’t been spectacular with this approach. So far there have just been too many problems and complications with resurfacing. More studies are needed to improve outcomes with this technique.

The most invasive approach is a total shoulder arthroplasty (also known as a total shoulder replacement or TSH). Patients seem to respond well to this procedure. They get significant pain relief, which then allows them to move freely and to be more active. Most implants (99 per cent) hold up well the first five years. There are good short and mid-term results reported; long-term wear eventually results in loosening and wear of the glenoid.

Young patients with shoulder arthritis really do have quite a few options to choose from for the treatment of this potentially disabling condition. Conservative care and joint sparing are the order of the day. Restorative procedures for damaged cartilage may be all that’s needed. But when symptoms continue to reduce what the patient can do on a daily basis, then a partial or complete joint replacement might be best. Given what we know about problems from these procedures, patients should be advised of all the pros and cons before deciding on the management approach that suits them best.

Many people at all ages and stages of life can and do develop shoulder pain. A common condition causing significant shoulder pain seen in patients across the lifespan is called subacromial impingement syndrome. Impingement means something is getting pinched. Subacromial tells us that the something in question is located under the acromion. The acromion is a piece of bone that comes around from behind where it starts in the shoulder blade and curves over the top of the shoulder.

At first (stage I), there is swelling and even hemorrhage (bleeding) of the subacromial bursa and rotator cuff. The bursa is a little cushion between the acromion and the head of the humerus (upper arm bone). Repetitive motions in younger adults (less than 25 years old) are linked with subacromial impingement syndrome.

The rotator cuff is always involved in shoulder impingement syndromes. It is made up of four tendons and their attached muscles. They enclose the entire shoulder like an envelope and give it support, stability, and functional movement. With subacromial impingement, the supraspinatus tendon of the rotator cuff is involved because it slips under the acromion and attaches into the greater tubercle, a bony bump on the humerus.

The supraspinatus abducts the arm (moves it away from the body). In someone with subacromial impingement syndrome, shoulder abduction and shoulder internal rotation cause severe pain. The supraspinatus muscle contracts to pull the arm up but at the same time, the head of the humerus slips up too far and bangs into the acromion. In the process, the supraspinatus gets pinched.

If nothing is done to stop this pattern of dysfunctional movement, fibrosis (fibrous scarring) and tendinopathy (irreversible tendon damage) develop leading to stage II of this condition. This occurs most often in adults between the ages of 25 and 40. As time goes by, and the shoulder continues to wear and tear from this syndrome, stage III impingement develops. By now, the patient is 40 years old or older, and the rotator cuff is partially or completely torn through.

There are many ways to approach this problem. Some are based on what stage the patient presents with at the time of diagnosis. In the early stage, nonsteroidal antiinflammatories are often prescribed but studies don’t really support their use. However, inflammation may be reduced with physical therapy modalities such as ultrasound or laser therapy.

In order to compare these two modalities, the authors divided patients with subacromial impingement syndrome into two groups and treated them for two weeks. Half the group received high-intensity laser therapy (HILT) to the soft tissues of the shoulder for five days each week. The other half had continuous ultrasound for 10 minutes over the shoulder joint. Ultrasound is a way to heat the tissues deep in the shoulder to bring blood circulation to the area for healing.

High-intensity laser works by exposing the tissue to light energy. The light is absorbed and then stimulates tissue healing at the cellular level. The authors describe the exact waveform, wavelength, and impulse power delivered to the shoulder. The intended result is to decrease pain. Whether or not these effects are the same in shoulder tendinopathies has not been proven yet. And this is the first study to compare the results of high-intensity laser with the results of ultrasound for subacromial impingement syndrome.

Before treatment began, patients in both groups were given several tests to measure pain, motion, strength, and function. The tests assessed activities of daily living, sleep, ability to work, and ability to participate in recreational activities.

At the time of the pretreatment tests, there were no significant differences between the two groups. The same tests were repeated after the two-week treatment period ended. Everyone was asked not to take pain relievers or antiinflammatories during the treatment. They were instructed to avoid doing any activities that would reproduce their symptoms and increase their pain.

After the treatment period was over, the patients were all retested using the same pre-treatment tests. The results were analyzed and showed that the high-intensity laser was the more effective modality. Patients in that group had much better movement, improved strength, and greater decrease in pain.

The authors say their findings support what other studies have shown: 1) that ultrasound is not more effective than a placebo in treating subacromial impingement syndrome and 2) that high-intensity laser is more beneficial than a placebo for this condition. They feel confident that future studies will reproduce their results and confirm the effectiveness of high-intensity laser therapy.

Research can now move forward and take a look at optimal dosages and length of time for treatment with high-intensity laser. The results of this modality should be compared with other conservative treatments and/or placebo groups.

Wine may improve with age but research shows the shoulder doesn’t. In fact, there’s a direct relationship between increasing age and the number of rotator cuff tears. At age 50, just slightly more than one in 10 adults has a rotator cuff tear seen on MRIs. By age 80, this has increased to five out of 10 (or half of all adults).

That seems high, but many of those people are asymptomatic (i.e., have no pain or other symptoms). They don’t complain of any pain and don’t report any problems. The damage is found when MRIs are done for something else, or as in the case of this report, the MRIs show these types of injuries when imaging is done for research purposes.

For those adults over the age of 66, shoulder pain on one side is actually a sign of rotator cuff tears in both shoulders. And that’s not all. Studies show that where there’s a rotator cuff tear, there’s likely a tear of the biceps tendon where it attaches to the labrum.

The labrum is a dense ring of fibrous cartilage around the rim of the acetabulum (shoulder socket). It helps deepen the socket and increases shoulder stability. If the labrum is torn from front to back, it’s called a superior labral anterior posterior (SLAP) lesion. Rotator cuff tears with SLAP lesions are usually treated surgically.

That’s where this study comes in. The authors are surgeons from a sports medicine clinic. They compared the results of surgery for rotator cuff tears and SLAP lesions when treated with rotator cuff repair and debridement of the SLAP lesion (group one) versus rotator cuff and SLAP repair (group two). All patients were 45 years old or older. They all had arthroscopic surgery. And they all had a tear of the supraspinatus tendon (one of the four tendons that makes up the rotator cuff).

Two other characteristics of the patients in this study included 1) the SLAP lesion was considered repairable and 2) the torn tendons weren’t retracted (pulled back) very far. The surgeon could grab the tendon and stitch it back in place.

To measure the results of treatment, range of motion was recorded before and after surgery. And each participant filled out the Tegner and UCLA self-reported tests of activity level and function, patient satisfaction, range-of-motion, and strength. Before surgery, the groups were evenly matched with similar results on all test scores.

After surgery, the debridement group had better results than the repair group. Everyone in both groups did improve, but patients in the debridement group got better faster. The got faster and better pain relief, which translated in to improved function as well. And two years later, they were still showing improved shoulder rotation compared with the repair group.

The authors concluded that in older adults minimal intervention might be best. With combined shoulder lesions (rotator cuff and labral tears), functional outcome is better when the SLAP lesion is shaved smooth rather than anchored back in place. The reason for this might be because (as has been shown in other studies), the labrum in older adults loses blood supply and has fewer new chondrocytes (cartilage cells) to replace the damaged ones.

Back in the 1970s, there was only one prosthetic implant available for patient’s needing a total shoulder replacement (TSR). Today, there are more than 70 different shoulder systems on the market. In this review article, surgeons from the William Beaumont Hospital in Michigan present information on the major types of prostheses surgeons use most often.

The authors offer guidelines for deciding which option might work best for different types of patients. Sometimes there’s really more than one that could work. So, the surgeon must examine each patient carefully in making that final decision as to which one to choose.

The surgery can be very complicated. Multiple factors must be considered such as the patient’s age, underlying pathology, condition of the rotator cuff (muscles around the shoulder), and current/desired level of function. Shoulder replacements are indicated when pain is disabling and loss of motion and strength leaves the person unable to complete daily tasks and activities.

Most patients who need a shoulder replacement have arthritis either from age-related degeneration (osteoarthritis) or from a previous injury (posttraumatic arthritis). Sometimes, there’s been a history of fracture, tumors, severe rotator cuff damage, and even a failed first shoulder replacement surgery.

Even though there are dozens and dozens to choose from, surgeons tend to pick between one of three main types of arthroplasty (another name for shoulder replacement). There’s the hemiarthroplasty (only one side of the joint is replaced), the reverse total shoulder arthroplasty (RTSA), and the total shoulder replacement (TSH) already mentioned.

Here’s a summary of the detailed information the authors offered about each of the other major options to choose from. First, the hemiarthroplasty. This is just the replacement of the humeral head and upper neck of the humeral bone supporting the head. At first, these were designed for people with humeral neck fractures. But the use of the hemiarthroplasty has expanded over time as surgeons found other problems that were solved with this component. Now it is also used for arthritis, rotator cuff tears, and osteonecrosis (bone death caused by loss of blood supply) of the humeral head.

Studies show that the hemiarthroplasty is more likely to be successful when used in younger patients and early after the injury (in other words, without a long delay between injury and operation). Sometimes it’s just difficult to decide between the hemiarthroplasty and a full shoulder replacement. Why do a full replacement when a partial replacement would work just as well? But there’s no sense in doing a partial replacement if the patient is going to end up needing a full shoulder replacement eventually anyway.

The most reasonable use of the hemiarthroplasty is for the patient who has bone loss and soft tissue damage that makes surgical reconstruction a very complex project. Without adequate bone mass and sufficient muscle strength, the implant loosens, which can lead to implant failure. Hemiarthroplasty offers a way around those complications.

It’s most effective when the shoulder socket is perfectly fine but the head of the humerus is arthritic, damaged from osteonecrosis or rotator cuff tears, or defective. Patients who receive a hemiarthroplasty report it is certainly better than doing nothing — they get pain relief, increased motion, and improved function. The net result is an improved quality of life.

It’s also possible to resurface the joint when arthritis has damaged the joint surface but there’s no need to tear the whole thing out and replace it. This procedure is called a resurfacing hemiarthroplasty. The humeral head is smoothed but not removed. Sparing the humeral side also preserves the patient’s natural joint angles. If there’s a need for a total shoulder replacement later, then it can be done sometime down the road. Shoulder resurfacing is used most often in young (55 years old or younger), active/athletic adults.

And for the patient with severe rotator cuff damage, hemiarthroplasty is still possible but with an extended-coverage head. This modification is needed because without the rotator cuff, it’s difficult to keep the humeral head in the center of the joint. The extended-coverage head makes contact more fully inside the socket. That feature helps keep it in the joint and more stable but without getting pinched under the acromion (the curved bone across the top of the shoulder).

A reverse shoulder arthroplasty is used in older adults who have a torn rotator cuff that can’t be repaired. Instead of the round ball replacing the head of the humerus (upper arm bone), the socket is attached to the bone. The round replacement ball of the joint (called the glenosphere) is inserted into the place where the natural shoulder socket used to be.

This design helps maintain shoulder stability when the muscles are deficient and unable to function as they should. In fact, many patients who suffer pseudoparesis (inability to lift the arm) benefit from a reverse shoulder arthroplasty. The change in the fulcrum allows them to lever the arm up even when the muscles are weak from irreparable injury or damage.

When both sides of the joint are involved, it makes the most sense to perform a total shoulder replacement. Loss of joint cartilage from arthritis leading to pain and disability are the main reasons to do a full joint replacement. The rotator cuff must be in good condition to support the joint and restore full function of the shoulder and arm. And there has to be enough good bone stock to support and hold the implant in place.

Many, many studies have shown the benefit of the total shoulder replacement (TSR). Compared with the other options, the TSR gives patients more motion, less pain, and improved strength. Regardless of where the erosion occurs in the joint or what causes it (osteoarthritis versus inflammatory arthritis), the complete replacement of both sides solves the problem.

That brings us to the topic of what to do when the shoulder replacement fails. Revision arthroplasty (a second surgery) is often possible. First, the surgeon evaluates what went wrong — did the implant come loose for some reason? If so, was it because of bone loss? Muscle weakness? Or was the implant in the wrong position, perhaps even the wrong size for the patient? Sometimes the implant just wears out and must be revised or replaced.

If any of those situations occurs, the patient should be prepared for the fact that the results of the revision usually aren’t as good as the original implant procedure. The revision must be designed for each individual based on the amount of bone stock available, the strength of the muscles, what can be salvaged, and what can’t be saved. Each individual muscle has a specific purpose and should be evaluated. Nerve function can be compromised by scarring, so the nerves must be carefully assessed as well.

When it comes to the need for reconstructive (or revision) shoulder surgery, surgeons are often faced with a complex challenge that can’t be solved with a simple formula. The guidelines presented in this article will help, but experience and first-hand assessment are the real keys to making the final treatment decision that is just right for the patient.

Evaluating pain and problems in the shoulder is different when the patient is older. The underlying causes aren’t the same as in active, younger adults. Older adults have more degenerative disease or injuries from falls. Younger adults experience more injuries from sports or athletic participation.

Although the basic interview, patient history, and physical exam are similar for these two age groups, there are some important differences. The authors of this article provide a review of the recommended history and exam for older adults with shoulder pain. This is part-one of a two-part article. The second article will focus on treatment options once the diagnosis has been made.

Any good medical interview allows the patient an opportunity to tell what’s wrong and how it happened. The examiner tries to fill in with questions that give him or her a full understanding of the patient’s daily activities. This includes hobbies, athletic participation or other physical activity, and desires/goals from treatment.

The patient interview actually continues as the examiner begins to assess pain, inspect the shoulder complex, measure range-of-motion, and test strength. The patient may report that the shoulder locks up or catches but sometimes the examiner hears and feels this during the exam. Some provocative tests reproduce the pain. That can be very useful information when sorting through a wide range of possible reasons for shoulder pain.

There is no single test that will quickly uncover the problem. Usually, several tests combined together give the examiner information that leads to a diagnosis. Researchers have not been able to package together a group of tests that can be used routinely with each shoulder pain patient for the most accurate diagnosis.

It may be necessary to go through quite a few of the available tests before discovering what’s wrong. Sometimes normal tests are more helpful than abnormal ones. At least the examiner can tell what’s working right. Abnormal test results have a way of muddying the waters because there can be several possible corresponding problems.

When it’s all said and done, the examiner steps back and takes a look at the big picture. Are there any other health problems? Does the patient have neck or back involvement? Are there any constitutional symptoms? Constitutional symptoms are those signs and symptoms that come in a cluster with any systemic disorder no matter which system is involved. For example, fever, chills, fatigue, unexplained perspiration, and nausea or vomiting are common constitutional symptoms.

It’s important to conduct a very thorough exam — even if the first test is positive for a specific pathology. After the patient points to the painful area, the examiner palpates or feels that area for any signs of soft tissue damage or change. Swelling, skin temperature, muscle atrophy (wasting), and soft tissue/boney bumps can be documented this way.

Pain as a diagnostic tool can be helpful. Location, quality, and aggravating and relieving factors provide useful clues. Does it hurt at the beginning, midrange, or end range of motion? The answer to that question can point to a specific soft tissue that is being pinched or compressed. Is the pain close to the surface? Skin deep?

Can the patient point to it with one finger or is it vague and diffuse? Pain deep in the shoulder may be caused by labral pathology. The labrum is a fibrous rim of cartilage around the shoulder joint. It is firmly attached to the acetabulum (shoulder socket) and provides depth and stability to the shoulder. Even tiny tears of this structure can cause intense pain.

A full range-of-motion assessment is also important. Any compensatory motions, loss of motion, or changes from one side to the other should be noted. That will help determine which shoulder-specific tests to perform.

Each muscle group can be tested for strength/weakness. Specific tests can be conducted for impingement, rotator cuff tears, labral tears, biceps tear or rupture, and nerve impingement or blood vessel compromise. Pulses, sensation, grip strength, and reflexes are useful tests to look for a neurologic or vascular (circulation) problem.

Shoulder exams take time to complete. No one test is sensitive enough or accurate enough to draw any final conclusions from it. The results of each test point to the next test to conduct or consider. Putting all the pieces together of the history and interview with the clinical findings from the tests performed can result in an accurate differential diagnosis. The examiner who uses a systematic approach with each patient will be efficient yet thorough.

Falls from skiing accidents, snowboarding injuries, car accidents and other traumatic events account for many first-time shoulder dislocations. When the shoulder doesn’t pop back in place on its own, the patient ends up in the emergency department or doctor’s office for a reduction (put it back in the socket). There are many ways to reduce the shoulder but most require anesthesia to put the patient asleep and relax the muscles or strong narcotic medications for pain.

In this report, surgeons from Japan propose a new method for reducing anterior (forward) shoulder dislocations. Most shoulder dislocations are anterior so this approach will be useful in many cases. No medication or anesthesia was used. The patient remained in the sitting position. There were no complications from the technique such as fractures or nerve injury.

The sitting position used was more comfortable for patients who were already holding the dislocated arm with the other hand. The patient was sitting in a chair facing the surgeon. The surgeon took hold of the patient’s forearm very gently and raised the arm straight forward 90 degrees. The surgeon placed his other hand on the patient’s chest wall against the front of the patient’s shoulder. The surgeon’s thumb was against the head of the humerus (upper arm bone).

Just by pulling on the patient’s arm with one hand while applying pressure on the humeral head with the other hand, the humeral head slipped back into the socket. If the patient tensed up, the surgeon just lowered the arm a little, waited for the pain to go away and the muscles to relax and started the procedure again. The hand against the shoulder helped control the tilt of the shoulder socket.

The technique is done slowly and gently. If the surgeon wasn’t able to successfully reduce the shoulder after several tries, the patient was placed supine (lying on his or her back). A forward elevation maneuver was used instead. The dislocated arm was placed overhead while the surgeon applied traction, gently rotating the arm outward until the head of the humerus slipped back into the socket.

Afterwards, everyone was given a sling to wear to support the arm during the acute phase of healing. X-rays were taken to confirm reduction. Results of this technique were evaluated by reviewing the charts of patients later. Data collected included previous history of shoulder dislocation, use of medications for reduction, type of reduction technique used, and before and after X-rays.

A total of 34 patients were treated for anterior shoulder dislocation with this new reduction method. The surgeon accomplished the task alone while talking with the patient. Combining the sitting position with a traction technique is new and has never been described before in medical journals. Compared with other methods of shoulder reduction, this was simple, unique, drug-free, and successful. It worked for almost 80 per cent of the patients.

The key to this technique is to work with patients who are already seated and self-supporting their arm. Changing positions causes the shoulder to tense up and can be avoided with this method. This method can be tried first before using drugs, mechanical force, or surgery. There was no clear reason why a small number of patients could not be reduced with this method. The success rate wasn’t quite as high as with some other methods, but the fact that no narcotics were needed was the added benefit.

The reverse shoulder total arthroplasty (rTSA) is used for older adults who have disabling shoulder pain and loss of function due to severe rotator cuff damage. In fact, for these patients, the rotator cuff (needed for a traditional total shoulder replacement) is beyond repair.

The rotator cuff is a group of four muscles, tendons, and connective tissue that envelopes the shoulder. The rotator cuff both moves and stabilizes the shoulder. Stabilizes means it holds the shoulder in the socket and prevents dislocations.

The reverse shoulder replacement has a round sphere called a glenosphere that inserts into the area where the socket used to be. The patient’s own round head of the humerus (upper arm) is cut off and replaced with a polyethylene (plastic) cup.

With this new configuration, the center of rotation changes. The angle of pull for some of the shoulder muscles also changes. Although the outcome is pain free motion, there are some limitations. For example, the patient no longer has full adduction (moving the arm across the body).

In this review article, surgeons from Switzerland share their knowledge and expertise in using the reverse total shoulder implant. They discuss the changes in shoulder biomechanics, possible complications, and their own experiences and results with this device. Photographs of patients’ motion before and after surgery are provided to demonstrate the improvements with the rTSA.

The rTSA had a rocky start when it was first introduced back in the 1970s. The results were so disastrous that by the late 1980s, surgeons had given up even trying to use this implant. But eventually, a group of surgeons found a way to improve the design and reintroduced the concept of a reverse total shoulder replacement.

Since then, controversy around this surgery has continued. Some studies report excellent results while others say the complication rate is too high to continue. Efforts are being made to improve current designs. And surgeons are advised to choose their patients carefully. The rTSA isn’t for everyone.

Patients most likely to benefit (and succeed) with the rTSA have a severely deficient rotator cuff that cannot be repaired. Without a properly functioning rotator cuff, when the deltoid muscle contracts, the necessary counterpull from the rotator cuff is missing. The patient ends up with pseudoparesis — an inability to lift the arm up overhead despite the fact that the patient has the necessary range-of-motion to do so.

A good candidate for the rTSA must have good nerve function in order to ensure stability of the joint. Other muscles important to shoulder motion such as the deltoid, teres minor, and latissimus dorsi must be in good working order. At the same time, the quality of bone must be good enough to hold the screws used to secure the implant to the bone. Because the complication rate is so high and the fact that the implant doesn’t last 10 years, patients must be over age 70 and inactive or at least, with minimal functional needs.

Patient selection is important but so is surgical technique. There are different ways to do this surgery. Some are more successful than others. The authors provide surgeons with a detailed description of their preferred surgical technique. They suggest that preoperative planning is very important. RTSA has also been shown effective in the treatment of patients with failed surgery for shoulder fracture.

Once the right patient has been chosen, three-dimensional CT scans help ensure that the planned operation is possible. Getting the right implant position goes a long way to provide improved motion and prevent loosening of the implant. Choosing the right implant size is also important. The larger glenospheres seem to work best.

While still in the operating room, the surgeon tests the arm for stability. Under the effects of anesthesia, the arm is moved through full abduction (away from the body) and internal rotation. There must be no sign of anterior (forward) dislocation. These movements are used most often by patients to get out of bed or up out of a chair.

Even though most studies have shown that deterioration appears on X-rays after five or six years, there are cases of continued success past the 10-year mark. Again, the authors stress the importance of choosing the right patient for the procedure. The benefits of the surgery far outweigh the disadvantages for patients who meet the criteria outlined.

Should there be problems with the rTSA, a second revision surgery may be needed. Usually it’s just a matter of removing and replacing one of the component pieces of the implant. Infection or hematoma (pocket of blood) may be treated without removing the implant. The joint is flushed to remove unwanted debris and (in the case of infection), the patient is put on antibiotics. Results are more likely to be poor if the implant has to be taken out for any reason.

The authors conclude that enough improvements have been made now in the rTSA that it’s worth keeping as a surgical procedure. Without it, some patients simply don’t have any other options. They would be stuck living with poor motion and limited function. Further improvements of the implant design and surgical technique are called for in future research. Hopefully, it will be possible to expand the number and types of patients who will benefit from this procedure.

Shoulder problems in the throwing athlete are common but very complex. It can be a real challenge to identify the specific cause of the problem and treat it quickly and easily. Many throwing athletes don’t allow enough time to rest the shoulder between games and especially after an injury. The authors of this article provide a review of the causes and mechanisms of shoulder throwing injuries. They describe how the anatomy of the shoulder changes with repetitive throwing. And they offer suggestions for a successful rehab program.

Over time and with much study, researchers are slowly coming to understand more and more about how the shoulder works and what shifts occur in muscle balance, motor control, and kinematics (movement) in the throwing athlete. Muscle fatigue, stretching out (laxity) of the shoulder capsule, and torsion or a slight twist of the humerus (upper arm bone) are examples of ways the shoulder complex can change with repeated throwing motions, thus leading to shoulder problems. Even the smallest damage to the soft tissues, joint surface, or bone can set up a chain of events that result in shoulder injuries.

The sequence of movements required in throwing sports when repeated over and over can cause microtrauma that eventually leads to break down of the tissues. There is a delicate balance of mobility and stability required with every high-speed pitch. Movement scientists are still unraveling the complexities of throwing mechanics and what contributes to injury. Understanding the way the shoulder and body move during throwing activities is helpful for the physical therapist who is guiding the athlete through recovery during the rehabilitation process.

The authors review (in detail) the kinematics of throwing. They provide drawings and descriptions of the six phases of throwing from wind-up to delivery. With pitches at 90 miles per hour or more, the entire pitch sequence can take less than five seconds. Acceleration and deceleration forces along with compressive, shear, and distractive forces of repetitive high-speed pitches can put the shoulder at risk for injury.

In order to deliver the pitch precisely where the pitcher wants it to go, specific arm motion and positions must accompany the exact timing of ball release. And the successful pitcher must be able to do this over and over with speed and accuracy. Sometimes those requirements exceed the fatigue strength of the muscles and other soft tissues around the shoulder.

New understanding of the role of the scapula (shoulder blade) has also changed how we view throwing injuries. Now we know that scapular dynamics are extremely important. It’s not just the arm and shoulder that are involved in a pitch. Half of the energy that goes behind a pitch comes from the legs and trunk. Rotational forces needed for the forward delivery of the pitch are transferred from the lower body to the shoulder through the scapulothoracic joint. The scapulothoracic joint refers to where the scapula moves over the rib cage.

Injury prevention has improved tremendously as a result of motion studies of throwing actions. Being able to see (and analyze) movements in slow motion has expanded the understanding of normal and abnormal shoulder function during throwing activities. This information has helped shape today’s injury prevention and rehab programs.

Physical therapy for injuries such as shoulder laxity and instability, impingement, and tendon or ligament tears is broken down into four phases. The first phase takes place when the injury is new or fresh. This is called the acute phase. The therapist helps the athlete understand the importance of activity modification and giving the injured tissues a chance to heal. Various treatment methods such as neuromuscular facilitation, lymphatic drainage, and rhythmic stabilization exercises are used by the therapist to help promote healing.

Phase two begins when the pain and inflammation of the acute phase have decreased. In this phase, the therapist uses specific exercises to strengthen and re-tune the muscles. Other exercises are used when there’s too much motion or not enough motion in any part of the arc of shoulder movement. The therapist must carefully examine each throwing athlete to identify exactly which soft tissues are affected, why, and what to do about it.

When tests show that the athlete’s shoulder is stable with only a mild loss of motion and no pain, then the program can be stepped up to the third phase. Here the training becomes more intensive with endurance drills, plyometric training for speed, and an interval throwing program. Interval throwing progresses pitches through various distances, speeds, and intensities on and off the baseball mound with plenty of rest periods in between. The player is taught how to regain speed without overtraining before moving to the final phase.

Phase four continues to advance the pitcher through a series of advanced interval throwing exercises, strengthening and conditioning exercises, and a maintenance program at the pre-injury level of performance and play. If all goes well, the athlete is returned to the game. If there has been no improvement (or not enough improvement), then additional testing and possibly surgery may be advised.

The authors provide therapists with additional information in how to apply this four-phase rehab program to players with specific problems that do require surgical repair such as a superior labrum anterior-posterior (SLAP) injuries or rotator cuff tears. SLAP lesions affect the labrum and biceps tendon where it attaches to the labrum. The labrum is a fibrous rim of cartilage around the rim of the shoulder socket. It helps hold the shoulder in place. Forces powerful enough to injure the labrum can be very disabling to the throwing athlete.

After surgery, the patient is guided through all four phases of rehab. Phase one is used when the surgical repair needs to be protected. The progression from phase one through phase four depends on the type of injury and type of repair. Minor surgical repairs such as debridement (shaving frayed edges of the labrum) can be progressed fairly quickly with little down time (immobilization). Players with severe full-thickness rotator cuff tears may not be able to return to a preinjury level of play. With all injuries, the therapist must assess scapular motion and provide rehab to restore normal kinetic motion when needed.

Scapular dyskinesia (loss of normal scapular motion) is a fairly new diagnosis. We know it is caused by muscular imbalances, trauma, or nerve injury. But what to do about it and how to treat it effectively are still being studied by physical therapists. Without a strong, normally functioning scapula, pitchers and other throwing athletes may end up compensating with other muscles and other shoulder motions. Such compensatory actions can also lead to increased load on the shoulder and yet another injury. The therapist includes exercises to strengthen and condition scapular muscles. Surgery is rarely needed for scapular dyskinesia.

The authors conclude by saying that many (if not most) shoulder injuries in throwing athletes can be successfully treated conservatively. Physical therapy to restore normal range and coordination of movement is the basis for regaining smooth kinetic motion. A program of specific exercises is often the answer to get the entire shoulder complex to a place where it can handle the demands of repetitive throwing in competitive sports. Shoulder conditioning (including adequate rest and recovery) is the key to preventing injuries in the first place.

Hip resurfacing has been around for almost 30 years. This treatment technique has been proven safe and effective. Instead of removing bone and replacing the joint, the surface of the bone is smoothed over and capped with a metal component. Now shoulder resurfacing is becoming more popular. And for the same reasons that hip resurfacing has been used: less bone is destroyed, fewer fractures occur, and the patient can still convert to a total joint if needed later.

In this review, orthopedic surgeons from three different well-known centers bring us up-to-date on the use of shoulder resurfacing. They describe when and how these implants are used along with photos and a discussion of the surgical procedure. The latest in design and expectations for the future are also considered.

Surgeons have several implant designs to choose from when performing a shoulder resurfacing procedure. The implants are made of cobalt-chromium or titanium-alloy. Some have a ceramic surface coating. Others provide a titanium porous (with holes) coating on the undersurface where the implant rests against the bone. The advantage of a porous surface is that the body can fill in the holes with bone to help cement the implant-joint interface together.

Early shoulder resurfacing implants had problems with loosening. Changes in the design seem to have helped reduce this problem. A recent development in shoulder resurfacing is the use of an implant that looks like a giant screw. This method allows for partial resurfacing of the humeral head (round ball at the top of the upper arm). It is used for patients who have smaller defects in the humeral head but don’t really need the entire surface smoothed and capped.

The shoulder has a wide range of motion and each patient has differences in normal shoulder anatomy. This is true from person to person but even from one shoulder to the other shoulder in the same person. Choosing the right implant type and size is an important first step. The surgeon must study the joint carefully to identify the shape of the humeral head, the angle of the humeral head, and the way the head fits into the socket.

Muscle tension around the joint is another consideration. The surgeon tries to restore as normal of biomechanical motion as possible. Getting the correct center of rotation and accurate placement of the implant can be a challenge with a total joint replacement. Many surgeons say that shoulder resurfacing makes these tasks much easier.

Not everyone is a good candidate for shoulder resurfacing. Patients who benefit most are those with pain from arthritis who have completed a program of physical therapy with little or no change in their painful symptoms and function.

Resurfacing is particularly attractive for younger, more active adults. This type of procedure cannot be done on people with severe osteoporosis (brittle bones) or fractures in the humerus. The authors comment that in their experience, a minimum of 60 per cent of normal humeral head bone stock is needed for patients with osteoporosis to be considered for resurfacing. So, having osteoporosis doesn’t mean shoulder resurfacing is out of the question. Their guideline of 60 per cent has not been studied or validated but provides surgeons with a helpful standard until evidence is provided.

The surgery itself is done with an open incision. The use of general anesthesia, regional anesthesia, or a combination of both is determined by the anesthesiologist at the time of the operation. This is based on patient needs, general health, preferences, and consideration of any comorbidities (other medical problems or conditions) present.

Diagrams, line drawings, and photographs are used to show how shoulder resurfacing can be done to preserve normal preoperative humeral head angles, position, and curvatures. The authors also describe their method for releasing the soft tissues around the joint and gaining access to the glenoid (socket). Any damage to the muscles around the shoulder present from before surgery is repaired (if possible). Any bone spurs along the clavicle (collar bone) are shaved off.

Sometimes there is a bit of trial and error as the surgeon fits different size implants in place. Shoulder motion and stability are checked before securing the implant. Muscle balance and tension is checked before closing the incision. Muscles around the shoulder that are too loose or too tight can result in shoulder dislocation.

The jury is not in yet on the best type of postoperative program for shoulder resurfacing. Some surgeons encourage their patients to move the arm right away. Others say to wait four to six weeks before rotating the joint fully in either direction (internal or external). The idea is to give the muscles a chance to heal after being cut during surgery. And some surgeons are combining a bit of both approaches by allowing some (but not all) motions right away. They gradually add in the other movements through full motion and then progress to a strengthening program over a period of weeks to months.

What are the results published so far for shoulder resurfacing? Only short-term and mid-term studies are available. But they show that 90 per cent of the patients report significant improvements in motion, pain, and strength. All of that leads to better function in daily activities, leisure activities, and sports participation. Patients say they can do just about anything they want from yoga to golf to mountain biking, hockey, even power lifting.

Compared with a total shoulder replacement, there are fewer complications and problems after shoulder resurfacing. Operative time is shorter and fewer days in the hospital are typical with shoulder resurfacing compared with joint replacement. There’s also less blood loss. And, of course, the main advantage is the availability of treatment for young, active patients who are limited by their pain.

The surgeon is faced with one other major decision during shoulder resurfacing. Should the socket side of the joint be replaced as well? There are pros and cons in this argument. Results of studies are from short-term follow-up. So far, there’s been some evidence that results are better when both sides of the joint are resurfaced. More study is needed in this area before clinical guidelines can be established and published.

What does the future look like for shoulder resurfacing? The authors expect it will be used more and more as time goes by. The results of current studies will show its benefits. Better materials and less invasive techniques will add to its appeal. Eventually, it may be possible to do the procedure arthroscopically. Already some surgeons are trying to do the partial resurfacing using an arthroscope. The less the soft tissues are disrupted, the better.

A fall onto the tip of the shoulder can disrupt the ligaments and capsule holding the acromioclavicular (AC) joint together. The result can be a dislocation of the AC joint. Sometimes this injury is referred to as a shoulder separation. The AC joint is located where the end of the clavicle (collar bone) meets the acromion. The acromion is a curved bone that comes from the shoulder blade across the top of the shoulder.

The AC joint is fairly complex with its many ligaments and strong capsule holding everything together. Damage to any of these soft tissues can be severe enough to require a surgical repair. Deciding when to do surgery and what type of surgery is the focus of this article.

Besides landing on the tip of the shoulder with enough force to disrupt the AC joint, there are two other ways this joint can be damaged. One is to fall onto an outstretched arm and hand with enough force up through the arm to dislocate the joint.

The other is through a fracture at the base of the coracoid process. The coracoid process is a piece of bone along the inside of the shoulder blade that forms a triangle with the acromion and the clavicle. The ligaments between these three structures are what form a strong and stable AC joint.

Treatment for AC joint injuries is usually based on the severity of the damage done to bone, ligaments, capsule, and nearby muscles. AC joint injuries are broken down into six categories classified as I through VI (from mild sprain to severe dislocation). The joint can be unstable in one of three directions: front and back (anterior-posterior), side-to-side, and vertical (up and down).

A type I injury means there’s no visible injury. The patient may have some swelling and tenderness right over the AC joint (front of the shoulder), but X-rays and motion are normal. A type II injury results in pain over the AC joint and positive findings on an X-ray (widening of the AC joint space). Sometimes there’s vertical instability but not often. Types I and II AC joint injuries are treated conservatively (without surgery).

Vertical (up and down) movement of the clavicle is more common with type III injuries. X-rays show the joint is dislocated. The acromion is separated from and slightly above the clavicle. Pushing up on the elbow puts the joint back together. But it may not stay there, which is a sign of instability.

Surgeons have the most difficulty in deciding about surgery for Type III injuries. The loss of contact between the clavicle and the acromion means that motion is going to be altered. If a rehab program isn’t enough to successfully treat this injury, then surgery is done to reconstruct the joint.

Sometimes individual patient demands require surgery early on. And in the case of a chronically dislocating AC joint, surgical intervention may be the only way to restore full, normal stability and movement. Overhead athletes and heavy manual laborers seem to fall into this group most often. And there’s some question that maybe patients with type III injuries fail because they didn’t complete their rehab program or the rehab program wasn’t quite enough. The shoulder can function normally without an intact clavicle. But it cannot do so when the shoulder muscles are weak and unable to stabilize the joint.

Types IV, V, and VI injuries are more severe. The AC joint becomes unstable and surgery is almost always necessary. The ligaments are disrupted and the joint is dislocated. In the most severe cases (Type VI), the muscles are detached from the clavicle. The joint can’t be put back in place and the nerves can be stretched leading to nerve palsy. When the injury (usually a Type VI) is caused by a high-energy trauma, there can be broken bones as well (e.g., clavicle, ribs).

Diagnosis and classification is based on the history (what happened or mechanism of injury), clinical presentation (patient’s symptoms and results of clinical tests), and findings on X-rays and CT scans.

Typical symptoms include local pain, tenderness, and swelling. There may be bruising and an obvious deformity when the joint is dislocated or a bone is broken.

What the examiner sees visually may depend on the degree of joint separation and direction of disruption. The pain is made worse by moving the arm away from the body or across the chest. Type III injuries are the only ones that can be reduced (put back in place). There isn’t displacement with Types I or II and Types IV through VI are dislocated too severely. The imaging studies help confirm the severity of the injury.

Once the diagnosis is made, then a plan of care is determined. Stress is removed from the joint during the acute phase (first 10 to 14 days) when there is a Type I or II injury. The patient wears a sling or shoulder immobilizer. When the pain is mild or gone, gentle exercises can be done. A physical therapist guides the patient though a rehab program to restore motion, strength, and endurance.

Heavy lifting and contact sports aren’t allowed until the ligaments have healed. This can take up to three months. Early return to these kinds of activities can cause a Type II injury to become Type III or a Type III injury to convert to a complete rupture (Type IV or worse).

Not all patients recover completely from Type I and II injuries. There may be some long-term symptoms such as clicking and pain or limitations with certain activities (e.g., push-ups). Studies have been done comparing patients with more severe injuries who were treated conservatively versus those who had surgery. The severity of the dislocation was judged based on how far apart the joint had separated. Patients with more than a two centimeter separation were placed in the group labeled severe.

Only a small portion (20 per cent) of the severe group treated conservatively had good-to-excellent results. This was compared with those patients who went ahead and had the surgery. Surgical repair resulted in 70 per cent success.

The authors sum things up about treatment by saying that low-grade, minor AC injuries are still treated these days with conservative care. More severe injuries are treated surgically. There’s always a chance of arthritis developing in either group. And patients treated nonoperatively can develop chronic instability.

That brings us to the final area of review in this study and that is: what kind of surgery has the best results? The surgeon must decide what technique to use and then plan the method to accomplish the task. Of course, the goal is to realign the AC joint. There is agreement that types IV, V, VI, and some type IIIs need surgical intervention, but that’s about as far as it goes. There isn’t much consensus on what type of surgery to do.

For example, if the main AC joint needs to be held together (a technique called fixation), should the surgeon use wires or a hook-plate? If fixation is needed between the coracoid process and the clavicle, then which is better: a screw or a suture loop?

And if the damage is severe enough to require ligament reconstruction, which muscle/tendon does the graft tendon come from (e.g., hamstring, anterior tibialis)? In some cases, the end of the clavicle is excised or removed altogether. Studies have called this practice into question. Future studies are needed to look at the success/failure of this technique before continuing to use it.

The authors review each surgical approach and describe both the techniques used and the pros and cons of each one. Complications following surgery seem to be related to the surgical technique used. Sometimes the hardware used for fixation breaks and moves causing damage to nearby nerves or blood vessels. The body may react to the fixation devices as if it were a foreign object to get rid of. Infection is always a danger.

Drawings, X-rays of screw placement, and photos taken during open surgery are provided to help surgeons see the steps needed to complete the reconstruction procedure. The importance of postoperative rehabilitation is emphasized. Immobility with the application of cold during the first few days is advised. Motion is allowed after two weeks with some restrictions.

Nothing heavier than five pounds may be lifted until the hardware is removed. Then full motion and a strengthening program can be added. Some differences in rehab are needed when ligament reconstruction is part of the procedure. The healing graft must not be disturbed in order to assure complete recovery. When it’s all said and done and full motion and strength have returned, then the patient can return to work or sports activities without restrictions.

There are many possible causes of shoulder pain in the overhead-throwing athlete. With six phases of the baseball pitch (wind up, early cocking, late cocking, acceleration, deceleration, and follow-through), there are many places where the neurovascular structures (nerves and blood vessels) can get pinched or compressed.

In this report, the authors walk us through all the most common causes of shoulder pain from an anatomical approach. They suggest that before a proper rehab program can begin, it’s important to find out which structures of the shoulder are involved. They provide beautifully colored illustrations of shoulder anatomy to assist the reader in identifying the location of those structures.

It could be there’s a problem with the way the scapula (shoulder blade) is moving. Perhaps there is something wrong inside the shoulder affecting the shoulder capsule and/or labrum. The capsule is a fibrous envelope that surrounds the shoulder joint giving it support and stability. The labrum is a dense fibrocartilage ring that is firmly attached around the shoulder socket. It provides depth and stability to the joint.

Sometimes the athlete has a rotator cuff tendinitis or even a rotator cuff tear. There could be a nerve palsy (paralysis), bursitis, or impingement (something is getting pinched). Whatever the cause, early diagnosis and treatment is the key to preventing a more serious injury. Getting the athlete back into the game as soon as possible is the goal.

All of that sounds pretty simple and straightforward. But it’s really quite a challenge to figure out what’s going on to cause pain and dysfunction in the shoulder of the throwing athlete. For one thing, the pitch is fast. There’s not much time to analyze which phase of the pitch is the point of breakdown. The biomechanical stresses on the different shoulder structures change quickly from the initial wind up to the final follow-through.

Each part of the shoulder complex from the scapula to the shoulder to the fingertips must work together in a complex series of coordinated motions. This is called the kinetic chain. Anything that alters the smooth transfer of energy along the kinetic chain can increase force produced by the shoulder. That’s when pain develops. Something has to give in order to keep up the pitching speed and control of the ball.

So how does the sports medicine specialist diagnose the problem? The authors recommend starting with a pitching and shoulder pain history. Information collected from the patient and/or family includes age the patient first started pitching and age at which different pitches were first thrown.

The examiner will also ask about number of years throwing, number of pitches, and type of pitches. Other data factored into the evaluation includes amount of complete rest from throwing in a year’s time, ratio of fastballs to breaking balls thrown, and history of injury or previous treatment to the throwing shoulder.

The exam will be compared to the other shoulder to get an idea of the patient’s normal motion, strength, and flexibility. It won’t be an exact match but close enough to get an idea of the patient’s profile. The shoulder complex will be tested for stability. Scapular position, motion and function will be assessed. From these tests, the source of shoulder pain can be narrowed down to the rotator cuff, the capsule, the labrum, the scapula, or the neurovascular structures.

Specific details for each of these structures are discussed. Rotator cuff injuries are first recognized by the symptoms — diffuse pain that’s worse when throwing overhead and worse at night. The pain may travel down the arm to the elbow. The symptoms come on slowly when the problem was caused by repetitive loads on the shoulder from throwing over and over. Acute (traumatic) injuries are more likely to develop symptoms suddenly rather than over a period of weeks to months.

If you picture the movements that the shoulder goes through, it’s easy to see how the back half and bottom of the capsule gets tight, forming a contracture. The front of the capsule gets stretched out from the position of cocking the arm back behind the head in order to throw it. The back half of the capsule doesn’t get that kind of stretch and may even tighten in an attempt to stabilize the shoulder as the arm and hand accelerate forward.

Capsular tightness or imbalance can lead to a loss of shoulder internal rotation, which then leads to a capsular-labral tear. Scapular problems can also develop when there is a tight posterior capsule (along the back of the shoulder joint). Improper positioning and movement of the scapula (called scapular dyskinesia) often leads to painful shoulder impingement. Shoulder problems involving these structures might put an end to pitching before the season even begins.

And finally, the authors devote a long section of the article to address painful shoulder problems caused by neurovascular disorders. Thoracic outlet syndrome, axillary artery thrombosis, aneurysm, and nerve palsy are the most likely neurologic or vascular problems encountered by the overhead-throwing athlete. Numbness and tingling of the fingers, loss of velocity when throwing the ball, shoulder pain, and a sense of heaviness or aching of the arm are the first signs of a possible nerve or blood vessel getting pinched, pulled, blocked, or compressed.

What can be done to prevent these complex, difficult-to-treat shoulder problems in the overhead-throwing athlete? First of all, being aware of the potential problems may help pitchers follow guidelines for limiting the number and types of pitches. That includes practices and games, not just games. Careful accounting is especially important in areas of the country where baseball is played year-round.

Second, preventive stretching of the capsule will help throwers who are developing or who already have a loss of internal rotation from capsular contracture (tightness). Year-round training including strengthening, conditioning, and stretching is advised both for year-round athletes and for those who are in the off-season. This type of program can help maintain a strong and healthy rotator cuff, prevent impingement of soft tissues or the neurovascular structures, and prevent injuries.

Third, the athlete should be encouraged to seek treatment as soon as pain occurs or an injury develops. The importance of early intervention is stressed. A program of conservative (nonoperative) care can make all the difference — even preventing more drastic measures such as surgery.

Athletes will follow a rehab program to condition them for full return to their former level of play. If these measures fail, then the appropriate surgery may be recommended. Since surgery will delay full recovery, every effort is made to provide a conservative program (including rehab) to address all of the upper quadrant complex (e.g., strength, flexibility, coordination, motion).

However, the athlete should be prepared that although most problems caught early enough are treatable, it does take time (as much as six to nine months’ time). In terms of getting back into the game, this is still better than one to two years with surgery, recovery, and rehab.

If you went from surgeon-to-surgeon, state-to-state, and region-to-region in the United States you would not find one single rehab program used by all for patients who have had surgery for a rotator cuff tear. And that’s true even though everyone agrees that patients must closely follow the postoperative Dos and Don’ts they are given. One of those Dos is to complete their rehab program from start to finish.

The authors of this study set out to review all of the published studies on rehabilitation for rotator cuff repairs. They wanted to see if there was enough evidence in a systematic review of this type to say just what is the optimal evidence-based rehab protocol for this problem.

They set their standard for studies to be included to those that were high-quality (Levels I and II) evidence. The studies had to involve randomized clinical trials of patients who had rehabilitation after surgery to repair the damaged rotator cuff.

Even after searching all of the most reputable databases, they only found 12 studies published over a 40-year period (1966 to 2008). And only four of those studies were appropriate because they met all the criteria set up by the review committee to qualify as a Level I or II high-quality evidence-based study. These four studies were limited to reviewing the results of continuous passive motion (CPM) after surgery and the use of supervised physical therapy versus unsupervised home exercise.

Before going on to describe the findings from these studies, the authors made it clear that each of these four studies had some weaknesses. The strength of the evidence was called into question because of those design flaws. So although they present the results, they advise the reader to consider the conclusions carefully.

Continuous passive motion (CPM) is a way to keep the arm moving with gentle range-of-motion. The arm is placed in a device that is set to whatever motion is desired. It is motorized and repetitively moves the arm through the preset arc of motion.

According to the two acceptable studies, CPM didn’t really improve overall strength or function. But patients did get improved motion. And some patients (women and people over age 60), reported a greater reduction in pain compared to men or younger women. The authors concluded that CPM is safe and effective. But for the cost of the machine, it appeared more cost effective to rely on a program of passive range-of-motion.

In the studies comparing a supervised physical therapy program versus a home program of exercise, there was no advantage of one over the other. Outcome measures of the results included range-of-motion, strength, function, and patient satisfaction. For those who exercised at home, instruction was provided by the therapist either in an individual session during the first week after surgery or via a videotape used at hoome demonstrating the exercise program.

With only four high-level studies to use in a systematic review, the authors point out the need for some decent trials to investigate the optimal rehab program for rotator cuff repairs. Just looking at one aspect of rehab (whether that is CPM, physical therapy, exercise or some other intervention), is not likely to answer the question of what rehab program is best for patients to follow after rotator cuff surgery. The benefit of this study was to show clearly that we are a long way from publishing standard guidelines for this problem.