Shoulder

Shoulder Arthroscopy
Rotator Cuff Repair
Biceps Tendon Rupture at the Shoulder/Biceps Tendinosis
Labral Repair
Shoulder Dislocation (Instability)
Shoulder Separation (AC Joint Separation)
Clavicle (Collar Bone) Fractures
Shoulder Impingement and Bursitis
Frozen Shoulder
Partial Shoulder Replacement (Hemiarthroplasty)
Shoulder Stretching Exercises

Shoulder Arthroscopy

Shoulder arthroscopy is surgery that uses a tiny camera called an arthroscope to examine or repair the tissues inside or around your shoulder joint. The arthroscope is inserted through a small incision in your skin.

What happens during the procedure?
First, I examine your shoulder while you are under anesthesia. Then I insert the arthroscope into your shoulder through a small incision. The camera is connected to a video monitor in the operating room.
I thoroughly inspect all the tissues of your shoulder joint and the area above the joint — the cartilage, bones, tendons, and ligaments. We confirm the diagnosis made by your physical examination, xrays and MRI.

The next step is to repair any damaged tissues. To do this, 2 to 3 more small incisions half an inch long are used to introduce other instruments. A tear in a muscle, tendon, or cartilage will be fixed. Damaged tissue may need to be removed.

What types of shoulder arthroscopy surgeries are there?

  • Rotator cuff repair: The edges of the muscles are brought together. The tendon is attached to the bone with sutures. Small anchors with attached suture are used to attach the tendon to the bone. The anchors can be made of bioabsorbable material or plastic. They do not need to be removed after surgery.
  • Surgery for impingement syndrome: Damaged or inflamed tissue (bursa) is cleaned out in the area above the shoulder joint itself. If there is a prominent spike of bone (the acromion) this may need to be shaved down (acromioplasty).
  • Surgery for shoulder instability: A torn labrum (the rim of cartilage that surrounds the socket of the shoulder joint) can lead to instability (dislocation) or pain. This may need to be repaired. Ligaments that attach to this area will also be repaired. A Bankart lesion is a tear on the labrum in the lower part of the shoulder joint. A SLAP lesion involves the labrum on the top part of the shoulder joint.

At the end of the surgery using the arthroscope, your incisions will be closed with stitches and covered with a dressing (bandage). Rarely I may need to do mini-open surgery if there is a lot of damage. Mini-open surgery means you will have a slightly larger incision. This is combined with arthroscopy.

Rotator Cuff Repair

Rotator cuff repair is a type of surgery to fix a torn tendon in the shoulder. I usually use only arthroscopic incisions but occasionally a mini-open incision is needed.

What happens during the procedure?
First, I introduce a small camera (arthroscope) to look at the tear and the rest of your shoulder to check the cartilage, tendons, and ligaments.

After evaluating the shoulder joint, the camera is reintroduced into the space above the rotator cuff tendons, called the subacromial space. I re-check the area above the rotator cuff, clean out inflamed or damaged tissue, and if necessary bone spurs can be removed.

The arthroscope and 2 to 3 additional tiny incisions are used to perform the surgery. The additional small incisions allow me to insert other instruments to repair damaged tissue.

The goal is to anatomically attach the tendon back to the bone. The tendon is attached with sutures by tiny anchors inserted into the bone. The suture anchors are made of material that dissolves over time or plastic and do not need to be removed. At the end of the surgery, the incisions are closed, and a dressing is applied. I take pictures and video of the procedure to show you what was found and what was done.

Labral Repair

Advances in medical technology allow orthopedic doctors to identify and treat injuries that went unnoticed 20 years ago. Arthroscopy is a tool that allows us to identify and treat a shoulder injury called a glenoid labral tear.

What are the symptoms of a labral tear?
The symptoms of a tear in the shoulder socket rim are very similar to those of other shoulder injuries. Symptoms may include:

  • Pain, usually with overhead activities
  • Catching, locking, popping, or grinding
  • Occasional night pain or pain with daily activities
  • A sense of instability in the shoulder
  • Decreased range of motion
  • Loss of strength

The procedure to repair a labral tear is similar to a rotator cuff repair procedure.

Shoulder Dislocation (Instability)

The shoulder joint is the body’s most mobile joint. But, this advantage also makes the shoulder an easy joint to dislocate. A partial dislocation means the head of the upper arm bone is partially out of the socket. A complete dislocation means it is all the way out of the socket. Both partial and complete dislocation will cause pain and unsteadiness in the shoulder.

How does it occur?
The shoulder joint will usually dislocate forward (anterior dislocation) or backward (posterior dislocation). The most common type of shoulder dislocation is when the shoulder slips forward (anterior instability). This means the upper arm bone (the ball) has moved forward and down out of its socket. It may happen when the arm is put in a throwing position.

How is it treated?
It is generally treated non-surgically. I immobilize the shoulder in a sling for several weeks following relocation. You will need to rest your shoulder for at least 6 weeks. The sore area can be iced 3 to 4 times a day.

After the pain and swelling go down, I will enroll you in physical therapy. The important thing is that your shoulder’s range of motion and strength return. Rehabilitation may also help prevent dislocating the shoulder again in the future. Rehabilitation will begin with gentle muscle toning exercises. Two to three months later weight training can be added.

If you are young and active shoulder dislocation may become a chronic condition. Surgery may be needed to repair or tighten the torn or stretched ligaments that help hold the joint in place, particularly in young athletes.

Shoulder Separation (AC Joint Separation)

A shoulder separation is different than a shoulder dislocation (glenohumeral dislocation). The injury actually involves the acromioclavicular joint (also called the AC joint). The AC joint is where the collarbone (clavicle) meets the highest point of the shoulder blade (acromion).

The most common cause for a separation of the AC joint is from a fall directly onto the shoulder. This is a frequent cycling and football injury. The fall tears the ligaments that surround and stabilize the AC joint. An AC joint separation occurs when the ligaments that stabilize the clavicle to the acromion process are injured or torn. As a result the clavicle can be displaced (moved) upwards. This condition is commonly known as a shoulder separation.

What are the types of separations?
There are different severities of AC joint separation. Classification of the different severities depends on the ligaments that are torn. One classification is as follows:

    • Type I: A sprain (without a complete tear) of either of the ligaments holding the joint together. The clavicle is not displaced.
    • Type II: A complete tear of the acromioclavicular ligament and a partial tear of the coracoclavicular ligaments. The clavicle is slightly displaced.
    • Type III: A complete tear of both the acromioclavicular ligament and the coracoclavicular ligaments. When this occurs the clavicle is significantly displaced (dislocated). These injuries occasionally require surgical intervention.
    • Types IV, V, VI: A complete tear of the acromioclavicular ligament and the coracoclavicular ligaments. The clavicle is severely dislocated and usually requires surgical intervention.

How is it repaired?
Where there is significant deformity, reconstructing the ligaments that attach to the underside of the collarbone can restore normal function. This type of surgery works well even if it is done long after the problem started, but the surgery is best done in the first two weeks. Injections into the joint or further surgery are occasionally required.

I use an Arthrex Tightrope either with or without a ligament reconstruction (depending on the injury). Sometimes the end of the clavicle must be removed to decrease pain in the shoulder after surgery. I have sub-specialty fellowship training in this technically demanding procedure. Whether treated conservatively or with surgery, the shoulder will require rehabilitation to restore and rebuild motion, strength, and flexibility.

Clavicle (collar bone) fractures

A broken collarbone is also known as a clavicle fracture. This is a very common fracture that occurs in people of all ages.

The collarbone (clavicle) is located between the ribcage (sternum) and the shoulder blade (scapula), and it connects the arm to the body. It is a strut that holds up the arm in place. The clavicle lies above several important nerves and blood vessels. However, these vital structures are rarely injured when the clavicle breaks, even though the bone ends can shift. Most clavicle breaks occur in the middle. Occasionally, the bone will break where it attaches at the ribcage or shoulder blade.

How does it occur?
Clavicle fractures are often caused by a direct blow to the shoulder. This can happen during a fall onto the shoulder, bicycle or sports injury, or a car collision. A fall onto an outstretched arm can also cause a clavicle fracture. There is typically a bump at the site of the fracture and pain especially with movement.

How is it diagnosed?
In the office I will carefully examine your shoulder to make sure that no nerves or blood vessels were damaged. In order to pinpoint the location and severity of the break, you will need an x-ray. It is often that I will take X-rays of the entire shoulder to check for additional injuries. If other bones are broken, your may need an MRI or CT scan to see better detail.

Can it be treated non-surgically?
If the broken ends of the bones have not shifted out of place and line up correctly, you may not need surgery. Broken collarbones can heal without surgery. A simple arm sling is usually used for comfort immediately after the break. The sling supports your arm and helps keep it in position while it heals.

Once your bone begins to heal, the pain will decrease and your may start gentle shoulder and elbow exercises. These prevent stiffness and weakness. More strenuous exercises can gradually be started once the fracture is completely healed. The fracture can move out of place before it heals. It is important to follow up as scheduled to make sure the bone stays in position. If the fracture fragments move out of place you may need surgery.

A large bump over the fracture site may develop as the fracture heals. This usually gets smaller over time, but a small bump will remain permanently.

[yellowbox]How is it repaired surgically?[/yellowbox]
If your bones are out of place you may benefit from surgery to align the bones exactly. This can improve shoulder strength when you have recovered. This is especially true in overhead athletes such as throwers, swimmers, and racket sport players.
During this operation, the bone fragments are first repositioned into their normal alignment, and then held in place with special screws by attaching metal plates to the outer surface of the bone.

After surgery, you may notice a small patch of numb skin below the incision. This numbness will likely become less noticeable with time. Because there is not a lot of tissue over the collarbone, you may be able to feel the plate through your skin.
Plates and screws can be removed after the bone has healed, if they are causing discomfort. Problems with the hardware are not common, but sometimes, seatbelts and backpacks can irritate the collarbone area. If this happens, the hardware can be removed after the fracture has healed at approximately 1 year after surgery.

(A) The clavicle is broken in more than one place and the fragments are severely out of alignment. (B) The fractured pieces are held in place by a combination of plates and screws.

[yellowbox]What is the rehabilitation?[/yellowbox]
Therapy programs typically start with gentle motion exercises. You will gradually add strengthening exercises to your program as your fracture heals. Although it is a slow process, following your physical therapy plan is an important factor in returning to all the activities you enjoy.

[yellowbox]Is it likely to have surgical complications?[/yellowbox]
People who use any kind of tobacco product, have diabetes, or are elderly are at a higher risk for complications during and after surgery. They are also more likely to have problems with wound and bone healing. Be sure to talk with your doctor about the risks and benefits of surgery for your clavicle fracture.
There are risks associated with any surgery, including:

  • Difficulty with bone healing
  • Lung injury
  • Hardware irritation

[yellowbox]What is the recovery like?[/yellowbox]
Your bone can heal almost twice as quickly with surgery but it can take months to get back to all of your activities. Healing takes longer in diabetics or people who smoke or chew tobacco. Most people return to regular activities within 3 months of their injury. Returning to regular activities or lifting with your arm before you have healed may cause your fracture fragments to move or your hardware to break. This may require you to start your treatment from the beginning. Once your fracture has completely healed, you can safely return to sports activities. This is usually 12 weeks after surgery.

Biceps Tendon Rupture at the Shoulder/Biceps Tendinosis


The biceps muscle is in the front of your upper arm. It helps you bend your elbow and rotate your arm. It also helps keep your shoulder stable. Many people can still function at a reduced level with a biceps tendon tear, and only need simple treatments to relieve symptoms. Some people require surgery to repair the torn tendon.

There are two attachments of the biceps tendon at the shoulder joint. The upper end of the biceps muscle has two tendons that attach it to bones in the shoulder. The long head attaches to the top of the shoulder socket (glenoid). The short head attaches to a bump on the shoulder blade called the coracoid process.

[yellowbox]What is a biceps tendon tear?[/yellowbox]
Biceps tendon tears can be either partial or complete.

  • Partial tears: Many tears do not completely sever the tendon. Wear of the tendon is called Tendinosis. Inflammation of the tendon is called Tendinitis.
  • Complete tears: A complete tear will split the tendon into two pieces.

In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear.

The long head of the biceps tendon is more likely to be injured. This is because it is vulnerable as it travels through the shoulder joint to its attachment point in the socket. Fortunately, the biceps has two attachments at the shoulder. The short head of the biceps rarely tears. Because of this second attachment, many people can still use their biceps even after a complete tear of the long head. Tear of your biceps tendon is often accompanied by damage other parts of your shoulder, such as the rotator cuff tendons.

[yellowbox]How does it occur?[/yellowbox]
There are two main causes of biceps tendon tears: injury and overuse.

  • Injury: If you fall hard on an outstretched arm or lift something too heavy, you can tear your biceps tendon.
  • Overuse: Most tears are the result of a wearing down and fraying of the tendon that occurs slowly over time. This naturally occurs as we age. It can be worsened by overuse – repeating the same shoulder motions again and again. Overuse can cause a range of shoulder problems, including tendonitis, shoulder impingement, and rotator cuff injuries. Having any of these conditions puts more stress on the biceps tendon, making it more likely to weaken or tear.

[yellowbox]Am I at risk for a tendon tear?[/yellowbox]
Your risk for a tendon tear increases with:

  • Age: Older people have put more years of wear and tear on their tendons than younger people.
  • Heavy overhead activities: Too much load during weightlifting is a prime example of this risk, but many jobs require heavy overhead lifting and put excess wear and tear on the tendons.
  • Shoulder overuse: Repetitive overhead sports – such as swimming or tennis – can cause tendon wear and tear.
  • Smoking: Nicotine use can affect nutrition in the tendon.
  • Corticosteroid medications: Excessive corticosteroid use has been linked to increased muscle and tendon weakness. This is why I limit use of injections to no more than 3 times per year per area.

[yellowbox]What are the symptoms of tendon tear?[/yellowbox]

  • Sudden, sharp pain in the upper arm
  • Sometimes an audible pop or snap
  • Cramping of the biceps muscle with strenuous use of the arm
  • Bruising from the middle of the upper arm down toward the elbow
  • Pain or tenderness at the shoulder and the elbow
  • Weakness in the shoulder and the elbow
  • Because a torn tendon can no longer keep the biceps muscle tight, a bulge in the upper arm above the elbow (“Popeye Muscle”) may appear, with a dent closer to the shoulder.

[yellowbox]How am I examined for a tendon tear?[/yellowbox]
It is also very important that you let me know about any other shoulder problems when planning your treatment. The biceps can also tear near the elbow, although this is less common. A tear near the elbow will cause a “gap” in the front of the elbow. I will check your arm for damage to this area.
In addition, rotator cuff injuries, impingement, and tendonitis are some conditions that may accompany a biceps tendon tear. I may order additional tests to help identify other problems in your shoulder.

Imaging used in examination

    • X-rays: Although X-rays cannot show soft tissues like the biceps tendon, they can be useful in ruling out other problems that can cause shoulder and elbow pain.
    • Magnetic resonance imaging (MRI): These scans create better images of soft tissues. They can show both partial and complete tears.

[yellowbox]What are methods of treatment?[/yellowbox]

  • Ice: Apply cold packs for 20 minutes at a time, several times a day to keep down swelling. Do not apply ice directly to the skin.
  • Non-steroidal anti-inflammatory medications: Drugs like ibuprofen or naproxen reduce pain and swelling.
  • Rest: Avoid heavy lifting and overhead activities to relieve pain and limit swelling.
  • Surgery

[yellowbox]What is the surgical treatment?[/yellowbox]
Patients who desire complete recovery of strength, such as athletes, may require surgery. Surgery may also be the best option for those with partial tears whose symptoms are not relieved with rest, ice and therapy.

Several new procedures have been developed that repair the tendon with minimal incisions. The goal of the surgery is to re-anchor the torn tendon back to the bone. This is an area of special interest for me, and a focus of my clinical research. Successful surgery can correct muscle deformity and return your arm’s strength and function to nearly normal. Complications with this surgery are rare. Re-rupture of the repaired tendon is uncommon.

[yellowbox]What is rehabilitation like?[/yellowbox]
After surgery, your shoulder will be immobilized briefly with a sling. Be sure to look at the shoulder rehabilitation pages for isolated Biceps Tenodesis for a detailed program of exactly what you will be able to do with therapy by the week.

Shoulder Impingement and Bursitis

Impingement is a common cause of pain in the adult shoulder. It results from pressure on the rotator cuff from part of the shoulder blade (scapula) as the arm is lifted.

The rotator cuff is a tendon linking four muscles: the supraspinatus, the infraspinatus, the subscapularis, and the teres minor. These muscles cover the “ball” of the shoulder (head of the humerus). The muscles work together to lift, stabilize, and rotate the shoulder.

[yellowbox]What is impingement?[/yellowbox]
The acromion is the front edge of the shoulder blade. It sits over and in front of the humeral head. As the arm is lifted, the acromion can rub or “impinge” on, the surface of the rotator cuff. This causes pain and limits movement.

[yellowbox]What is bursitis?[/yellowbox]
The pain may be due to a “bursitis,” or inflammation of the bursa or a “tendonitis” of the cuff itself. In some circumstances, a partial tear of the rotator cuff may cause the pain. All of these are addressed at the time of surgery.

Partial Shoulder Replacement (Hemiarthroplasty)

Shoulder replacement is surgery to replace the bones of the shoulder joint with artificial parts. This can performed for arthritis or for a fracture which cannot be repaired

[yellowbox]What happens during the procedure?[/yellowbox]
You will receive general anesthesia before this surgery. This means you will be asleep and unable to feel pain. I add local or regional anesthesia to minimize any post-operative pain. The shoulder is a ball and socket joint. The ball end fits into a shallow socket, at the end of another bone. This type of joint allows the highest degree of flexibility.

For shoulder replacement, the rounded end of your arm bone will be resurfaced with a rounded metal head. The socket part of your shoulder joint can be smoothed or if it is in good condition left alone. It can also be replaced with a smooth plastic shell (lining) that will be held in place with special cement. If only 1 of these 2 bones needs to be replaced, the surgery is called a partial shoulder replacement (hemiarthroplasty).

For shoulder joint replacement, I make a 4-6 inch open incision going between the muscles over your shoulder joint is necessary. I then:

  • Remove the top surface of your upper arm bone
  • Cement the new metal head and stem into place
  • Smooth the surface of the old socket or place a new shell.
  • Close your incision with sutures
  • Place a dressing (bandage) over your wound

This surgery usually takes 1 to 2 hours.

Frozen Shoulder

Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move. Frozen shoulder occurs in about 2% of the general population. It most commonly affects people between the ages of 40 and 60, and occurs in women 3 times more often than men. There is a strong association with diabetes, thyroid disease, stroke, myocardial infarction, trauma and immobilization. Later occurrence in the contralateral shoulder is seen in 30% of cases.

[yellowbox]What is frozen shoulder?[/yellowbox]
In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint. The hallmark sign of this condition is being unable to move your shoulder – either on your own or with the help of someone else. It develops in three stages:

  • Freezing: In the “freezing” stage, you have increasing pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months. This can be interrupted with a corticosteroid injection and therapy.
  • Frozen: Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the “frozen” stage, daily activities may be very difficult.
  • Thawing: Shoulder motion slowly improves during the “thawing” stage. Complete return to close to normal strength and motion typically takes from 6 months to 2 years.
In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.

 

[yellowbox]How does it occur?[/yellowbox]
The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

  • Diabetes. Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known. You must have laboratory tests for Diabetes if you have a frozen shoulder.
  • Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson’s disease, and cardiac disease. These should also be tested by your primary care doctor.
  • Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients passively move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

[yellowbox]What are the symptoms?[/yellowbox]
Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.

[yellowbox]How is it diagnosed?[/yellowbox]

  • Physical Examination: People with frozen shoulder have limited range of motion both actively and passively.
  • Imaging Examination: Other examinations that may help rule out other causes of stiffness and pain include:
    • X-rays may show other problems in your shoulder, such as arthritis.
    • Magnetic resonance imaging (MRI) and ultrasound—these studies can create better images of problems with soft tissues, such as a torn rotator cuff.

[yellowbox]What is the treatment?[/yellowbox]
Frozen shoulder generally gets better over time, although it may take up to 3 years. We want to short-circuit this gradual process to get your shoulder better as quickly as possible. The focus of treatment is to control pain and restore motion and strength through physical therapy.

[yellowbox]Nonsurgical Treatment[/yellowbox]
More than 90% of patients improve with relatively simple treatments to control pain and restore motion. I try to treat all frozen shoulders without surgery.

  • Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.
  • Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint and capsule.
  • Physical therapy. Specific exercises will help restore motion. Therapy includes stretching or range of motion exercises for the shoulder.LINK TO SHOULDER STRETCHING EXERSIZES, see bottom of doc

[yellowbox]Surgical Treatment[/yellowbox]
If your symptoms are not relieved by therapy and anti-inflammatory medicines, you and your doctor may discuss surgery. It is important to talk with your doctor about your potential for recovery continuing with simple treatments, and the risks involved with surgery. The goal of surgery for frozen shoulder is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.

  • Manipulation under anesthesia: During this procedure, you are put to sleep. Your shoulder is moved which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of motion.
  • Shoulder arthroscopy: In this procedure, I cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.

Manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have very good outcomes with these procedures.

These photos taken through an arthroscope show a normal shoulder joint lining (left) and an inflamed joint lining damaged by frozen shoulder.

[yellowbox]What is recovery like?[/yellowbox]
After surgery, physical therapy is necessary to maintain the motion achieved with surgery. Recovery times vary, from 6 weeks to three months. Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.

Long-term outcomes after surgery are good, with most patients having reduced or no pain and greatly improved range of motion. In some cases a small amount of stiffness remains. Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present. It is essential to treat the underlying cause of the frozen shoulder if one can be found.

Shoulder Stretching Exercises

[yellowbox]External Rotation — Passive Stretch[/yellowbox]
Stand in a doorway and bend your affected arm 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.

External Rotation – Passive Stretch

[yellowbox]Forward Flexion — Supine Position[/yellowbox]
Lie on your back with your legs straight. Use your good arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat ten times.

Forward Flexion – Supine Position

[yellowbox]Crossover Arm Stretch[/yellowbox]
Gently pull one arm across your chest just below your chin as far as possible. Hold for 30 seconds. Relax and repeat ten times.

Crossover Arm Stretch