Shoulder
Overview
Shoulder pain can affect all phases of life. Work, sports, daily living, even sleep can become a burden with a painful shoulder. All of our experienced Shoulder Specialists at CSS are fellowship trained in shoulder surgery and have spent years in practice honing their skills.
Conditions & Treatments
The shoulder is the most mobile joint in the human body, with a complex arrangement of structures working together to provide the necessary movement. The shoulder is a ball-and-socket joint made up of three bones: the humerus (the bone in the upper arm), the scapula (the shoulder blade), and the clavicle (the collarbone). A strong network of soft tissues and bones work cohesively to provide movement and stability to the shoulder. The head of the humerus fits into a shallow socket in the scapula with the shoulder capsule, which is a strong connective tissue, surrounds the shoulder joint. Synovial fluid lubricates the joint and the shoulder capsule to ease the movement of the shoulder.
Frozen Shoulder
Frozen shoulder, which is also known as adhesive capsulitis, is a condition that begins with a gradual onset of pain and a limitation of shoulder motion which gradually gets worse, making the shoulder very hard to move. The discomfort and loss of movement can become so severe that even simple daily activities become difficult. In frozen shoulder, the shoulder capsule thickens and becomes very stiff due to the development of stiff bands of tissue, called adhesions. Sometimes, there is less synovial fluid in the joint contributing to the stiffness.
Surgery should only be considered if the symptoms do not improve after prolonged non-operative treatment. The specific procedure will depend on the severity of the condition and should be discussed with the physician extensively:
- Steroid Injections – Injecting the shoulder joint with cortisone, a powerful anti-inflammatory medicine, might aide in decreasing pain and improving shoulder mobility in the early stages of a frozen shoulder.
- Shoulder Manipulation – This procedure typically requires the individual to undergo anesthesia. While they are asleep, the physician will force the shoulder to move which causes the shoulder scar tissue to stretch or tear. This procedure released the stiffness and increases range of motion.
- Surgery – Shoulder arthroscopy for frozen shoulder is rare, however if more-conservative treatments and other procedures have not helped reduce symptoms, the physician may recommend surgery to relieve adhesions or scar tissues from the shoulder joint.
Regardless of the treatment approach taken, patients go through a rehabilitation program which includes physical therapy exercises that are crucial to restore range of motion. Each patient is unique, so the therapy program will vary based on his/her level of pain, extent of injury, and desired level of activity they would like to return to. Recovery after surgery can take anywhere from four to six months depending on the complexity of the procedure, but the individual’s commitment to following all the exercises prescribed by the physical therapist is the most important factor in returning to all the desired activities.
Glenohumeral Arthritis
There are two joints in the shoulder, both of which can be affected by arthritis. The acromioclavicular joint (AC joint) is located where the clavicle meets the tip of the scapula. The glenohumeral joint is located where the head of the humerus fits into the scapula. There are many forms of arthritis with five major types that typically affect the glenohumeral joint:
- Osteoarthritis – Osteoarthritis is the most common form of arthritis and occurs when the protective cartilage on the ends of your bones wears down over time. It’s often called a degenerative joint disease where the cartilage experiences a significant amount of wear and tear over a long period of time, generally occurring in individuals over the age of 50.
- Rheumatoid Arthritis (RA) – Rheumatoid arthritis is quite possibly the most serious form of arthritis as it is a major crippling disorder. Unlike osteoarthritis, rheumatoid arthritis affects the synovial membrane (lining of the joints), causing a painful swelling, resulting in joint deformity and bone erosion. Rheumatoid arthritis is three to four times more likely to occur in women and may affect various systems of the body such as eyes, heart, lungs, skin, and the nervous system.
- Post-Traumatic Arthritis – Traumatic arthritis is caused by a major or repeated trauma to the articular cartilage. This is most common among individuals who were/are athletic or active. Injuries to joints such as a fracture or dislocation can cause major damage to the articular cartilage, which leads to arthritic changes in the joint over time.
- Avascular Necrosis – Avascular necrosis occurs when the blood supply to the head of the humerus is limited or disrupted due to an injury such as a dislocation or fracture. It can also be a complication from some medications. The lack of blood can cause the bone to breakdown and damage the articular cartilage, resulting in arthritis. This can also occur spontaneously without an injury.
- Rotator Cuff Tear Arthopathy – Rotator cuff tear arthopathy is the development of arthritis as a result of a long-standing, large tear in the rotator cuff. When this occurs, the torn rotator cuff is no longer able to hold the head of the humerus in the glenoid socket, causing the ball to ride up, out of the socket. This can damage the surfaces of the bones and cause arthritis.
If shoulder pain persists and the non-operative treatments have been exhausted, the physician may recommend an operative approach. The exact procedure will vary based on the extent of damage and the cause of the pain.
- Shoulder Arthroplasty (Replacement) – When glenohumeral arthritis reaches the advanced stages, shoulder replacement surgery may become necessary. This procedure involves the removal of one (hemiarthroplasty) or both sides (total shoulder arthroplasty/ reverse total shoulder arthroplasty) of the glenohumeral joint and replacing them with man-made prosthetic implants, generally made of metal alloys, high-grade plastics and polymers. Not everyone is a candidate for this procedure, so it’s important to discuss options with the physician.
Recovery time after surgery depends on the complexity of the procedure, but the individual’s commitment to following all the exercises prescribed by the physical therapist is the most important factor in returning to all the desired activities.
Shoulder Replacement
There are two joints in the shoulder, both of which can be affected by arthritis. The acromioclavicular joint (AC joint) is located where the clavicle meets the tip of the scapula. The glenohumeral joint is located where the head of the humerus fits into the scapula. There are many forms of arthritis with five major types that typically affect the glenohumeral joint:
- Osteoarthritis – Osteoarthritis is the most common form of arthritis and occurs when the protective cartilage on the ends of your bones wears down over time. It’s often called a degenerative joint disease where the cartilage experiences a significant amount of wear and tear over a long period of time, generally occurring in individuals over the age of 50.
- Rheumatoid Arthritis (RA) – Rheumatoid arthritis is quite possibly the most serious form of arthritis as it is a major crippling disorder. Unlike osteoarthritis, rheumatoid arthritis affects the synovial membrane (lining of the joints), causing a painful swelling, resulting in joint deformity and bone erosion. Rheumatoid arthritis is three to four times more likely to occur in women and may affect various systems of the body such as eyes, heart, lungs, skin, and the nervous system.
- Post-Traumatic Arthritis – Traumatic arthritis is caused by a major or repeated trauma to the articular cartilage. This is most common among individuals who were/are athletic or active. Injuries to joints such as a fracture or dislocation can cause major damage to the articular cartilage, which leads to arthritic changes in the joint over time.
- Avascular Necrosis – Avascular necrosis occurs when the blood supply to the head of the humerus is limited or disrupted due to an injury such as a dislocation or fracture. It can also be a complication from some medication. The lack of blood can cause the bone to breakdown and damage the articular cartilage, resulting in arthritis. This can also occur spontaneously without an injury.
- Rotator Cuff Tear Arthopathy – Rotator cuff tear arthopathy is the development of arthritis as a result of a long-standing, large tear in the rotator cuff. When this occurs, the torn rotator cuff is no longer able to hold the head of the humerus in the glenoid socket, causing the ball to ride up, out of the socket. This can damage the surfaces of the bones and cause arthritis.
As with most arthritic conditions, the initial treatment will be more-conservative, non-operative treatment. If shoulder pain persists and the non-operative treatments have been exhausted, the physician may recommend an operative approach. Shoulder replacement surgery is extremely technical; therefore, the physician will evaluate the individual’s conditions and situation and provide recommendation for the best approach.
Total Shoulder Arthroplasty – Total shoulder arthroplasty, also known as total shoulder replacement, is performed when arthritis or degenerative shoulder joint disease makes the shoulder stiff and painful. Individuals with bone-on-bone arthritis are ideal candidates for this procedure. An incision is made in front of the arm. The tendons and muscles surrounding the shoulder joint are moved away to expose the glenoid and the humeral head and the shoulder is moved to provide easy access to the joint. The humeral head is then removed and the glenoid cavity is cleaned out in preparation for the replacement prosthesis. The hollow channel inside the humerus is prepared for the humeral stem to be inserted. The physician may then either use cement to secure the stem in the hollow channel or “press-fit” the stem into the channel. A carefully fitted ball is secured to the end of the stem and a plastic insert is attached to the glenoid cavity. The shoulder joint is then repositioned and all surrounding tissue is put back into place. The incision is closed and the procedure is completed.
Stemmed Hemiarthroplasty – Depending on the condition of the shoulder the physician may recommend a stemmed hemiarthroplasty, or partial shoulder replacement. For example, individuals who have severely fractured the head of the humerus, but have maintained a normal socket, are ideal candidates for this procedure. The surgical procedure is identical to that of a total shoulder replacement, however the glenoid cavity is left alone and the metal ball that is secured to the humeral stem is positioned into the normal glenoid cavity.
Resurfacing Hemiarthroplasty – Depending on the condition of the shoulder and the humerus, the physician may recommend a resurfacing hemiarthroplasty. Younger individuals who have no fresh fractures of the humeral head or neck and a normal glenoid cavity with healthy cartilage surface may be candidates for this procedure. A resurfacing hemiarthroplasty replaces just the joint surface of the humeral head with a cap-like man-made prosthesis. There is no need for a humeral stem in this procedure since there are no fractures. The advantage of this procedure is that it is a conservative way to preserve the original bone.
Reverse Total Shoulder Replacement – In some cases, the physician may recommend a reverse total shoulder replacement. Individuals who have completely torn their rotator cuff and have osteoarthritis and have severe arm weakness, patients with fractures, or those who have previously had a total shoulder replacement that has failed may be candidates for this procedure. In a reverse total shoulder replacement surgery, the socket and the metal ball are switched. The surgical process is identical to that of a total shoulder replacement, however, the socket is secured to the end of the humeral stem and a carefully fitted ball is placed in the glenoid cavity. In other words, the ball and socket joint becomes a socket and ball joint. This allows the individual to use their deltoid muscle instead of their rotator cuff to lift and rotate the arm.
There will be pain after a shoulder replacement surgery. However, the physician will provide the necessary medication for managing pain. Regardless of the treatment approach taken, patients go through a rehabilitation program which includes physical therapy exercises that are crucial to restore range of motion. Home care with respect to wound care, diet and exercise will be critical for the first few weeks following surgery. Each patient is unique, so the therapy program will vary based on his/her level of pain, extent of injury, and desired level of activity they would like to return to. Recovery time after surgery depends on the complexity of the procedure, but the individual’s commitment to following all the exercises prescribed by the physical therapist is the most important factor in returning to activities.
Acromioclavicular (AC) Joint Separation
The acromioclavicular joint, often referred to as the AC joint, is where the clavicle (collarbone) meets the highest point of the scapula (shoulder blade) which is called the acromion. There are ligaments, which are tough bands of tissue, which hold the clavicle and the scapula together and help stabilize the joint by restricting excessive movement. An AC separation, also known as a shoulder separation, is an injury to the ligaments holding your AC joint together. An AC separation is a common injury among athletes and active individuals participating in contact sports such as football and hockey, but can happen to anyone who falls and lands on the tip of their shoulder or elbow. AC separations are often confused with shoulder dislocations, which involve the separation of the glenohumeral joint as opposed to the AC joint.
If conservative treatments and other procedures have not helped reduce symptoms, the physician may recommend surgery to reduce pain or restore function and stability.
Distal Clavicle Resection – After an AC joint injury, some patients will develop damage to the cartilage in the AC joint causing continued pain. The physician may recommend a minimally-invasive arthroscopic procedure called distal clavicle resection or excision to help relieve pain and restore range of motion. Small incisions are made around the joint where surgical instruments and the scope, which is essentially a small camera, will go into these incisions and the image will be sent to a video monitor allowing the physician to see inside the joint. Using special surgical instruments, the physician will remove a small portion of the end of the clavicle, preventing the damaged, arthritic surfaces from rubbing against one another and causing pain. Sutures will be used to close the incisions and the arm will be placed inside a sling for five to seven days until the incisions have healed. VIDEO
AC Joint Reconstruction – If the diagnosed pain is a result of AC joint instability, the physician may recommend a reconstructive procedure to improve stability and restore function. An AC joint reconstruction involves repair of the torn or stretched ligaments so that they are better able to hold the AC joint in place. This procedure may utilize arthroscopy (a small camera to see inside the shoulder) to assist, but depending on the severity of the condition, some patients may require an open surgery which involves a larger incision over the shoulder to perform repairs. Following the surgery, the arm is kept in a sling for up to six weeks to facilitate healing.
Recovery after surgery can take anywhere from six weeks to three months depending on the complexity of the procedure, but the individual’s commitment to following all the instructions and guidelines given by the physician and the exercises prescribed by the physical therapist is an important factor in returning to all the desired activities.
Labral Tears
The glenoid is a shallow and flat part of the scapula and makes up the socket of the shoulder. The labrum is essentially a rim of soft tissue, much like a gasket, that turns the flat surface into a deeper socket that molds to fit the head of the humerus. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles originate from the scapula and insert onto the humerus and are responsible for both movement and dynamic stability of the shoulder joint. The rotator cuff helps raise and rotate the arm and as the arm is raised and keeps the humerus seated tightly in the glenoid fossa. The labrum may start to tear if there is excessive movement within the joint, causing the humerus to rub against the labrum, or with trauma. The labrum may also become damaged over time. Tears of the labrum are fairly common. While some tears are completely asymptomatic and cause no problems for the patient, others can cause pain, catching sensations, or a sense of shoulder instability. The bicep tendon actually inserts directly to the top of the labrum as well. There are some situations where the bicep tendon may be causing pain related to the labral tear.
If more-conservative treatments have not helped reduce symptoms, the physician may recommend surgery to reduce pain and avoid further damage to the joint and surrounding tissues and muscles. The exact procedure will depend on the nature and location of the labral tear:
Debridement – In most cases of labral tears, if the tear is small and is mostly getting caught as the shoulder moves, simply removing the frayed edges and any loose parts floating in the shoulder may get rid of the symptoms. This “cleaning out” process is called debridement and is typically done arthroscopically where small incisions are made around the joint. Surgical instruments and the arthroscope, which is essentially a small camera, will go into these incisions and the image will be sent to a video monitor allowing the physician to see inside the joint. Using special surgical instruments, the physician my remove the loose parts that are causing pain and inflammation. Sutures will be used to close the incisions and the arm will be placed inside a sling for five to seven days until the incisions have healed.
Bankart Repair – When the shoulder capsule is stretched or torn or the labrum detaches itself from the glenoid, shoulder dislocation or instability can cause severe pain and discomfort. When this happens, a pocket forms at the front of the glenoid allowing the humeral head to move and dislocate into the pocket. When the shoulder dislocates, the front, or anterior, portion of the labrum is often torn; this is called a Bankart lesion or tear and is the most common form of labral injury to the shoulder. A Bankart repair is a minimally-invasive arthroscopic surgery where small incisions are made around the joint where surgical instruments and the arthroscope, which is essentially a small camera, will go into these incisions and the image will be sent to a video monitor allowing the physician to see inside the joint. Using surgical instruments inserted into the joint, the physician will reattach the labrum to the glenoid using sutures and anchor-like devices. Often, a Bankart lesion is associated with tears to the shoulder capsule surrounding the joint and is typically located in the same area as the detached labrum. Therefore, the physician will also make any necessary repairs to the capsule using sutures. Once the labrum is attached and all necessary repairs are made, the incisions are closed and the procedure is complete. The arm may be placed inside a sling for five to seven days until the incisions have healed. The surgery is followed by a period of immobilization and a course of physical therapy (usually 3 months) to restore function without causing recurrent instability or stretching out the repair. VIDEO
SLAP Lesion Repair – Individuals who participate in overhead sports such as weightlifting can experience labral tears as a result of repeated shoulder motion. In individuals over the age of 40, however, tearing of the superior (top) labrum can be seen as part of the normal aging process. In a superior labrum anterior and posterior (SLAP) injury, the superior (top) part of the labrum where bicep tendon attaches to the labrum is injured. SLAP lesions or tears occur in the front as well as the back of this point of attachment; therefore it is possible for some damage to the bicep tendons to occur. There are several types of SLAP tears, therefore the physician will determine the best way to repair the injury once he or she enters the joint arthroscopically Using surgical instruments inserted into the joint, the physician may elect to reattach the labrum to the glenoid using sutures and anchor-like devices. Alternatively, the bicep tendon may be detached from the superior labrum where it is pulling at torn tissue and causing pain. The bicep tendon may remain detached or may be reattached in an area that will not cause pain, depending on the patient. Once all necessary repairs are made, the incisions are closed and the procedure is complete. The arm may be placed inside a sling for five to seven days until the incisions have healed, followed by a period of immobilization and a course of physical therapy. VIDEO
Recovery after surgery can take anywhere from six weeks to six months depending on the complexity of the procedure, but the individual’s commitment to following all the restrictions set forth by the surgeon and the exercises prescribed by the physical therapist is the most important factor in returning to all the desired activities.
Multidirectional Instability
Atraumatic shoulder instability, also called multidirectional instability is often described as general laxity, or looseness of the shoulder’s glenohumeral joint in multiple directions which causes symptoms. Ligaments, which are tough bands of tissues within the capsule that hold bones together, provide support and stability to the bones by restricting excessive motion. However, some individuals have increased looseness in the ligaments surrounding the glenohumeral joint. This laxity can be a natural condition that is present since birth or be a condition that has developed over time.
If conservative treatments have not helped reduce symptoms, the physician may recommend surgery to reduce pain and restore stability and function of the shoulder. Depending on the severity of the instability, the physician may recommend a minimally-invasive arthroscopic procedure called a capsular shift. Small incisions are made around the joint where surgical instruments and the arthroscope, which is essentially a small camera, will go into these incisions and the image will be sent to a video monitor allowing the physician to see inside the joint. Due to shoulder instability, the capsule that helps hold the humeral head in the glenoid may have been stretched, so the physician will fold the excess tissue and suture them together in order to tighten the capsule. Sutures will be used to close the incisions and the arm will be placed inside a sling for five to seven days until the incisions have healed. This will be followed by a course of physical therapy. VIDEO
Recovery after surgery typically takes at least six months depending on the complexity of the procedure, but the individual’s commitment to following their physician’s instructions and all the exercises prescribed by the physical therapist is the most important factor in returning to activities.
Rotator Cuff Impingement
The rotator cuff is a group of four muscles and their tendons that originate on various parts of the scapula (shoulder blade) and insert onto the humerus. The rotator cuff muscles work together to provide movement, rotation, and stability to the shoulder. One of the most commonly injured rotator cuff muscles is the supraspinatus, which runs over the top of the shoulder, just underneath the lateral-most projection of the scapula, called the acromion. Over time, bone spurs can form underneath the acromion, causing the rotator cuff to become frayed and damaged, or impinge. In some cases, the rotator cuff partially or completely tears, causing pain and loss of motion and strength. This can be likened to a rope become frayed over time as it rubs against a hard, jagged surface.
When one or more of the rotator cuff tendons is torn, it no longer attaches to the head of the humerus completely. In most cases, torn rotator cuff tendons begin by fraying and as the damage progresses, the tendon can completely tear.
There are two different types of tears:
Partially Torn Rotator Cuff – This type of problem denotes that there has been some damage to the rotator cuff, such as fraying or partial tears inside of the tendon, but that the tendon has not completely torn off from its attachment to the humerus. VIDEO
Completely Torn Rotator Cuff –This type of tear is a full-thickness tear where the tendon has completely torn off from the humerus. VIDEO
In cases where there is obvious impingement, but no major tears, a subacromial decompression might be a viable option in order create more space in the suacromial area and reduce the pressure on the muscle. VIDEO
Recovery after surgery can take anywhere from two to nine months depending on the complexity of the procedure, but the individual’s commitment to following all the restrictions set forth by the surgeon and the exercises prescribed by the physical therapist is the most important factor in returning to all the desired activities.