Shoulder

Rotator cuff tear
One of the most important components of the shoulder, the rotator cuff is comprised of a group of muscles and tendons that hold the shoulder joint in place. The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint. A tear in the rotator cuff is a common cause of pain and disability among adults and often requires significant time for rehabilitation.

Cause:
A rotator cuff tear commonly occurs in people over the age of 50, as well as among younger people following acute trauma or repetitive overhead work or sports activity. Another injury to the shoulder, such as a fracture or dislocation, may cause in a tear.

Prevention:
Before vigorous activity, take time to condition the shoulder to strengthen it and avoid inflammation. Use lower resistance and higher repetitions to strengthen the small muscles of the rotator cuff. Avoid undertaking any sports activities or gardening without properly warming up. While this is “good advice,” it may not prevent a rotator cuff tear from happening.

Excessive strain on the rotator cuff, swelling and soreness can result from overhead movement or reaching behind the back. The act of throwing is the most stressful motion on the shoulder.

Treatment:
Often non-surgical treatment can relieve pain and improve the shoulder’s function. In those instances, we may recommend rest and limited overhead activity, use of a sling, anti-inflammatory medication, steroid injection, strengthening exercise and/or physical therapy. Depending on the extent of the injury, strength and mobility may take several weeks or months to restore.

If these options don’t relieve the symptoms, surgery may be recommended. Surgery may also be the best option if any of these conditions are present: the tear is acute and painful, it is the dominant arm of an active individual, or need maximum arm strength is needed for overhead work or sports.

In determining the best type of surgery, the orthopedist will consider the size, shape and location of the tear. Many surgical repairs can be done on an outpatient basis. More complex procedures will require hospitalization.

Shoulder instability (dislocation)
When a shoulder dislocates, there is shoulder instability. Symptoms to look for include swelling, numbness, weakness and bruising. Sometimes dislocation may tear ligaments or tendons in the shoulder.

Cause:
A traumatic injury can dislocate the shoulder. Sometimes, it is the end result of a severe shoulder sprain; it can also result from a congenital abnormality.

The most common type of shoulder dislocation is when the shoulder slips forward. This means the upper arm bone moved forward and down, out of its joint. It may happen when the arm is put in a throwing position. The shoulder joint can dislocate forward, backward, or downward.

Prevention:
Warm up adequately prior to any physical activity, practice or competition. Athletes should participate in a strength and flexibility program appropriate for the sport, especially prior to throwing. For repetitive instability rotator cuff and scapular muscle strengthening is important.

Treatment:
A doctor will place the ball of the upper arm bone back into the joint socket, which is called closed reduction. Once the shoulder joint is back in place, the severe pain is relieved. Then rest is needed.

An orthopedist may prescribe a sling or other device to immobilize the shoulder for several weeks following treatment after the first episode; lesser time for subsequent times. The sore area should be iced 3-4 times a day. Once the pain and swelling decrease, rehabilitation exercises can be started to help restore the shoulder's range of motion and strengthen its muscles. Rehab may also help prevent dislocating the shoulder again. Initially, the emphasis is on gentle muscle toning exercises with weights added as strength is developed and following physician's instructions.

Shoulder arthritis
Pain and stiffness that progressively worsens and is aggravated by activity may indicate arthritis of the shoulder, this is confirmed with appropriate X-rays. Depending on the joint that is affected, pain may be centered in the back of the shoulder and may intensify with changes in the weather or it may be focused on the front of the shoulder. Limited motion may occur, making it more difficult to comb hair or reach up to a shelf. Sometimes, the shoulder makes a grinding sound when it is moved. As the disease progresses, any movement of the shoulder causes pain. Night pain is common and sleeping may be difficult.

Although shoulder arthritis is much less common than hip or knee arthritis, three major types of arthritis generally affect the shoulder.

• Osteoarthritis, a degenerative condition that destroys the smooth outer covering (articular cartilage) of bone, usually affects people over 50 years of age. It is more common in the AC joint than in the glenohumeral shoulder joint.

• Rheumatoid arthritis, a systemic inflammatory condition of the joint lining, usually affects multiple joints on both sides of the body.

• Posttraumatic arthritis, a form of osteoarthritis, develops after an injury such as a fracture or dislocation of the shoulder. Arthritis can also develop after a rotator cuff tear.

Treatment:
Initial treatment of arthritis of the shoulder includes resting the shoulder, taking nonsteroidal anti-inflammatory medications such as aspirin or ibuprofen to reduce inflammation, icing the shoulder for 20 to 30 minutes two or three times a day, and taking glucosamine and chondroitin sulfate. If the diagnosis is rheumatoid arthritis, a disease-modifying drug such as methotrexate may be prescribed by a rheumatologist.

If conservative treatment does not reduce pain, there are surgical options.

Impingement AC arthritis, bursitis
Cause:
The most common causes of pain in the adult shoulder, we call shoulder impingement syndrome. It results from the long roof of the shoulder putting pressure on the rotator cuff tendons as the arm is lifted. When the front edge of the shoulder blade rubs or impinges on the surface of the rotator cuff, movement is limited and the shoulder is painful. The pain may be due to an inflammation of the bursa that overlies the rotator cuff. In some circumstances, a partial tear of the rotator cuff may cause impingement pain.

Prevention:
Both young athletes and middle-aged people experience impingement. Young athletes who use their arms overhead for swimming, baseball and tennis are particularly vulnerable. Those who do repetitive lifting or overhead activities using the arm such as paper hanging, construction or painting are also susceptible. Pain may also develop as the result of minor trauma or spontaneously with no apparent cause.

Treatment:
Resting, avoiding overhead activities, and a course of oral non-steroidal anti-inflammatory medication are often the first steps. Stretching exercises can improve range of motion. An injection of local anesthetic and a cortisone preparation to the affected area may help. An orthopedist might also recommend a program of supervised physical therapy. Treatment may take several weeks to months. Many patients experience a gradual improvement and return to function.

If function does not improve, surgery may be indicated. Surgery will remove the impinging structures, creating more space for the rotator cuff. The most common surgical treatment is subacromial decompression.

Fracture proximal humerus, clavicle, AC separation
Cause:
Fractures of the humerus, scapula and clavicle usually result from a direct blow or a fall onto an outstretched hand.

Treatment:
Most are not treated with surgery. Treatment usually consists of a sling for comfort. Range of motion exercises are begun as soon as acute pain resolves, usually within two weeks. Early mobilization is important to avoid loss of range of motion, possibly leading to frozen shoulder.

Surgery can be done to stabilize the bone with plates and screws. AC joint separations are initially treated without surgery emphasizing an exercise program. Repair is possible later, if pain and loss of function persist.

Arthroscopy
Arthroscopy allows the orthopedic surgeon to insert a pencil-thin device into tiny incisions to look inside the joint. The images inside the joint are relayed to a TV monitor, allowing the doctor to make a diagnosis. Other surgical instruments can be inserted to make repairs. Arthroscopy often can be done on an outpatient basis.

The mini-open surgical method involves both the use of an arthroscope and a short incision to access the torn tendon. By using the arthroscope, the surgeon can also look into the shoulder joint and clean out any damaged tissue or bone spurs.

Shoulder replacement
There are several different types of shoulder replacements. The usual total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem and a plastic socket. The components come in various sizes. Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement. Depending on the condition of the shoulder, a surgeon may replace only the ball. Sometimes, this decision is made at the time of the surgery.

Recovery and rehabilitation is related to the type of surgery performed inside the shoulder, rather than whether there was an arthroscopic or open surgical procedure.