Shoulder Care

The biceps long head tendon enters the shoulder joint through a groove that runs between two of the rotator cuff tendons and then attaches to the labrum at the top of the shoulder socket.  This tendon can develop significant fraying and inflammation and is commonly seen in conjunction with tears of the rotator cuff.  A tear in the subscapularis portion of the rotator cuff will allow the biceps to come out of its groove which creates fraying and tearing similar to a rope coming off of a pulley.  Much like rotator cuff issues, biceps may be initially treated non-surgically.  Precise injections can be useful in treating the biceps.  Surgically, the biceps can be attached to the humerus which is called a tenodesis.

Shoulder dislocations are when the humeral head comes out of the socket.  Most often this causes a tear of the labrum which is the cartilage rim around the edge of the socket.  These injuries can come from a single traumatic event or can come from general looseness of the tissues around the joint (laxity).  Subluxations refer to the ball only partially coming out of the socket.  These are also commonly associated with a tear of the labrum.

For subluxations and small labral tears, the usual initial treatment is a dynamic stability program in physical therapy.  When the rotator cuff and scapular muscles are working optimally, the humeral head stays better centered within the socket and is less likely to load the labrum.

For full dislocations, especially those that occur in young athletes involved in contact sports, recurring or repeated dislocations become a major concern.  For that reason, surgery is often recommended.  Most of these can be treated with an arthroscopic labral repair.  The capsule can also be tightened during this procedure.  The amount of this tightening depends on many factors and is very specific to the individual patient.

For severe dislocations where some of the bony socket rim is broken (bony Bankart lesion) an open surgery such as a Latarjet procedure may be needed.  Here, some nearby bone from the coracoid is used to rebuild part of the socket.  The bone on the back of the humeral head can also be broken with a dislocation which is called a Hill Sachs lesion.  This can be treated with an arthroscopic procedure called remplissage.

Very loose shoulders without a traumatic injury are called multidirectional instability (MDI).  These are usually treated with extensive rehab.  In very persistent cases, the capsule can be surgically tightened for these patients as well.

These are commonly known as AC separations.  There are several grades of these (1 through 5).  Most of these are grade 1 or 2 and are treated non-surgically.  Once the symptoms are reduced and patients have good strength, they can go back to sports as tolerated.  More severe separations (grades 3 through 5) may require surgical stabilization.  The recovery and rehabilitation after this can take several months.

Years later, some of the milder AC joint injuries can go on to develop AC joint arthritis.  This can cause a painful bump on the top of the shoulder.  This can be treated non-surgically by reducing the inflammation and possibly an injection.  If persistently painful, an arthroscopic distal clavicle excision can be performed.

This condition is caused by shoulder joint inflammation which leads to scarring and thickening of the capsule.  This can occur spontaneously (idiopathic and more common in females) or can occur secondary to other issues like rotator cuff injuries.  It is more common among diabetic patients as well as other conditions such as hypothyroidism or Dupuytren’s disease.

Most often, this can be treated without surgery but a full recovery can be very slow.  One thing that is very clear is that the inflammation must be controlled in order for therapy to be successful.  For persistent cases (more likely in diabetic shoulders), an arthroscopic capsule release is usually very successful.

Arthritis of the glenohumeral joint (ball and socket) can cause severe loss of motion and pain. There are number of types of arthritis (osteoarthritis, posttraumatic arthritis, rheumatoid arthritis to name a few).  Mild and moderate cases are treated with mobility exercises and anti-inflammatories.  The mobility of the shoulder blade can allow remarkable compensation for the lack of motion at the true shoulder joint.

Severe or persistent cases can be treated with shoulder replacement or resurfacing.  For younger patients with significant arthritis and an intact rotator cuff, shoulder resurfacing is a good option.  Here, most of the humeral head is preserved and essentially a cap is placed on it while the socket also gets a new surface.

For severe arthritis where the rotator cuff is either very thin and unreliable or is irreparably torn, a reverse replacement is recommended. Here the ball and socket are switched so that now the socket is at the top of the humerus.  Why would this help?  The answer goes back to the primary function of the rotator cuff which is to keep the ball centered in the socket while the larger muscles move the arm in space.  When the rotator cuff is unable to do this long-term, a good solution is to switch the ball and socket.  This allows the socket, which is now at the top of the humerus, to rotate around the ball which is now fixed to the scapula.  This procedure restores stability and leverage to the shoulder.  The implants used for the shoulder continue to improve and are becoming less and less invasive.  The rehabilitation process is still considerable but, in most cases, there is minimal time where the arm is immobilized.

• Pectoralis Rupture
• Suprascapular Nerve Injuries
• Perilabral cysts