Complete Care for Your Shoulders
The shoulder is one of the most mobile joints in the body. Also, the strength of the muscles surrounding the shoulder is very important in most recreational activities. We treat the following injuries and conditions:
Rotator Cuff Tears & Conditions
When the rotator cuff tendon tissue gets pinched between the humerus and the acromion bone above, this is called impingement. This can lead to tendinitis and bursitis. These are collectively known as impingement syndrome. Usually this causes pain over the shoulder and upper arm with reaching. Most of these can be improved gradually with rehab (which leads to better centering of the humerus and the shoulder socket which in turn reduces the pinching). Left untreated this can deteriorate into partial and even full rotator cuff tears
Complete (full-thickness) Tears
Tears can occur from one sudden acute injury or with accumulation of damage from chronic impingement or repeated overload. Treatment depends on the age of the patient and the size of the tear along with other factors. One concern for more active and younger patients (which can be very broad in the world of rotator cuff injuries!), is the concern of worsening of the tear over time. Some studies have shown as high as a 75% rate of tear worsening for active patients who have been treated non-surgically. However, it must also be noted that tears can be found in patients who have never had any shoulder symptoms. For those that to get satisfactory results with a rehab program, the tear can be monitored to be sure there is no tear progression. For those who do not improve with rehab or who have a high likelihood of tear worsening, surgical repair is recommended. The vast majority of tears can be repaired arthroscopically. After repair, the rehabilitation can take a few months but the overall satisfaction rate and return to activity is very high.
Tears that do not go fully through the tendon tissue are partial tears. Most often initial treatment is nonsurgical unless the partial tear is large and nearly full-thickness. Some of these may require surveillance to be sure they do not deteriorate into full-thickness tears.
Tears larger than an inch or so or that involve more than two of the four rotator cuff tendons are considered massive tears. Treatment of these still depends significantly on how they affect the patient’s activity and pain level. Surprisingly, some patients can still reach a satisfactory activity level without surgery. For others, repair may need to be considered. In some cases, the tear can become so large that repair is not an option as it will not allow the patient to regain satisfactory function. Repairability can be estimated but not guaranteed by MRI criteria:
- Atrophy: how much the muscle tissue has shrunk down
- Retraction: how far the rotator cuff tendon tissue is pulled away from its attachment to the humerus
- Superior migration: how much has the rotator cuff lost its ability to keep the humerus centered in the socket.
Sometimes the actual repair ability cannot be determined until the time of surgery and after its associated rehab. There are ways to augment the repair in surgery including biologic patches and use of growth factors and cells. Fortunately, there are even good options when there is no potential for repair. These include reverse shoulder replacement and superior capsule reconstruction.
Proximal Biceps Injuries
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.
AC Joint Injuries
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.
Frozen Shoulder (Adhesive Capsulitis)
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.
Other Areas of Shoulder Treatment
- Pectoralis Rupture
- Suprascapular Nerve Injuries
- Perilabral cysts