THE SHOULDER. Shoulder Pain. Fractures. Instability and Dislocations of the Shoulder

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1 THE SHOULDER Shoulder Pain 1. Fractures 2. Sports injuries 3. Instability/Dislocations 4. Rotator Cuff Disease and Tears 5. Arthritis Fractures The shoulder is made up of three primary bones, the clavicle, the humerus and the scapula. They are hooked together by numerous ligaments and function by muscles and tendons working in unison to maintain a range of motion and stability. Injury to any of these structures, the clavicle, the humerus, and the scapula can be produced by direct trauma or indirect trauma such as a twisting injury. Fractures can be produced through the bones that are not only painful, but can be functionally disabling. Fractures about the shoulder can be treated in numerous ways depending upon the fracture type, the associated injuries, and the bone quality and general health of the injured patient. Some fractures only require simple immobilization with sling or straps. Other fractures require pin or plate fixation. Or more complex fractures may require arthroplasty techniques that replace the articular surface of the fractured bones. All of these require the skills and decision making of physicians who are experienced in the care of shoulders. At The Orthopaedic Center, TOC, we offer those services through our excellent trauma service as well as the physicians who specialize in care of shoulder problems. Instability and Dislocations of the Shoulder The stability of the shoulder depends on the joint capsule and muscles about the shoulder. Most of the common dislocations that occur are usually anterior where the humeral head goes out the front of the shoulder. Usually with the arm turned out and up as in the throwing motion. Less frequently is posterior dislocation, where the head of the humerus going out the back of the shoulder. Usually this is secondary to some type of major trauma but sometimes it can also be related to seizures or electrical shocks. Another form of instability is simply subluxation. This is where the humeral head does not come completely out of the joint but rather slides around loosely in the joint because the ligaments are loose and lax. Treatment for shoulder instability varies according to the patient and type of dislocation.

2 The first time you dislocate your shoulder anteriorly usually it is simply reduced and held into a sling immobilization for a period of time. This is followed by a rehabilitation program, and usually in the older patient this results in a very stable shoulder. About 50% of the time in the younger patient recurrent instability may follow, and may require surgery. If instability does follow or you have a recurrent dislocation or subluxation of the shoulder, most often surgical stabilization of the shoulder is recommended. This is usually done arthroscopically, a small telescope is inserted into the shoulder, and specialized sewing techniques are used to repair the torn or displaced capsules and ligaments that cause the instability. This is usually done as an outpatient or with an overnight stay. Occasionally it may require an open procedure in certain patients because of their body habitus, but most often it can be done arthroscopically. After a period of immobilization postoperatively, an extensive period of rehabilitation is instituted, and the shoulder is rehabilitated to its near original function level. And at that point usually most patients can return back to all activities they had preoperatively, before dislocations occurred. If you have questions about shoulder instability and would like to discuss it with one of the experienced shoulder surgeon, please contact us at The Orthopaedic Center, Dr. Fambrough s Shoulder Clinic. Sports Injuries The shoulder is highly susceptible to injury in sports with direct contact. Injury can result in contusions and stretches of the muscles and ligaments about the shoulder. It can result in dislocation or subluxation of the shoulder. (See Instabilities of the Shoulder) You can also stretch nerves such as stinger injury injury in football. Severe contact injuries can result in fractures or a combination of the above. Treatment of sports injuries usually entails caring for the acute injury either with immobilization or surgery. It is usually followed by a period of rehabilitation designed to get the athlete back into the full participation of his sport as soon as it is safe. An experienced shoulder surgeon such as Dr. Fambrough at The Orthopaedic Center can guide you through the recovery and help you return to the sport as rapidly as healing will allow. If you need to discuss your shoulder problems with an experienced shoulder surgeon at The Orthopaedic Center please call and make an appointment with us.

3 ROTATOR CUFF DISEASE / TERMS Overview of Rotator Cuff Surgery at The Orthopaedic Center Shoulder weakness from rotator cuff tears can be restored by surgery when the quality of the tendon is sufficient. The rotator cuff is a group of four tendons that blend together to help stabilize and move the shoulder. Each of these four tendons connects to a muscle originating on the shoulder blade or scapula to the upper part of the arm bone or the humerus. The names of these muscle tendon components of the rotator cuff are the supraspinatus which runs over the top of the ball of the shoulder joint, the subscapularis, which runs across the front of the humeral head and the infraspinatus and the teres minor, which runs across the back of the humeral head. Please refer to shoulder anatomy under the Swarm interactive anatomy segment at this point. This demonstrates the main elements of the rotator cuff and their functions. The biceps tendon runs between the subscapularis and the supraspinatus. Tears in the rotator cuff result from a combination of injury and weakening of the tendon from wear and tear, disuse, repeated use of steroids (cortisone) injections, and smoking. The extent of injury necessary to tear a rotator cuff depends on the quality of the tendon. Young healthy rotator cuff tendon is almost impossible to tear. However, in the older multiple injured, multiple injected tendon and a smoker may tear with no injury at all. Tears in the younger individuals are more likely to extend only partway through the tendons, what we call partial thickness tears. Tears in the older individuals are more likely to tear completely through the tendons or full thickness tears and into multiple tendons. The mechanism of injury most likely to cause tears in the rotator cuff are those in which the arm is elevated and forced downward, or when the shoulder attempts a sudden jerky lifting motion. Full thickness tears do not heal by themselves because the muscles pull the edges of the tear apart. However, it is possible for a full or partial thickness tear to stabilize, leaving the shoulder with reasonable comfort and function. A surgeon experienced in shoulder surgery can repair a rotator cuff if there are enough good quality tendons available. The more force necessary to produce a tear the more likely it is that the tear will be surgically repairable. Healthy tendons require a major force to tear it. Tears resulting from a major injury can usually be repaired successfully if surgery is not delayed more than several weeks. Weakened degenerative cuff tissue is more easily torn, even by normal activities. Doable repair of these tears my not be possible because of the lack of sufficient quality and quantity of tendon tissue. For these reasons patients should seek prompt evaluation of shoulder weakness by an experienced shoulder surgeon, especially if that weakness comes on suddenly or after injury. To schedule an appointment call (256) and ask for Dr. Fambrough s Shoulder Clinic.

4 ROTATOR CUFF TEARS OF THE SHOULDER Rotator cuff tears are common cause of shoulder weakness and pain that can often be improved by expert shoulder surgery. The symptoms of rotator cuff tears are usually noticeable weakness, pain, and loss of the ability to use the shoulder for every day activities. Commonly you have difficulty sleeping on the affected shoulder and have limited range of motion, will notice a catching or grinding feeling in the shoulder when the shoulder is moved. The rotator cuff tears usually get worse over time, but this rate of progression of the tears varies greatly from patient to patient. Types of tears of the rotator cuff Rotator cuff tears may involve the entire thickness of the rotator cuff described as full thickness tears or they may be incomplete or partial thickness tears. Full thickness tears may involve only one tendon, usually the supraspinatus. They may extend or become massive involving multiple tendons as well. See Swarm interactive for rotator cuff tears Rotator cuff tears may be degenerative as it may occur in poor quality tissue, or it may be traumatic as it arises from a major injury. Cuff tear arthropathy refers to the combination of a massive cuff tear and arthritis of the shoulder. Similar Conditions Rotator cuff disease must be distinguished from shoulder arthritis, arthritis of the acromioclavicular joint, subacromial bursitis, frozen shoulder, and neck arthritis, each of which may produce similar symptoms. Shoulder arthritis usually causes pain and limited shoulder motion. X-rays confirm the presence of the arthritis. Arthritis of the acromioclavicular joint usually produces pain localized on the top of the shoulder that can be made worse by using the arm in front of the body or across the chest. Shoulder strength is usually normal. Subacromial bursitis may cause catching and pain in the shoulder but shoulder strength is maintained. Frozen shoulder is characterized by shoulder stiffness but the shoulder is usually strong. Neck arthritis with nerve impingement may cause shoulder pain and weakness that is worse when the head is held in certain positions. In this case electromyography may identify the presence of nerve involvement in the neck. Some have used the term impingement syndrome to refer to various types of cuff disease. Modern diagnostic approaches usually permit a very specific diagnosis for shoulder pain. The Incidence of Rotator Cuff and Risk Factors Conditions of the rotator cuff are the most common cause of problems of the shoulder. They are more likely to be found in people over the age of 40, smokers, and individuals who have had multiple steroid injections. People over the age of 40 who dislocate their shoulders are likely to have a rotator cuff tear. Those who have cuff tears in one shoulder are likely to have a similar problem in the opposite shoulder. Diagnosis A physician diagnosis rotator cuff disease by reviewing the patient s history, performing a very thorough physical examination of the joint, and taking proper x-rays, and obtaining confirmatory imaging studies such as an MRI scan. The examination of the shoulder with cuff disease reveals weakness or pain on exertion of the shoulder against resistance. Sometime the shoulder is stiff or noisy on movement.

5 X-rays of the shoulder are usually normal in the presence of rotator cuff disease. They are usually taken to exclude other problems. Sometimes spurs can be seen in the acromioclavicular joint, or under the acromion. Also the shape of the acromion can be abnormal and seen on plain x-rays. Rotator cuff tendons do not show on ordinary x-ray examination of the shoulder. An MRI scan, shows not only the bony structure of the shoulder, but also shows the rotator cuff tendons, the surrounding nerves, fluid accumulation, other related structures about the shoulder including the glenoid labrum, and the quality of the muscle and tendon that is affected by the disease. Medication Treatment for rotator cuff disease includes 1. Medications. Medications cannot help a torn tendon heal. However, mild pain relieving medications may make the shoulder with the rotator cuff tears more comfortable. Cortisone injections into the shoulder may lessen the discomfort of the rotator cuff problems but may also weaken the tendon tissue. Multiple injections of steroids are discouraged for this reason. Sometimes a single injection into the shoulder will assist with the diagnosis of rotator cuff disease. 2. Exercises. While prompt surgery is usually recommended for acute cuff tears in the general healthy shoulder, exercises may be helpful in maintaining the flexibility and the strength of the joint with long standing tears. In most cases these exercises can be done by the patient at home with very little equipment. Shoulder exercises are best performed gently several times a day on an on-going basis. The exercises are not dangerous if they are performed gently so that they do not risk enlarging the tear. Your shoulder surgeon can help you understand the exercises needed to maintain the range of motion that can be done at home in a gentle fashion so that it does not entail pain to the patient. Sometimes a physical therapist is needed for more difficult problems, but usually the patients are able to do their own exercises very effectively. Benefits of the Surgical Repair When combined with a good rehabilitation effort, rotator cuff surgery allows people to regain much of their lost comfort and function in the shoulder with cuff disease. In experienced hands, this procedure can address the restricting scar tissue and roughness that frequently accompany rotator cuff disease. If the quantity and the quality of the tissue is good surgery can help repair the tendon back to the bone from which it was torn. This is most likely to succeed soon after a cuff tear in the otherwise healthy shoulder of a non-smoker who has not had multiple cortisone injections. Rotator cuff surgery can improve the mechanics of the shoulder, but cannot make the joint as well as it was before the cuff tear. In many cases the tendons and muscles around the shoulder have been weakened or from prolonged disuse before the surgery. The tissue may be insufficient for a strong repair. In such cases carefully smoothing out the cuff area and removing the offending scar tissue and spurs, and moving the shoulder immediately after the surgery so that new scars are not formed may improve the mechanics of the shoulder. If the cuff is repaired, it takes months before the tendon is strong enough to heal to the bone. During this time strengthening exercises should be avoided so that the healing is not impaired. After the healing, it may take more months of gentle exercises before the shoulder achieves maximum improvement. The effectiveness of the procedure depends on the health and motivation of the patient, the condition of the shoulder, and the expertise of the surgeon. When performed by an experienced surgeon, rotator cuff surgery usually leads to improved shoulder comfort and function. The greatest improvements are in the ability of the patient to sleep, perform activities of daily living, and engage in non-contact recreational activities.

6 Rotator cuff surgery at The Orthopaedic Center If you are interested in discussing rotator cuff surgery with an experienced shoulder surgeon, please call The Orthopaedic Center at (256) Ask for Dr. Fambrough s Shoulder Clinic. Considering Rotator Cuff Surgery Rotator cuff surgery can optimize the comfort and function of shoulders with rotator cuff tears. Types of Surgery Recommended When healthy tendons in the rotator cuff have been torn it is often possible to perform rotator cuff repair. The surgery is usually done totally arthroscopically; through small puncture wound incisions. The goal is to perform a strong repair of the diseased and ruptured tendon back to bony surface of the humeral head. A procedure known as an acromioplasty has been advocated for the treatment of rotator cuff disease as well, since frequently there are bone spurs under the acromion that irritate the rotator cuff. Timing of Rotator Cuff Surgery Before cuff surgery is undertaken the patient needs to (1) be in optimal health (2) understand and accept the risk and alternatives of surgery and (3) understand the postoperative rehabilitation program that will be required. In cases of chronic rotator cuff tears, the surgery can be performed when conditions are optimal. Sometimes the pain and stiffness from the rotator cuff will need to be mobilized, before surgery is accomplished. In cases of acute rotator cuff tears in otherwise healthy tissue, the best chance of achieving an excellent result is surgical repair within the first month after the tear. Rotator cuff surgery is not an emergency. If possible acute rotator cuff tears should be considered for repair within the first month after the injury. Rotator cuff surgery in chronic repairs is an elective procedure that can be scheduled when circumstances are optimal. In both instances, the patient has time to become informed about the disease, and select an experienced shoulder surgeon. Surgical Options The goal of surgery is to repair the tendon of the rotator cuff back to the bony portions of the humeral head, in a fashion so that it passes smoothly underneath the coracoacromial arch. See repair of rotator cuff under Swarm technology. Our method of repair of rotator cuffs, at The Orthopaedic Center, is arthroscopic by Dr. Fambrough, an experienced shoulder surgeon. This method has many advantages and by selecting an experienced shoulder surgeon, these can be discussed in detail with Dr. Fambrough. Effectiveness In the hands of an experienced shoulder surgeon, rotator cuff surgery can be effective to restore comfort and function of the shoulder of a well-motivated patient. Often the greatest benefits are the improvability to sleep on the effective shoulder and to perform usual activities of daily living. As long as the shoulder is cared for properly and subsequent injuries are avoided the benefit can last for decades. However, it is important to recognize that surgery cannot improve the basic quality of the tendon tissue. Thus recurrent tears often follow repair of poor quality tendon.

7 Risk The risk of rotator cuff surgery includes, but are not limited to, the following: Infection Injuries to nerves and blood vessels Irreparability of the rotator cuff tendon Stiffness of the joint Re-tear of the repaired rotator cuff Continued pain Need for additional surgeries There are also risks associated with anesthesia. An experienced shoulder team such as at The Orthopaedic Center will use special techniques to minimize these risks but cannot eliminate them completely. Managing Risk Many of the risks of rotator cuff surgery can be managed effectively if they are properly identified and treated. Infections may require a wash out in the operating room and subsequent antibiotic treatment. Blood vessels or nerve injury may require repair. Stiffness may require exercises or additional surgery. Re-tear of the repaired rotator cuff may require consideration of additional surgery. If the patients have questions or concerns about the course after surgery the surgeon should be informed as soon as possible. Rotator Cuff Surgery at The Orthopaedic Center If you would like to discuss rotator cuff surgery at The Orthopaedic Center please contact The Orthopaedic Center at (256) Ask for Dr. Fambrough s Shoulder Clinic. Preparing For Rotator Cuff Surgery Rotator cuff surgery is considered for healthy and motivated individuals in whom rotator cuff tears interferes with rotator cuff function. Successful rotator cuff surgery depends on a partnership between the patient and the experienced shoulder surgeon. The patient s motivation and dedication are important elements of a partnership. Patients should optimize their health so that they will be in the best possible condition for this procedure. Smoking should be stopped a month before the surgery and not resume for at least three months afterwards, ideally, never. This is because smoking interferes with the healing of the rotator cuff repair and the strength of the cuff tendons. Any heart, lung, kidney, bladder, tooth or gum problems should be managed before surgery. Any infection may be a reason to delay the operation. The patient s shoulder surgeon needs to be aware of all health issues including allergies and known prescription medications that the patient is taking. Some may need to be modified or stopped. For instance, aspirin and anti-inflammatory medications may affect the way the blood clots. Timing of the Surgery and Recovery Period Surgery for chronic tears may be delayed until the time is best for the patient s overall well being. Acute tears are those that occur suddenly should be repaired within the first month or so after the tear.

8 After rotator cuff repair, the patient needs to plan on being less functional than usual for at least 12 or more weeks after the procedure. The shoulder should not be used for vigorous activities after rotator cuff repair until your experienced shoulder surgeon gives specific instructions. Excessive use of the tendon risk causing failure of the repair. Driving, shopping and performing usual work or chores may be difficult during this time. Plans for necessary assistance need to be made before surgery. For people who live alone or those without readily available help, arrangements for home help should be made well in advance. Your shoulder surgeon could answer any questions you have about the surgery and the recovery. Cost and Insurance The Orthopaedic Center will be glad to provide you with information concerning fees of the shoulder surgery. These usually include the surgeon s fee, the hospital fee, and the degree for which your insurance covers these costs. The Surgical Team Rotator cuff surgery is a technically demanding procedure that is ideally performed by an experienced shoulder surgeon such as Dr. Fambrough, in a setting where several shoulder surgeries are done on a routine basis. Patients should inquire as to the number of rotator cuff repairs that the surgeon performs each year and the number of these procedures that are performed in the center where he does surgery. Surgeons specializing in rotator cuff surgery can be found at The Orthopaedic Center, and are recognized by the American Board of Orthopaedic Surgeons, the American Board of Sports Medicine, and the Arthroscopy Association of North America. If you would like to make an appointment to discuss shoulder surgery with Dr. Fambrough at The Shoulder Clinic, please call (256) Surgical Details About Rotator Cuff Surgery Rotator cuff surgery is a highly technical procedure; each step plays a critical role in the outcome. Please review Swarm technology, rotator cuff repair, and arthroscopic. After the anesthesia has been administered the shoulder is prepared and the patient is positioned on the operating table. Arthroscopic procedures are performed by placing small puncture wounds in the shoulder and a probe is introduced into the shoulder. The entire shoulder is inspected for all other pathology. All bones, joints and ligaments are inspected closely. The rotator cuff is inspected as well as the biceps tendon. The bursa is inspected with the arthroscope at this point, and the bursa is removed. The rotator cuff is mobilized, and the decision is made whether or not this repair can be done arthroscopically with minimal incisions. The bone spurs are removed, and inspection of the acromioclavicular joint is also undertaken. The goal of the repair is to re-attach good quality tendon to a location on the arm bone from which it was torn. The shoulder surgeon usually releases the tissue from the surrounding tissue, and attaches it back to the bone either by direct sutures through the bone, or by appropriate anchoring techniques. The tendon is drawn securely into the bony portion of the arm, so that the repair will be stable, but it takes several weeks for this tendon to heal back into the bone. Anesthetic Usually the surgery is performed under a general anesthetic; occasionally a block is performed to assist in pain relief after surgery. Length of Surgery

9 Rotator cuff surgery usually takes one to two hours depending upon the complexity of the repair and the repair technique. After surgery it may require another hour or so in the recovery room before the patient is awake. Dr. Fambrough will determine the type of immobilization that is required for the shoulder after surgery. If you would like to discuss shoulder surgery with an experienced shoulder surgeon at The Orthopaedic Center, please call (256) and ask for Dr. Fambrough s Should Clinic. Recovering From Surgery Recovery of comfort and function after rotator cuff surgery continues for a year after the surgical procedure. Rotator cuff surgery is a major surgical procedure that involves release of scar tissue and suturing of the tendons and the bones. The pain from this surgery is managed by the anesthetic and by pain medications. Immediately after surgery strong medications are often used either by injection, or by oral medications. This is usually sufficient to control the pain. Occasionally a pain pump is required which is placed inside the patients shoulder to use for a short period of time. Oral pain medications are usually needed only for the first one to two weeks after the procedure. Pain medications can be very powerful and effective. Their proper use lies in the balancing of their pain relieving effect and their other, less desirable effects. Good pain control is an important part of the postoperative management. Pain medications can cause drowsiness, slowness of breathing, difficulties in emptying the bladder and bowel, nausea, vomiting, and allergic reactions. Patients who have taken substantial narcotic medications in the recent past may find that usual doses of pain medication are less effective. For some patients, balancing the benefit and the side effects of pain medication is challenging. Patients should notify their surgeon if they have had previous difficulties with pain medication or pain control. Hospital Stay Frequently the surgery can be performed as an outpatient and the patient return home after the surgical procedure. Sometimes in the more difficult procedures, or if an open procedure is required, the patient may need to spend one night in the hospital after the surgical procedure. Bandages that cover the incision are usually left in place for 48 hours, and then changed to a smaller bandage. In the case of arthroscopic surgery, frequently a Band-Aid at this point is all that is necessary. Recovery and rehabilitation Shoulder motion after a rotator cuff repair is usually delayed. Most of the scar tissue is removed, but the goals of rotator cuff surgery are to relieve the scar tissue, as well as create a stable repair for the rotator cuff back to bone. Immobilization techniques will vary depending upon the type of tear that was found, as well as the type of surgery that was performed. Dr. Fambrough will discuss this with you in details. At Home Activities Patients usually require some assistance with self-care, activities of daily living, shopping, and driving for approximately three months after the surgical repair of a rotator cuff. Patient s usually go home after the surgery, but will need assistance. Recovery of comfort and function after rotator cuff surgery continues for many months after the surgery. Improvement in some activities may be evident as early as three months. With persistent effort though patients make progress for as long as a year after the surgery. Effects of General Health on Healing

10 The healing after rotator cuff surgery can be compromised by smoking, poor nutrition, and medications such as steroids. Diabetes can cause additional scar tissue. Heart and lung disease, as long as they are well managed, do not seem to have an effect on the healing. Rehabilitation After a period of immobilization, the rotator cuff is mobilized and rehabilitation is performed. Usually it is done with patient education, and exercises are performed by the patient, emphasizing range of motion, flexibility, and stretching exercises. After a period of healing, a strengthening program is added. Usually this is at 8 to 12 weeks after the surgical procedure so that healing of the tendon can occur back to the bony portions before it is stressed. Recovery may take three months after surgery. Sometimes driving must be delayed until that time particularly if it occurs in the right shoulder because the right shoulder s demands of shifting gears, etc., on driving. With the consent of their surgeons patients can usually return back to activities such as swimming, golf and tennis at 3 to 6 months after their surgery. Long-term limitations Patients who have had rotator cuff surgery should avoid activities that involve major impact on their shoulder such as chopping wood, contact sports and sports with major risk of falls are added loads such as lifting weights overhead and heavy resistance exercises. These activities may increase the chance of a repeat tear of the rotator cuff. Conclusion Rotator cuff surgery can help restore comfort and function to shoulders with rotator cuff tears. In the hands of an experienced shoulder surgeon, such as Dr. Fambrough, rotator cuff surgery can be a most effective method of restoring comfort and function to the shoulders of rotator cuff tears in healthy and motivated patients. Preplanning and persistent rehabilitation efforts will help assure the best possible results for the patient. If you would like to discuss shoulder surgery with an experienced shoulder surgeon at The Orthopaedic Center, please call (256) and ask for Dr. Fambrough at the Should Clinic.

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