Bellapianta Orthopedics Shoulder

Allowing a full 180-degree range of motion on three different planes, the shoulder is a truly extraordinary joint. It is a complex structure made of three separate joints, working together to give you a tremendous range of motion. Yet, it is often true that the more a joint can do, the more can go wrong — and so the more specialized treatment it requires. Dr. Bellapianta has the expertise and experience to provide comprehensive care of the shoulder including nonsurgical treatments, arthroscopic, and open surgeries.

Since your shoulder is such a complicated part of your body, there are many conditions that can affect it. The following helps provide you with an overview of some of the more common shoulder ailments.

Conditions of the Shoulder

What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion in the arm — from scratching your back to throwing the perfect pitch.

Mobility has its price, however. It may lead to increasing problems with instability or impingement of the soft tissue or bony structures in your shoulder, resulting in pain. You may feel pain only when you move your shoulder, or all of the time. The pain may be temporary or it may continue and require medical diagnosis and treatment.

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket.

These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.

Most shoulder problems fall into four major categories:

Tendon inflammation (bursitis or tendinitis) or tendon tear
Instability
Arthritis
Fracture (broken bone)

Other much less common causes of shoulder pain are tumors, infection, and nerve-related problems.

Bursitis

Bursae are small, fluid-filled sacs that are located in joints throughout the body, including the shoulder. They act as cushions between bones and the overlying soft tissues, and help reduce friction between the gliding muscles and the bone.

Sometimes, excessive use of the shoulder leads to inflammation and swelling of the bursa between the rotator cuff and part of the shoulder blade known as the acromion. The result is a condition known as subacromial bursitis. Bursitis often occurs in association with rotator cuff tendinitis. The many tissues in the shoulder can become inflamed and painful. Many daily activities, such as combing your hair or getting dressed, may become difficult.

Tendinitis

A tendon is a cord that connects muscle to bone. Most tendinitis is a result of a wearing down of the tendon that occurs slowly over time, much like the wearing process on the sole of a shoe that eventually splits from overuse.

Generally, tendinitis is one of two types:

ACUTE. Excessive ball throwing or other overhead activities during work or sport can lead to acute tendinitis.
CHRONIC. Degenerative diseases like arthritis or repetitive wear and tear due to age, can lead to chronic tendinitis.

The most commonly affected tendons in the shoulder are the four rotator cuff tendons and one of the biceps tendons. The rotator cuff is made up of four small muscles and their tendons that cover the head of your upper arm bone and keep it in the shoulder socket. Your rotator cuff helps provide shoulder motion and stability.

Tendon Tears

Splitting and tearing of tendons may result from acute injury or degenerative changes in the tendons due to advancing age, long-term overuse and wear and tear, or a sudden injury. These tears may be partial or may completely split the tendon into two pieces. In most cases of complete tears, the tendon is pulled away from its attachment to the bone. Rotator cuff and biceps tendon injuries are among the most common of these injuries.

Impingement

Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the underlying soft tissues when the arm is lifted away from the body. As the arm is lifted, the acromion rubs, or "impinges" on, the rotator cuff tendons and bursa. This can lead to bursitis and tendinitis, causing pain and limiting movement. Over time, severe impingement can even lead to a rotator cuff tear.

Instability

Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse.

Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.

Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Recurring dislocations, which may be partial or complete, cause pain and unsteadiness when you raise your arm or move it away from your body. Repeated episodes of subluxations or dislocations lead to an increased risk of developing arthritis in the joint.

Arthritis

Shoulder pain can also result from arthritis. There are many types of arthritis. The most common type of arthritis in the shoulder is osteoarthritis, also known as "wear and tear" arthritis. Symptoms, such as swelling, pain, and stiffness, typically begin during middle age. Osteoarthritis develops slowly and the pain it causes worsens over time.

Osteoarthritis, may be related to sports or work injuries and chronic wear and tear. Other types of arthritis can be related to rotator cuff tears, infection, or an inflammation of the joint lining.

Often people will avoid shoulder movements in an attempt to lessen arthritis pain. This sometimes leads to a tightening or stiffening of the soft tissue parts of the joint, resulting in a painful restriction of motion.

Fracture

Fractures are broken bones. Shoulder fractures commonly involve the clavicle (collarbone), humerus (upper arm bone), and scapula (shoulder blade).

Shoulder fractures in older patients are often the result of a fall from standing height. In younger patients, shoulder fractures are often caused by a high energy injury, such as a motor vehicle accident or contact sports injury.

Fractures often cause severe pain, swelling, and bruising about the shoulder.

Rotator Cuff Tears

A rotator cuff tear is a common cause of pain and disability among adults. Each year, almost 2 million people in the United States visit their doctors because of a rotator cuff problem.

A torn rotator cuff will weaken your shoulder. This means that many daily activities, like combing your hair or getting dressed, may become painful and difficult to do.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder is a ball-and-socket joint: the ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade.

Your arm is kept in your shoulder socket by your rotator cuff. The rotator cuff is a group of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.

There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.

Description

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus.

Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be involved.

In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.

There are different types of tears.

Partial tear. This type of tear is also called an incomplete tear. It damages the tendon, but does not completely sever it.

Full-thickness tear. This type of tear is also called a complete tear. It separates all of the tendon from the bone. With a full-thickness tear, there is basically a hole in the tendon.

Cause

There are two main causes of rotator cuff tears: injury and degeneration.

Acute Tear

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age.

Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater likelihood of a rotator cuff tear in the opposite shoulder -- even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.

Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body's natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.

Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

Risk Factors

Because most rotator cuff tears are largely caused by the normal wear and tear that goes along with aging, people over 40 are at greater risk.

People who do repetitive lifting or overhead activities are also at risk for rotator cuff tears. Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers. Painters, carpenters, and others who do overhead work also have a greater chance for tears.

Although overuse tears caused by sports activity or overhead work also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall.

Symptoms

The most common symptoms of a rotator cuff tear include:

Pain at rest and at night, particularly if lying on the affected shoulder
Pain when lifting and lowering your arm or with specific movements
Weakness when lifting or rotating your arm
Crepitus or crackling sensation when moving your shoulder in certain positions

Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.

Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.

Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.

It should be noted that some rotator cuff tears are not painful. These tears, however, may still result in arm weakness and other symptoms.

Shoulder Impingement/Rotator Cuff Tendinitis

One of the most common physical complaints is shoulder pain. Your shoulder is made up of several joints combined with tendons and muscles that allow a great range of motion in your arm. Because so many different structures make up the shoulder, it is vulnerable to many different problems. The rotator cuff is a frequent source of pain in the shoulder.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

Your arm is kept in your shoulder socket by your rotator cuff. These muscles and tendons form a covering around the head of your upper arm bone and attach it to your shoulder blade.

There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm.

Description

The rotator cuff is a common source of pain in the shoulder. Pain can be the result of:

Tendinitis. The rotator cuff tendons can be irritated or damaged.
Bursitis. The bursa can become inflamed and swell with more fluid causing pain.
Impingement. When you raise your arm to shoulder height, the space between the acromion and rotator cuff narrows. The acromion can rub against (or "impinge" on) the tendon and the bursa, causing irritation and pain.

Cause

Rotator cuff pain is common in both young athletes and middle-aged people. 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 a minor injury. Sometimes, it occurs with no apparent cause.

Symptoms

Rotator cuff pain commonly causes local swelling and tenderness in the front of the shoulder. You may have pain and stiffness when you lift your arm. There may also be pain when the arm is lowered from an elevated position.

Beginning symptoms may be mild. Patients frequently do not seek treatment at an early stage. These symptoms may include:

Minor pain that is present both with activity and at rest
Pain radiating from the front of the shoulder to the side of the arm
Sudden pain with lifting and reaching movements
Athletes in overhead sports may have pain when throwing or serving a tennis ball
As the problem progresses, the symptoms increase:
Pain at night
Loss of strength and motion
Difficulty doing activities that place the arm behind the back, such as buttoning or zippering
If the pain comes on suddenly, the shoulder may be severely tender. All movement may be limited and painful.

SLAP Tears

A SLAP tear is an injury to the labrum of the shoulder, which is the ring of cartilage that surrounds the socket of the shoulder joint.

Anatomy

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. Surrounding the outside edge of the glenoid is a rim of strong, fibrous tissue called the labrum. The labrum helps to deepen the socket and stabilize the shoulder joint. It also serves as an attachment point for many of the ligaments of the shoulder, as well as one of the tendons from the biceps muscle in the arm.

Description

The term SLAP stands for Superior Labrum Anterior and Posterior. In a SLAP injury, the top (superior) part of the labrum is injured. This top area is also where the biceps tendon attaches to the labrum. A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. The biceps tendon can be involved in the injury, as well.

Cause

Injuries to the superior labrum can be caused by acute trauma or by repetitive shoulder motion. An acute SLAP injury may result from:

A motor vehicle accident
A fall onto an outstretched arm
Forceful pulling on the arm, such as when trying to catch a heavy object
Rapid or forceful movement of the arm when it is above the level of the shoulder
Shoulder dislocation
People who participate in repetitive overhead sports, such as throwing athletes or weightlifters, can experience labrum tears as a result of repeated shoulder motion.
Many SLAP tears, however, are the result of a wearing down of the labrum that occurs slowly over time. In patients over 30 to 40 years of age, tearing or fraying of the superior labrum can be seen as a normal process of aging. This differs from an acute injury in a younger person.

Symptoms

The common symptoms of a SLAP tear are similar to many other shoulder problems. They include:

A sensation of locking, popping, catching, or grinding
Pain with movement of the shoulder or with holding the shoulder in specific positions
Pain with lifting objects, especially overhead
Decrease in shoulder strength
A feeling that the shoulder is going to "pop out of joint"
Decreased range of motion
Pitchers may notice a decrease in their throw velocity, or the feeling of having a "dead arm" after pitching

Frozen Shoulder

Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move.

After a period of worsening symptoms, frozen shoulder tends to get better, although full recovery may take up to 3 years. Physical therapy, with a focus on shoulder flexibility, is the primary treatment recommendation for frozen shoulder.

Frozen shoulder most commonly affects people between the ages of 40 and 60, and occurs in women more often than men. In addition, people with diabetes are at an increased risk for developing frozen shoulder.

Anatomy

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.

To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

Description

In frozen shoulder, the shoulder capsule thickens and becomes stiff and tight. Thick bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint.

The hallmark signs of this condition are severe pain and being unable to move your shoulder -- either on your own or with the help of someone else. It develops in three stages:

Stage 1: Freezing

In the "freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

Stage 2: Frozen

Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

Stage 3: Thawing

Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

Cause

The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

Diabetes. Frozen shoulder occurs much more often in people with diabetes. The reason for this is not known. In addition, diabetic patients with frozen shoulder tend to have a greater degree of stiffness that continues for a longer time before "thawing."

Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

Symptoms

Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.

Biceps Tenodesis Treatment

Nonsurgical Treatment

For most people, pain from a long head of biceps tendon tear resolves over time. Mild arm weakness or arm deformity do not typically bother most patients.

In addition, if you have not damaged a more critical structure, such as the rotator cuff, nonsurgical treatment is a reasonable option. This can include:

Ice. Apply cold packs for 20 minutes at a time, several times a day to keep down swelling. Do not apply ice directly to the skin.

Nonsteroidal anti-inflammatory drugs (NSAIDs). Anti-inflammatory drugs like ibuprofen, aspirin, or naproxen can reduce pain and swelling.

Rest. Avoid heavy lifting and overhead activities to relieve pain and limit swelling. Your doctor may recommend using a sling for a brief time.

Physical therapy. Flexibility and strengthening exercises will restore movement and strengthen your shoulder.

Surgical Treatment

You rarely need surgical treatment for a long head of the biceps tendon tear. However, some people who develop cramping of the muscle or pain, or who require complete recovery of strength, such as athletes or manual laborers, may benefit from surgery. Surgery may also be the right option for those with partial tears whose symptoms are not relieved with nonsurgical treatment.

Procedure. Several procedures have been developed to repair the tendon with minimal incisions. The goal of the surgery is to re-anchor the torn tendon back to the bone. Your doctor will discuss with you the options that are best for your specific case.

Complications. Complications with this surgery are rare. Re-rupture of the repaired tendon is uncommon.

Rehabilitation. After surgery, your shoulder may be immobilized temporarily with a sling.

Your doctor will soon start you on therapeutic exercises. Flexibility exercises will improve range of motion in your shoulder. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.

Be sure to follow your doctor's treatment plan. Although rehabilitation is a slow process, your commitment to physical therapy is the most important factor in eventually returning to all the activities you enjoy.

Surgical Outcome. Successful surgery can correct muscle deformity and return your arm's strength and function to nearly normal.

Rotator Cuff Tears: Surgical Treatment Options

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). A partial tear, however, may need only a trimming or smoothing procedure called a debridement. A complete tear is repaired by stitching the tendon back to its original site on the humerus.

When Rotator Cuff Surgery is Recommended

Your doctor may offer surgery as an option for a torn rotator cuff if your pain does not improve with nonsurgical methods. Continued pain is the main indication for surgery. If you are very active and use your arms for overhead work or sports, your doctor may also suggest surgery.

Other signs that surgery may be a good option for you include:

Your symptoms have lasted 6 to 12 months
You have a large tear (more than 3 cm) and the quality of the surrounding tendon tissue is good
You have significant weakness and loss of function in your shoulder
Your tear was caused by a recent, acute injury

Surgical Repair Options

There are a few options for repairing rotator cuff tears. Advancements in surgical techniques for rotator cuff repair include less invasive procedures. While each of the methods available has its own advantages and disadvantages, all have the same goal: getting the tendon to heal.

The type of repair performed depends on several factors, including your surgeon's experience and familiarity with a particular procedure, the size of your tear, your anatomy, and the quality of the tendon tissue and bone.

Many surgical repairs can be done on an outpatient basis and do not require you to stay overnight in the hospital. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

You may have other shoulder problems in addition to a rotator cuff tear, such as biceps tendon tears, osteoarthritis, bone spurs, or other soft tissue tears. During the operation, your surgeon may be able to take care of these problems, as well.

The three techniques most commonly used for rotator cuff repair include traditional open repair, arthroscopic repair, and mini-open repair. In the end, patients rate all three repair methods the same for pain relief, strength improvement, and overall satisfaction.

Open Repair

A traditional open surgical incision (several centimeters long) is often required if the tear is large or complex. The surgeon makes the incision over the shoulder and detaches one of the shoulder muscles (deltoid) to better see and gain access to the torn tendon.

During an open repair, the surgeon typically removes bone spurs from the underside of the acromion (this procedure is called an acromioplasty). An open repair may be a good option if the tear is large or complex or if additional reconstruction, such as a tendon transfer, is indicated.

Open repair was the first technique used for torn rotator cuffs. Over the years, new technology and improved surgeon experience has led to less invasive procedures.

All-Arthroscopic Repair

During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery. All-arthroscopic repair is usually an outpatient procedure and is the least invasive method to repair a torn rotator cuff.

Mini-Open Repair

The mini-open repair uses newer technology and instruments to perform a repair through a small incision. The incision is typically 3 to 5 cm long.

This technique uses arthroscopy to assess and treat damage to other structures within the joint. Bone spurs, for example, are often removed arthroscopically. This avoids the need to detach the deltoid muscle.

Once the arthroscopic portion of the procedure is completed, the surgeon repairs the rotator cuff through the mini-open incision. During the tendon repair, the surgeon views the shoulder structures directly, rather than through the video monitor.

Recovery

Pain Management

After surgery, you will feel pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few weeks after your surgery.

Rehabilitation

Rehabilitation plays a vital role in getting you back to your daily activities. A physical therapy program will help you regain shoulder strength and motion.

Immobilization. After surgery, therapy progresses in stages. At first, the repair needs to be protected while the tendon heals. To keep your arm from moving, you will most likely use a sling and avoid using your arm for the first 4 to 6 weeks. How long you require a sling depends upon the severity of your injury.

Passive exercise. Even though your tear has been repaired, the muscles around your arm remain weak. Once your surgeon decides it is safe for you to move your arm and shoulder, a therapist will help you with passive exercises to improve range of motion in your shoulder. With passive exercise, your therapist supports your arm and moves it in different positions. In most cases, passive exercise is begun within the first 4 to 6 weeks after surgery.

Active exercise. After 4 to 6 weeks, you will progress to doing active exercises without the help of your therapist. Moving your muscles on your own will gradually increase your strength and improve your arm control. At 8 to 12 weeks, your therapist will start you on a strengthening exercise program.

Expect a complete recovery to take several months. Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery. Although it is a slow process, your commitment to rehabilitation is key to a successful outcome.

Outcome

The majority of patients report improved shoulder strength and less pain after surgery for a torn rotator cuff.

Each surgical repair technique (open, mini-open, and arthroscopic) has similar results in terms of pain relief, improvement in strength and function, and patient satisfaction. Surgeon expertise is more important in achieving satisfactory results than the choice of technique.

Factors that can decrease the likelihood of a satisfactory result include:

Poor tendon/tissue quality
Large or massive tears
Poor patient compliance with rehabilitation and restrictions after surgery
Patient age (older than 65 years)
Smoking and use of other nicotine products
Workers' compensation claims

Complications

After rotator cuff surgery, a small percentage of patients experience complications. In addition to the risks of surgery in general, such as blood loss or problems related to anesthesia, complications of rotator cuff surgery may include:

Nerve injury. This typically involves the nerve that activates your shoulder muscle (deltoid).
Infection. Patients are given antibiotics during the procedure to lessen the risk for infection. If an infection develops, an additional surgery or prolonged antibiotic treatment may be needed.
Deltoid detachment. During an open repair, this shoulder muscle is detached to provide better access to the rotator cuff. It is stitched back into place at the end of the procedure. It is very important to protect this area after surgery and during rehabilitation to allow it to heal.
Stiffness. Early rehabilitation lessens the likelihood of permanent stiffness or loss of motion. Most of the time, stiffness will improve with more aggressive therapy and exercise.
Tendon re-tear. There is a chance for re-tear following all types of repairs. The larger the tear, the higher the risk of re-tear. Patients who re-tear their tendons usually do not have greater pain or decreased shoulder function. Repeat surgery is needed only if there is severe pain or loss of function.

SLAP Tears Treatment

Nonsurgical Treatment

In most cases, the initial treatment for a SLAP injury is nonsurgical. Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.

Physical Therapy

Specific exercises will restore movement and strengthen your shoulder. Flexibility and range-of-motion exercises will include stretching the shoulder capsule, which is the strong connective tissue that surrounds the joint. Exercises to strengthen the muscles that support your shoulder can relieve pain and prevent further injury. This exercise program can be continued anywhere from 3 to 6 months, and usually involves working with a qualified physical therapist.

Surgical Treatment

Your doctor may recommend surgery if your pain does not improve with nonsurgical methods.

Arthroscopy. The surgical technique most commonly used for treating a SLAP injury is arthroscopy. During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays pictures on a video monitor, and your surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.

Treatment options.There are several different types of SLAP tears. Your surgeon will determine how best to treat your SLAP injury once he or she sees it fully during arthroscopic surgery. This may require simply removing the torn part of the labrum, or reattaching the torn part using sutures. Some SLAP injuries do not require repair with sutures; instead, the biceps tendon attachment is released to relieve painful symptoms.

Your surgeon will decide the best treatment option based upon the type of tear you have, as well as your age, activity level, and the presence of any other injuries seen during the surgery.

Complications. Most patients do not experience complications from shoulder arthroscopy. As with any surgery, however, there are some risks. These are usually minor and treatable. Potential problems with arthroscopy include infection, excessive bleeding, blood clots, shoulder stiffness, and damage to blood vessels or nerves.

Your surgeon will discuss the possible complications with you before your operation.

Rehabilitation. At first, your shoulder needs to be protected while the repaired structures heal. To keep your arm from moving, you will most likely use a sling for 2 to 6 weeks after surgery. How long you require a sling depends upon the severity of your injury and the complexity of your surgery.

Once the initial pain and swelling has settled down, your doctor will start you on a physical therapy program that is tailored specifically to you and your injury.

In general, a therapy program focuses first on flexibility. Gentle stretches will improve your range of motion and prevent stiffness in your shoulder. As healing progresses, exercises to strengthen the shoulder muscles and the rotator cuff will gradually be added to your program. This typically occurs 6 to 10 weeks after surgery.

Your doctor will discuss with you when it is safe to return to sports activity. In general, throwing athletes can return to early interval throwing 3 to 4 months after surgery.

Outcomes

The majority of patients report improved shoulder strength and less pain after surgery for a SLAP tear. Because patients have varied health conditions, complete recovery time is different for everyone.

In cases of complicated injuries and repairs, full recovery may take several months. Although it can be a slow process, following your surgeon's guidelines and rehabilitation plan is vital to a successful outcome.

Shoulder Joint Replacement

Although shoulder joint replacement is less common than knee or hip replacement, it is just as successful in relieving joint pain.

Shoulder replacement surgery was first performed in the United States in the 1950s to treat severe shoulder fractures. Over the years, shoulder joint replacement has come to be used for many other painful conditions of the shoulder, such as different forms of arthritis.

Today, about 53,000 people in the U.S. have shoulder replacement surgery each year, according to the Agency for Healthcare Research and Quality. This compares to more than 900,000 Americans a year who have knee and hip replacement surgery.

If nonsurgical treatments like medications and activity changes are no longer helpful for relieving pain, you may want to consider shoulder joint replacement surgery. Joint replacement surgery is a safe and effective procedure to relieve pain and help you resume everyday activities.

Whether you have just begun exploring treatment options or have already decided to have shoulder joint replacement surgery, this article will help you understand more about this valuable procedure.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder is a ball-and-socket joint: The ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade. This socket is called the glenoid.

The surfaces of the bones where they touch are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily. A thin, smooth tissue called synovial membrane covers all remaining surfaces inside the shoulder joint.

In a healthy shoulder, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost any friction in your shoulder.

The muscles and tendons that surround the shoulder provide stability and support.

All of these structures allow the shoulder to rotate through a greater range of motion than any other joint in the body.

Description

In shoulder replacement surgery, the damaged parts of the shoulder are removed and replaced with artificial components, called a prosthesis.

The treatment options are either replacement of just the head of the humerus bone (ball), or replacement of both the ball and the socket (glenoid).

Cause

Several conditions can cause shoulder pain and disability, and lead patients to consider shoulder joint replacement surgery.

Osteoarthritis (Degenerative Joint Disease)

Osteoarthritis is an age-related wear-and-tear type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones of the shoulder softens and wears away. The bones then rub against one another. Over time, the shoulder joint slowly becomes stiff and painful.

Unfortunately, there is no way to prevent the development of osteoarthritis. It is a common reason people have shoulder replacement surgery.

Osteoarthritis of the shoulder. As the cartilage that covers the ends of the bones wears away, it can result in bone rubbing on bone and produce painful bone spurs.

Rheumatoid Arthritis

This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed inflammatory arthritis.

Post-traumatic Arthritis

This can follow a serious shoulder injury. Fractures of the bones that make up the shoulder or tears of the shoulder tendons or ligaments may damage the articular cartilage over time. This causes shoulder pain and limits shoulder function.

Rotator Cuff Tear Arthropathy

A patient with a very large, long-standing rotator cuff tear may develop cuff tear arthropathy. In this condition, the changes in the shoulder joint due to the rotator cuff tear may lead to arthritis and destruction of the joint cartilage.

Avascular Necrosis (Osteonecrosis)

Avascular necrosis, or osteonecrosis, is a painful condition that occurs when the blood supply to the bone is disrupted. Because bone cells die without a blood supply, osteonecrosis can ultimately cause destruction of the shoulder joint and lead to arthritis. Chronic steroid use, deep sea diving, severe fracture of the shoulder, sickle cell disease, and heavy alcohol use are all risk factors for avascular necrosis.

Severe Fractures

A severe fracture of the shoulder is another common reason people have shoulder replacements. When the head of the upper arm bone is shattered, it may be very difficult for a doctor to put the pieces of bone back in place. In addition, the blood supply to the bone pieces can be interrupted. In this case, a surgeon may recommend a shoulder replacement. Older patients with osteoporosis are most at risk for severe shoulder fractures.

Failed Previous Shoulder Replacement Surgery

Although uncommon, some shoulder replacements fail, most often because of implant loosening, wear, infection, and dislocation. When this occurs, a second joint replacement surgery — called a revision surgery — may be necessary.

Is Shoulder Joint Replacement for You?

The decision to have shoulder replacement surgery should be a cooperative one between you, your family, your family physician, and your orthopaedic surgeon.

There are several reasons why your doctor may recommend shoulder replacement surgery. People who benefit from surgery often have:

Severe shoulder pain that interferes with everyday activities, such as reaching into a cabinet, dressing, toileting, and washing.
Moderate to severe pain while resting. This pain may be severe enough to prevent a good night's sleep.
Loss of motion and/or weakness in the shoulder.
Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, and/or physical therapy.

Orthopaedic Evaluation

Your family physician may refer you to an orthopaedic surgeon for a thorough evaluation to determine if you can benefit from this surgery.

An evaluation with an orthopaedic surgeon consists of several components:

A medical history. Your orthopaedic surgeon will gather information about your general health and ask you about the extent of your shoulder pain and your ability to function.
A physical examination. This will assess shoulder motion, stability, and strength.
X-rays. X-rays help to determine the extent of damage in your shoulder. They can show loss of the normal joint space between bones, flattening or irregularity in the shape of the bone, bone spurs, and loose pieces of cartilage or bone that may be floating inside the joint.
Other tests. Occasionally, your doctor may order blood tests, a computed tomography (CT) scan, a magnetic resonance imaging (MRI) scan, or a bone scan to determine the condition of the bone and soft tissues of your shoulder.

Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether shoulder joint replacement is the best method to relieve your pain and improve your function. Other treatment options — including medications, injections, physical therapy, or other types of surgery — will also be discussed and considered.

Shoulder Replacement Options

Shoulder replacement surgery is highly technical. It should be performed by a surgical team with experience in this procedure. There are different types of shoulder replacements. Your surgeon will evaluate your situation carefully before making any decisions.

They will discuss with you which type of replacement will best meet your health needs. Do not hesitate to ask which type of implant will be used in your situation, and why that choice is right for you.

Total Shoulder Replacement

The standard total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem, and a plastic socket.

These components come in various sizes. They may be either cemented or press fit into the bone. If the bone is of good quality, your surgeon may choose to use a non-cemented (press-fit) humeral component. If the bone is soft, the humeral component may be implanted with bone cement. In most cases, an all-plastic glenoid (socket) component is implanted with bone cement.

Implantation of a glenoid component is not advised if:

The glenoid has good cartilage
The glenoid bone is severely deficient
The rotator cuff tendons are irreparably torn
Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement.

Stemmed Hemiarthroplasty

Depending on the condition of your shoulder, your surgeon may replace only the ball. This procedure is called a hemiarthroplasty. In a traditional hemiarthroplasty, the surgeon replaces the head of the humerus with a metal ball and stem, similar to the component used in a total shoulder replacement. This is called a stemmed hemiarthroplasty.

Some surgeons recommend hemiarthroplasty when the humeral head is severely fractured but the socket is normal. Other indications for a hemiarthroplasty include:

Arthritis that involves only the head of the humerus, with a glenoid that has a healthy and intact cartilage surface
Shoulders with severely weakened bone in the glenoid
Some shoulders with severely torn rotator cuff tendons and arthritis
Sometimes, surgeons make the decision between a total shoulder replacement and a hemiarthroplasty in the operating room at the time of the surgery.
Studies show that patients with osteoarthritis get better pain relief from total shoulder arthroplasty than from hemiarthroplasty.

Resurfacing Hemiarthroplasty

Resurfacing hemiarthroplasty involves replacing just the joint surface of the humeral head with a cap-like prosthesis without a stem. With its bone-preserving advantage, it offers those with arthritis of the shoulder an alternative to the standard stemmed shoulder replacement.

Resurfacing hemiarthroplasty may be an option for you if:

The glenoid still has an intact cartilage surface
There has been no fresh fracture of the humeral neck or head
There is a desire to preserve humeral bone

For patients who are young or very active, resurfacing hemiarthroplasty avoids the risks of component wear and loosening that may occur with conventional total shoulder replacements in this patient population. Due to its more conservative nature, resurfacing hemiarthroplasty may be easier to convert to total shoulder replacement, if necessary, at a later time.

Reverse Total Shoulder Replacement

Another type of shoulder replacement is called reverse total shoulder replacement. Reverse total shoulder replacement is used for people who have:

Completely torn rotator cuffs with severe arm weakness
The effects of severe arthritis and rotator cuff tearing (cuff tear arthropathy)
Had a previous shoulder replacement that failed
An X-ray of a reverse total shoulder replacement.

For these individuals, a conventional total shoulder replacement can still leave them with pain. They may also be unable to lift their arm up past a 90-degree angle. Not being able to lift your arm away from the side can be severely debilitating.

In reverse total shoulder replacement, the socket and metal ball are switched: A metal ball is attached to the shoulder bone, and a plastic socket is attached to the upper arm bone. This allows the patient to use the deltoid muscle instead of the torn rotator cuff to lift the arm.

Complications

Your orthopaedic surgeon will explain the potential risks and complications of shoulder joint replacement, including those related to the surgery itself and those that can occur over time after your surgery.

When complications occur, most are successfully treatable. Possible complications include the following:

Infection. Infection is a complication of any surgery. In shoulder joint replacement, infection may occur in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.
Prosthesis Problems. Although prosthesis designs and materials, as well as surgical techniques, continue to advance, the prosthesis may wear down and the components may loosen. The components of a shoulder replacement may also dislocate. Excessive wear, loosening, or dislocation may require additional surgery (revision procedure).
Nerve damage. Nerves in the vicinity of the joint replacement may be damaged during surgery, although this type of injury is infrequent. Over time, these nerve injuries often improve and may completely recover.

Preparing for Surgery

Medical Evaluation

If you decide to have shoulder replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your family physician several weeks before surgery. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, must also be evaluated by a specialist, such as a cardiologist, before the surgery.

Medications

Be sure to talk to your orthopaedic surgeon about the medications you take. Some medications may need to be stopped before surgery. For example, the following over-the-counter medicines may cause excessive bleeding and should be stopped 2 weeks before surgery:

Non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen
Most arthritis medications
If you take blood thinners, either your primary care doctor or cardiologist will advise you about stopping these medications before surgery.

Home Planning

Making simple changes in your home before surgery can make your recovery period easier.

For the first several weeks after your surgery, it will be hard to reach high shelves and cupboards. Before your surgery, be sure to go through your home and place any items you may need afterwards on low shelves.

When you come home from the hospital, you will need help for a few weeks with some daily tasks like dressing, bathing, cooking, and laundry. If you will not have any support at home immediately after surgery, you may need a short stay in a rehabilitation facility until you become more independent.

Your Surgery

Before Your Operation

Wear loose-fitting clothes and a button-front shirt when you go to the hospital for your surgery. After surgery, you will be wearing a sling and will have limited use of your arm.

You will most likely be admitted to the hospital on the day of your surgery. After admission, you will be taken to the preoperative preparation area and will meet a doctor from the anesthesia department.

You, your anesthesiologist, and your surgeon will discuss the type of anesthesia to be used. You may be provided a general anesthetic (you are asleep for the entire operation), a regional anesthetic (you may be awake but have no feeling around the surgical area), or a combination of both types.

Surgical Procedure

The procedure to replace your shoulder joint with an artificial device usually takes about 2 hours.

After surgery, you will be moved to the recovery room, where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room.

Recovery

Your medical team will give you several doses of antibiotics to prevent infection. Most patients are able to eat solid food and get out of bed the day after surgery. You will most likely be able to go home on the first, second, or third day after surgery.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor and to stop taking them as soon as your pain begins to improve. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Pain management is an important part of your recovery. You will begin physical therapy soon after surgery, and when you feel less pain, you can start moving sooner and get your strength back more quickly. Talk with your doctor if postoperative pain becomes a problem.

Rehabilitation

A careful, well-planned rehabilitation program is critical to the success of a shoulder replacement. You usually start gentle physical therapy soon after the operation. Your surgeon or physical therapist will provide you with a home exercise program to strengthen your shoulder and improve flexibility.

Your Recovery At Home

When you leave the hospital, your arm will be in a sling. You will need the sling to support and protect your shoulder for the first 2 to 6 weeks after surgery, depending on the complexity of your surgery and your surgeon's preference.

Wound care. You will have staples running along your wound or a suture beneath your skin. The staples will be removed several weeks after surgery. A dissolving suture beneath your skin will not require removal.

Avoid soaking the wound in water until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing.

Activity. Exercise is a critical component of home care, particularly during the first few weeks after surgery. Follow your surgeon's home exercise plan to help you regain strength. Most patients are able to perform simple activities such as eating, dressing, and grooming, within 2 weeks after surgery. Some pain with activity and at night is common for several weeks after surgery.

You are not allowed to drive a car for 2 to 6 weeks after surgery.

Do's and Don'ts

The success of your surgery will depend largely on how well you follow your orthopaedic surgeon's instructions at home during the first few weeks after surgery. Here are some common do's and don'ts for when you return home:

Don't use the arm to push yourself up in bed or from a chair because this requires forceful contraction of muscles.
Do follow the program of home exercises prescribed for you. You may need to do the exercises 2 to 3 times a day for a month or more.
Don't overdo it! If your shoulder pain was severe before the surgery, the experience of pain-free motion may lull you into thinking that you can do more than is prescribed. Early overuse of the shoulder may result in severe limitations in motion.
Don't lift anything heavier than a glass of water for the first 2 to 4 weeks after surgery.
Do ask for assistance. Your physician may be able to recommend an agency or facility to help if you do not have home support.
Don't participate in contact sports or do any repetitive heavy lifting after your shoulder replacement.
Do avoid placing your arm in any extreme position, such as straight out to the side or behind your body for the first 6 weeks after surgery.

Many thousands of patients have experienced an improved quality of life after shoulder joint replacement surgery. They experience less pain, improved motion and strength, and better function.

Research