Shoulder Injuries & Treatments -- March 31, 2008 -- Dr. Ed Glenn - NewsChannel5.com | Nashville News, Weather & Sports

Medical Mondays: 
Shoulder Injuries & Treatments
Monday, March 31, 2008 
Ed Glenn, MD, orthopaedic surgeon
SAINT THOMAS HOSPITAL

Topic Overview

Minor shoulder problems, such as sore muscles and aches and pains, are common. Shoulder problems develop from everyday wear and tear, overuse, or an injury. They can also be caused by the natural process of aging.

Your shoulder joints move every time you move your arms. To better understand shoulder problems and injuries, you may want to review the anatomy and function of the shoulder. The shoulder is a ball-and-socket joint with three main bones: the upper arm bone (humerus), collarbone (clavicle), and shoulder blade (scapula). These bones are held together by muscles, tendons, and ligaments. The shoulder joint has the greatest range of motion of any joint in the body. Because of this mobility, the shoulder is more likely to be injured or cause problems. The acromioclavicular (AC) joint, which lays over the top of the shoulder, is also easily injured.

Shoulder problems can be minor or serious. Symptoms may include pain, swelling, numbness, tingling, weakness, or changes in temperature or color. Shoulder injuries most commonly occur during sports activities, work-related tasks, projects around the home, or falls. Home treatment often can help relieve minor aches and pains.

Sudden (acute) injury

Injuries are the most common cause of shoulder pain.

A sudden (acute) injury may occur from a fall on an outstretched arm, a direct blow to the shoulder, or abnormal twisting or bending of the shoulder. Pain may be sudden and severe. Bruising and swelling may develop soon after the injury. If nerves or blood vessels have been injured or pinched during the injury, the shoulder, arm, or hand may feel numb, tingly, weak, or cold, or may look pale or blue. Acute injuries include:

• Bruises (contusions ), which occur when small blood vessels under the skin tear or rupture, often from a twist, bump, or fall. Blood leaks into tissues under the skin and causes a black-and-blue color that often turns purple, red, yellow, and green as the bruise heals.
• Injuries to the tough, ropelike fibers (ligaments) that connect bone to bone and help stabilize the shoulder joints (sprains).
• Injuries to the tough, ropelike fibers that connect muscle to bone (tendons).
• Pulled muscles (strains).
• Injuries to nerves, such as brachial plexus neuropathy.
• Separation of the shoulder, which occurs when the outer end of the collarbone (clavicle) separates from the end (acromion) of the shoulder blade because of torn ligaments. This injury occurs most often from a blow to a shoulder or a fall onto a shoulder or outstretched hand or arm.
• Damage to one or more of the four tendons that cover the shoulder joint (torn rotator cuff), which may occur from a direct blow to or overstretching of the tendon.
• Broken bones (fractures). A break may occur when a bone is twisted, struck directly, or used to brace against a fall.
• Pulling or pushing bones out of their normal relationship to the other bones that make up the shoulder joint (subluxation or dislocation).

Overuse injuries

You may not recall having a specific injury, especially if symptoms began gradually or during everyday activities. Overuse injuries occur when too much stress is placed on a joint or other tissue, often by overdoing an activity or through repetition of an activity. Overuse injuries include:

• Inflammation of the sac of fluid that cushions and lubricates the joint area between one bone and another bone, a tendon, or the skin (bursitis).
• Inflammation of the tough, ropelike fibers that connect muscles to bones (tendinitis). Bicipital tendinitis is an inflammation of one of the tendons that attach the muscle (biceps) on the front of the upper arm bone (humerus) to the shoulder joint. The inflammation usually occurs along the groove (bicipital groove) where the tendon passes over the humerus to attach just above the shoulder joint.
• Muscle strain.
• A frozen shoulder, a condition that limits shoulder movement and may follow an injury.
• Overhead arm movements, which may cause tendons to rub or scrape against a part of the shoulder blade called the acromion. This rubbing or scraping may lead to abrasion or inflammation of the rotator cuff tendons (also called impingement syndrome).

Other causes of shoulder symptoms

Overuse and acute injuries are common causes of shoulder symptoms. Less common causes of shoulder symptoms include:

• Muscle tension or poor posture.
• Pain that is coming from somewhere else in your body (referred shoulder pain).
• Breakdown of the cartilage that protects and cushions the shoulder joints (osteoarthritis).
• Calcium buildup in the tendons of the shoulder.
• An irritated or pinched nerve or a herniated disc in the neck.
• Infection in the skin (cellulitis), joint (infectious arthritis), bursa (septic bursitis), or bone (osteomyelitis).
• Invasive cancer that has spread to the bones of the shoulder or spine.
• Abuse. Any shoulder injury (especially a dislocated shoulder) that cannot be explained, does not match the explanation, or occurs repeatedly may be caused by abuse.

Treatment

Treatment for a shoulder injury may include first aid measures, physical therapy, medicine, and in some cases surgery. Treatment depends on:

• The location, type, and severity of the injury.
• How long ago the injury occurred.
• Your age, health condition, and activities, such as work, sports, or hobbies.

Rotator cuff repair

Surgery may be used to treat a rotator cuff disorder if the injury is very severe or if nonsurgical treatment has failed to improve shoulder strength and movement sufficiently.

The rotator cuff is a group of four tendons and the related muscles that stabilize the shoulder joint and allow you to raise and rotate your arm. The shoulder is a ball-and-socket joint with three main bones: the upper arm bone (humerus), the collarbone (clavicle), and the shoulder blade (scapula). These bones are held together by muscles, tendons, ligaments, and the joint capsule. The rotator cuff helps keep the arm bone seated into the socket of the shoulder blade.

Surgery to repair a torn rotator cuff tendon usually involves:

• Debridement, in which loose fragments of tendon and bursa and other debris from inside the irritated, injured, or torn area of the confined space in the shoulder where the rotator cuff moves (subacromial space) are removed.
• Making more room in the subacromial space so that the rotator cuff tendon is not pinched or irritated. If necessary, this process may include shaving bone or removing growths on the upper point of the shoulder blade (subacromial smoothing).
• Sewing the torn edges of the supraspinatus tendon together to the top of the upper arm bone (humerus).

In open shoulder surgery, a surgeon makes a large incision [2 in. to 3 in.] in the shoulder to open it and view the shoulder directly while repairing it. One open-surgery technique, sometimes called mini-open, allows the surgeon to reach the affected tendon by making a small incision to split the deltoid muscle. This method reduces your chances of problems from a deltoid injury.

Open-shoulder surgery often requires a short stay in the hospital.

General anesthesia or a nerve block may be used for these types of surgical repair.

Complete tears can sometimes be repaired with arthroscopic surgery.

What To Expect After Surgery

Discomfort after surgery may decrease with taking pain medications prescribed by your health professional.

The arm may be protected in a sling for a defined period of time, especially when at risk of additional injury.

Physical therapy after surgery is crucial to a successful recovery. A rehabilitation program may include the following:

• As soon as you awake from anesthesia, you may start doing exercises that flex and extend the elbow, wrist, and hand.
• The day after surgery, if your health professional allows, passive exercises that move your arm may be done 4 to 5 times daily (a machine or physical therapist helps the joint through its range of motion).
• More aggressive and progressive exercises and stretches, with the assistance of a physical therapist, may start 2 to 12 weeks after surgery, depending on the type of surgery. The necessity of these exercises depends on the severity of your tear and the complexity of the surgical repair.
• Unassisted range-of-motion exercises with light weights can start a few months after surgery.

Why It Is Done

Surgery to repair a rotator cuff is done when:

• A complete rotator cuff tear causes severe shoulder weakness.
• The rotator cuff has failed to improve with conservative nonsurgical treatment alone (such as physical therapy).
• You need full shoulder strength and function for your job or activities, or you are young.
• You are in good enough physical condition to recover from surgery and will commit to completing a program of physical rehabilitation.

How Well It Works

Rotator cuff repair surgery restores more strength to the shoulder than arthroscopic debridement and decompression alone. The more strength that is restored, the more shoulder function you will have.

Risks

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:

• Infection of the incision or of the shoulder joint.
• Persistent pain or stiffness, which may get better over time.
• Damage to the deltoid tendon or muscle (if the deltoid is detached, additional surgery may be necessary to repair it).
• The need for repeated surgery because tendons do not heal properly or tear again.
• Nerve damage (uncommon).
• Reflex sympathetic dystrophy (rare).

What To Think About

Massive tears [greater than 2 in. or involving more than one rotator cuff tendon] often cannot be repaired. Grafting and patching procedures are possible, but they are not much better at restoring strength than debridement and decompression, which is less risky and requires less rehabilitation.

Less active people (usually those older than 60) with confirmed rotator cuff tears that do not cause pain, significant weakness, or sleep problems can safely go without surgery unless symptoms become worse.

• Some people who do not have surgery to repair severe rotator cuff tears develop cuff tear arthropathy, a condition of progressive arthritis, pain, and significant loss of strength, flexibility, and function.
• The risk of developing cuff tear arthropathy may be less serious than the risks of surgery for a less active person older than 70.
• In some cases, arthroscopic debridement and smoothing adequately relieves pain and restores enough function to allow daily activities, and open surgery is then not necessary.

Shoulder replacement surgery

Joint replacement involves surgery to replace the ends of bones in a damaged joint. This surgery creates new joint surfaces.

In shoulder replacement surgery, doctors replace the ends of the damaged upper arm bone (humerus) and usually the shoulder bone (scapula) or cap them with artificial surfaces lined with plastic or metal and plastic. Shoulder joint components may be held in place with cement, or they may be made with material that allows new bone to grow into the joint component over time to hold it in place without cement.

The top end of your upper arm bone is shaped like a ball. Muscles and ligaments hold this ball against a cup-shaped part of the shoulder bone. Surgeons usually replace the top of the upper arm bone with a long metal piece, inserted into your upper arm bone, that has a rounded head. If the cup-shaped surface of your shoulder bone that cradles your upper arm bone is also damaged, doctors smooth it and then cap it with a plastic or metal and plastic piece.

Surgeons are now trying a newer procedure called a reverse total shoulder replacement for people who have painful arthritis in their shoulder and also have damage to the muscles around the shoulder. In this procedure, after the surgeon removes the damaged bone and smoothes the ends, he or she attaches the rounded joint piece to the shoulder bone and uses the cup-shaped piece to replace the top of the upper arm bone. Early results are encouraging.¹