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About Orthopaedic Surgery

Shoulder

Anatomy | Rotator Cuff Tears | Rotator Cuff Tendinitis/Bursitis Dislocation | Arthritis/Total Shoulder Replacement
Frozen Shoulder | Shoulder Arthrosopy | Shoulder Separation

Anatomy
The shoulder is a joint whose anatomy has the following important features from a clinical standpoint: (1) it is a ball and socket joint with a very shallow socket which allows a large range of motion but at the cost of the tendency to dislocate if the ligaments become injured. (2) the rotator cuff tendons, especially the supraspinatus tendon, do not have much room under the acromion of the scapula (shoulder blade). This leads frequently to tendinitis, tears of the rotator cuff, and inflammation of the subacromial bursa (bursitis). Top

Rotator Cuff Tears
The rotator cuff tendons attatch to the upper end of the humerus and help to rotate the humerus in the shoulder socket (glenoid) as well as to pull the humeral head down as the deltoid muscle pulls the humerus up (see "Shoulder Anatomy"). Tears of the tendons, particularly of the supraspinatus tendon, can be caused by injury to the shoulder and/or the gradual degeneration of the tendons from pressure and friction caused by the overlying acromion process. The symptoms of rotator cuff tears consists of weakness and pain, particularly with shoulder elevation and at nighttime.

The diagnosis is usually suspected after a physical examination, but can be confirmed by an arthrogram (an x-ray in which dye is injected into the shoulder to see if a leak is present), by an MRI (magnetic resonance imaging), or by arthroscopy. Treatment in active patients should consist of early surgical repair of the tendons; if the tear has been present too long repair may not be possible. Arthroscopy may be useful in decreasing the size of incision needed for repair and, in older, less active patients, in relieving pain by opening up the space under the acromion (acromioplasty), taking the pressure off the torn tendon without repair of the tendons.

Convalescence following rotator cuff repair requires time to allow the tendons to heal, followed by protected motion to decrease the troublesome stiffness which frequently occurs, and, finally, muscular strengthening to increase function and to protect the repaired tendons. Top

Rotator Cuff Tendinitis and/or Bursitis
The tendons of the rotator cuff, which rotate the upper humerus and help raise the arm by pulling the humeral head down as the deltoid muscle pulls the arm up, can be irritated by pressure from the acromion process of the scapula and the coraco-acromial ligament (see "Shoulder Anatomy"). This irritation of the tendons &/or of the lubricating bursa is referred to as "tendinitis" &/or "bursitis." Collectively they are known as an "impingement syndrome."

The symptoms of impingement syndrome are typically those of pain, usually with motion and at night, but sometimes constantly. There may be snapping sensations with motion. Aspirin and ibuprofen frequently help the pain. Often the symptoms start after an injury due to the resultant weakening of the shoulder muscles caused by the pain from the injury.

The diagnosis of impingement syndrome is made by physical examination, and assisted by plain x-rays, and, sometimes, arthrograms or MRI's to exclude rotator cuff tears (see "Rotator Cuff Tears").

Initial treatment consists of oral or injected anti-inflammatory medications, and strengthening of the shoulder musculature. If these fail, surgical removal of the offending acromial prominences or spurs, either by open or arthroscopic means (see "Shoulder Arthroscopy"), may be done. If the tendinitis is due to a shoulder instability problem, surgical correction of the ligamentous laxity may be necessary if strengthening is not helpful. Top

Dislocation
The humeral head is held in the shallow glenoid socket by ligaments (see "Shoulder Anatomy"). If these ligaments are detached from the glenoid by injury, or are lax due to genetic or developmental causes, the head of the humerus may slip out of the socket completely (dislocation) or incompletely (subluxation). The most common direction of instability is anterior, with posterior and inferior much less common.

In cases of anterior instability due to injury the ligamentous attachments to the glenoid rim are torn loose in what is known as a "Bankart lesion." When the arm is raised to the side in external rotation, similar to the position one assumes to prepare to throw a ball, the humeral head is forced out through the area of ligamentous attachment.

Diagnosis is made by history and physical examination, with MRI, special x-ray views, examination under anesthesia, and arthroscopy helping to further cement the diagnosis.

Treatment of recurrent dislocation is surgical, whereby the ligamentous glenoid labrum is reattached to the glenoid (socket) rim. In cases of subluxation which are not caused by injury, exercises to strengthen the shoulder muscles are often helpful. If not, or in post-injury subluxation not cured by exercise, stabilization by ligament reattachment or tightening may be needed.

Although arthroscopic shoulder stabilization is technically feasible, it is still in the developmental stage and not widely done, since the success rate for this operation has not been as high as for open stabilization, especially in active, athletic patients, and since the recovery is not significantly shortened by arthroscopic means. Top

Arthritis/Total Shoulder Replacement
When the cartilage surface the humeral head and glenoid socket become worn due to degenerative arthritis, rheumatoid arthritis, or post traumatic arthritis, the shoulder can become stiff and/or painful. Properly taken x-rays will confirm the diagnosis.

Treatment consists of anti-inflammatory medications, such as aspirin, ibuprofen, etc., initially. If that is not effective, replacement of the shoulder joint with a prosthesis which substitutes for the humeral head (hemireplacement) or for the humeral head and glenoid socket (total shoulder replacement) can be done. This operation is usually effective in reducing or eliminating pain, and often improving motion. Top

Frozen Shoulder
Frozen shoulder, or arthrofibrosis, is the development of a stiff shoulder in the absence of significant trauma. Sometimes trivial trauma will trigger the inflammation in the shoulder; frequently, there is no injury at all. The shoulder becomes stiff and, usually, painful in the early inflammatory stages. Diagnosis depends primarily on the exclusion of other shoulder conditions. The treatment usually consists of gentle range of motion exercises. If no improvement occurs over several months, manipulation or surgical release of tight ligaments may be done. Typically, frozen shoulder is a condition which improves spontaneously, although improvement often takes one to four years. Top

Shoulder Arthrosopy
Diagnosis and treatment of shoulder problems is frequently done by arthroscopic, rather than by open surgical means. An arthroscope can be utilized to visualize most of the shoulder structures through small incisions, and, similarly, additional small incisions can be utililzed to introduce instruments to perform surgical procedures. The advantages of doing these procedures arthroscopically include smaller incisions, less pain, and, ideally, a shorter recovery period and earlier initiation of rehabilitation.

Procedures which lend themselves to arthroscopic surgery include arthroscopic acromioplasty (see "tendinitis/bursitis"), release of tight ligaments for frozen shoulder, and, some feel, shoulder reconstruction for dislocation or for rotator cuff repair. Many feel that the latter two procedures are not good indications, since the recovery period is not significantly shortened at the risk of a lower success rate. Top

Shoulder Separation (Acromioclavicular Separation):

A fall on the point of the shoulder, forcing the shoulder blade downward, can cause injury to the ligaments which hold the collarbone (clavicle) to the shoulder blade (scapula). If the injury doesn't cause any displacement upward of the clavicle from the scapula, the ligaments are just stretched. This is called a Type I Acromioclavicular (A-C) Separation. A Type II A-C separation results when the ligaments between the collarbone and the shoulder blade at the A-C joint are ruptured and the clavicle is elevated a little. If the joint is completely disrupted, the ligaments at the A-C joint, as well as those between the clavicle and the coracoid process of the scapula are ruptured; this is referred to as a Type III A-C separation.

Treatment for all of these injuries rarely requires surgery. Pain medications, rest, and rehabilitation is usually all that is required, even in Type III separations. The patient is left with a bump on the top of the shoulder in Type II and Type III separations, but function and pain relief are normally satisfactory. In the uncommon case of persistent pain or of a patient who wants the bump to be corrected, surgery to reconstruct the ligaments, with or without removal of the last centimeter of the collarbone, can be performed. Top

NOTE: The information on this site is informational only and is not intended to be medical advice. NO ANSWERS TO MEDICAL QUESTIONS WILL BE GIVEN BY E-MAIL OR OTHER CORRESPONDENCE. Contact your physician for advice about specific medical conditions.

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