The Shoulder

 

           

The shoulder joint is a ball and socket joint designed to allow significant mobility to the arm.  There are two main bones involved in the shoulder joint, the humerus (“ball”) and the scapula (“socket”).  The ball and socket are lined with smooth cartilage that allows for smooth gliding of the shoulder joint.  The scapula also has another part called the acromion which forms the roof of the shoulder joint. 

Within the shoulder joint is the labrum, which is a cartilage rim around the socket.  This deepens the socket and ads stability to the shoulder joint.  The front or back of the labrum are usually injured during shoulder dislocations.  The top of the labrum is vulnerable to injury in throwing athletes or with chronic wear and tear. 

Above the ball and socket joint is the rotator cuff.  The rotator cuff is comprised of the tendons of four muscles that come together to attach to the humerus.  They are essential to normal shoulder movement and strength. 

What are disease processes that can occur in the shoulder?

Shoulder Instabilty/Labral Tear

 
Shoulder instability can result from a partial or complete dislocation of the ball from the socket.  The ball can spontaneously reduce back to the socket or may require a reduction done by a health care provider.  When the shoulder dislocates, ligaments that hold the shoulder in place typically are injured (usually the shoulder labrum).  Often, these ligaments/labrum do not heal completely and the patient can have recurrent episodes of instability.  The younger the patient is, the more likely they will have recurrent instability.
 
Instability can usually be repaired by a minimally invasive arthroscopic procedure.  During this procedure, small incisions are made to introduce a tiny microscope into the shoulder as well as instruments to perform the repair of the labrum/ligaments.  Physical therapy is needed after the procedure and patients can return to full activity in 4-6 months.

Rotator Cuff Tear

 
The rotator cuff is an important stabilizer of the shoulder joint.  Rotator cuff tears usually occur as a chronic degenerative process but can also occur acutely due to an injury.  Symptoms from a rotator cuff tear include significant shoulder pain which can radiate further down the arm.  Patients can also have pain at night that disturbs their sleep.  They also experience weakness with certain motions of the arm as well as limited mobility of the shoulder.
 
Rotator cuff tears can be partial or complete.  Complete tears can gradually increase in size which eventually can lead to arthritis of the shoulder.  Therefore, we are aggressive about recommending repair of the rotator cuff to prevent this predictable course.  Partial tears, depending on the severity, can be treated with physical therapy or with surgery.
 
Rotator cuff repair can be performed using a minimally invasive arthroscopic technique versus an open incision.  We prefer the minimally invasive arthroscopic approach.  In this procedure, we make small incisions to introduce a tiny microscope into the shoulder as well as instruments to perform the repair.  Small anchors attached to strong sutures are used to reattach the torn rotator cuff back to the bone.  Physical therapy is needed after the procedure and patients can return to full activity in 4-6 months.

Impingment Syndrome Of The Shoulder

 
Impingement syndrome is a condition where the soft tissues between the humerus bone and the acromion bone are inflamed and irritated.  Often there is an associated bone spur on the acormion bone that propagates this impingement syndrome.  Impingement syndrome often accompanies other shoulder diagnoses such as rotator cuff partial or complete tears as well as biceps tendonitis.  Impingement syndrome results in shoulder pain with certain movements of the shoulder, limited range of motion, and pain at night, particularly when sleeping on the affected side.
 
Impingement syndrome can be treated initially with oral anti-inflammatory medications and physical therapy.  If this is not effective, we can help it along by injecting a strong anti-inflammatory injection into the affected area.  This, usually coupled with physical therapy, helps resolve most isolated shoulder impingement.  However, for those patients in which this also is ineffective, minimally invasive shoulder arthroscopy and removal of the inflamed tissue and the associated bone spur typically resolves the symptoms.

Calcific Tendonitis Of The Shoulder

 
Calcium deposits are a fairly common occurrence in the shoulder.  Usually they embed within the soft tissues of the shoulder or in the tendon of the rotator cuff. These deposits typically are not symptomatic.  However, when they become inflamed or leak into surrounding tissue, they can be extremely painful.  This is known as calcific tendonitis of the shoulder. Calcium deposits can also grow to a size where they can cause tearing of the rotator cuff itself.   A plain x-ray is sufficient for diagnosis but an MRI may be necessary to rule out other concurrent shoulder problems.
 
Calcific tendonitis can improve with oral anti-inflammatory medications coupled with rest and gradual physical therapy.  If this does not improve, we can help it along by injecting a strong anti-inflammatory injection into the affected area.  This, usually coupled with physical therapy, helps resolve most calcific tendonitis of the shoulder.  However, for those patients in which this is also ineffective, minimally invasive shoulder arthroscopy and removal of the calcium deposits typically resolves the symptoms.

Acromioclavicular (AC) Joint Disease

 
The acromioclavicular joint is the joint between the acromion bone and the end of the clavicle bone, thus the name “AC” joint.  The position of these bones with respect to eachother is maintained by strong ligaments known as the coracoclavicular and acromioclavicular ligaments.
 
The AC joint can be injured due to a traumatic injury when the individual falls and lands on the shoulder and injures these ligaments.  This is called an AC joint disruption or dislocation.  It is also known as a “separated shoulder.”  Depending on the severity of the injury, the disruption can be treated with rest followed by physical therapy or by surgery to restore the alignment of these bones.
 
The AC joint is also a joint that is subject to arthritis after chronic wear and tear.  AC joint arthritis can be very painful, especially when reaching across the body with the arm or when sleeping on the affected side.  Both of these actions compress one end of the degenerated joint into the other end.
 
This condition can be treated with oral anti-inflammatory medications and physical therapy.  Often times, this will not be enough and the patient may benefit from a strategically placed anti-inflammatory injection into the small AC joint itself.  As a third-line treatment, some patients may require partial resection of the AC joint.  This can be done arthroscopically or by a small incision over the end of the clavicle.  This procedure usually resolves all AC joint arthritis related symptoms.

Biceps Tendonitis And Biceps Tendon Disease

 
The biceps tendon is a tendon that originates from just above the shoulder socket, travels in the front part of the shoulder, and attaches to the biceps muscle.  The elasticity of the tendon as well as it blood supply can diminish as we age and is subject to wear and tear.  Biceps tendonitis can be extremely painful with pain located in the front of the shoulder and radiating down the front of the arm.
 
Biceps tendonitis can be treated initially with oral anti-inflammatory medication and physical therapy.  We can help the recovery along with a strategically placed anti-inflammatory injection into the sheath of the biceps tendon itself.  This, usually coupled with physical therapy, can improve most biceps tendonitis.  If this is ineffective, a minimally invasive arthroscopic procedure to treat biceps tendonitis may be necessary.  The biceps tendon may be released surgically from its origin or may be detached and reattached elsewhere after removing the diseased portion of the tendon.

Superior Labrum (SLAP) Tear

 
The superior labrum is a rim of cartilage around the top of the socket of the shoulder joint.  It is associated closely with the origin of the biceps tendon itself.  This rim of cartilage is subject to injury by chronic wear and tear or in the younger athletic population, by overhead/throwing activity.  When this superior labrum is injured, it is known as a SLAP (superior labrum anterior posterior) tear.  SLAP tears usually cause pain deep in the shoulder or a pinching sensation in the front or back of the shoulder.  Patients describe sharp pain with certain movements of the shoulder and in particular, with throwing or lifting items overhead.
 
SLAP tears can be diagnosed with an MRI coupled with a special contrast agent injected into the shoulder called an arthrogram.  Symptoms of a SLAP tear can improve with physical therapy.  Often times, physical therapy may not resolve the symptoms and a minimally invasive arthroscopic procedure is required to repair the SLAP tear.  Physical therapy is needed after the procedure and patients can return to full activity in 2-5 months, depending on the extent of the tear.

Frozen Shoulder/Adhesive Capsulitis

 
Frozen shoulder is technically known as adhesive capsulitis.  This is a condition of the shoulder in which the mobility of the shoulder is rapidly lost due to contraction and disease within the shoulder capsule itself.  The cause for frozen shoulder is not known, but people with diabetes or thyroid disease are more susceptible to frozen shoulder.  Patients with frozen shoulder usually report a gradual increase in shoulder pain which can be quite severe.  They also report a marked decrease in the mobility of the shoulder and inability to perform common everyday tasks because of the condition.
 
Frozen shoulder can be treated with aggressive physical therapy to reverse the disease process of adhesive capsulitis.  We may administer an anti-inflammatory injection into the shoulder to help with regaining the motion and treating the associated pain.  Typically, time, physical therapy, and a well-placed anti-inflammatory injection lead to reversal of this condition.  Less commonly, a minimally invasive arthroscopic procedure coupled with manual manipulation of the shoulder under anesthesia is required to regain shoulder mobility and treat the condition.  Frequent and aggressive physical therapy is needed after the procedure to maintain shoulder range of motion.

Arthritis Of The Shoulder

 
Arthritis of the shoulder is a condition where the smooth cartilage lining the shoulder joint begins to wear.  This results in the humerus bone rubbing on the socket bone, causing pain.  Patients report pain and limited mobility of the shoulder due to arthritis.
 
Currently, no treatment can restore the cartilage lining back to the shoulder joint.  However, symptoms of arthritis can be treated with oral anti-inflammatory medications and physical therapy.  A well directed anti-inflammatory injection between the ball and socket can also help with symptoms.  A minimally invasive arthroscopic procedure to clean out the loose debris and smoothen the remaining cartilage can help with symptoms as well.  A definitive solution is a more extensive operation that involves replacing part or all of the shoulder joint with metal and plastic implants so that the worn bone surfaces no longer rub on each other, nearly eliminating the pain from arthritis.