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C. Thomas Vangsness, Jr., M.D.

ORTHOPAEDIC SURGEON

What are some of the reasons that I can have shoulder pain?


STIFFNESS

A. Adhesive capsulitis is the medical term for a stiff “frozen” shoulder. Often times this comes from trauma but this can arise without any reason at all. People with diabetes commonly get this. It tends to occur more commonly in middle-aged women without trauma. It can also occur in the other shoulder.

A. Patients with “frozen shoulder” have symptoms of pain and often times they cannot do simple everyday life activities such as combing their hair, reaching behind their back, or putting their hand in their back pocket, etc. Pain is usually increased with attempts to lift their hands overhead as this motion is limited.

A. Generally studies show that “frozen shoulders” will “thaw” (tightness lessens), but this can take many months. However, sometimes this pain in the shoulder does not go away and requires surgical intervention.

A. There are several treatment options for the stiff shoulder. The most common initial treatment is a well thought out physical therapy program with a strong emphasis on home exercises/stretching. If this does not decrease the pain and increase the motion, occasionally you will have to undergo a manipulation of the shoulder (glenohumeral joint) while you are briefly put under a general anesthesia.

A. A frozen shoulder is stiff because of scar tissue inside the shoulder. Surgery is occasionally needed if there is longstanding severe stiffness and persistent pain or metabolic reasons such as diabetes. Surgery can involve putting an arthroscope into the shoulder, looking inside and possibly cutting the tight structures from the inside such as the shoulder capsule and the ligaments. This is done as an outpatient procedure.

A. It is very important that you move your shoulder right after a manipulation or surgical debridement. This may involve physical therapy and a rigorous stretching/strengthening home program.

A. The goal of recovery and rehabilitation is to maintain as much motion in the shoulder as possible. This will require daily exercise and patient responsibility. Physical therapy is very important.


ROTATOR CUFF TEARS

A. Rotator cuff tears can result from a traumatic event. However, they generally occur as part of the aging process of the collagen in the tendons about the shoulder.

A. The main symptom is pain, especially pain that prevents you from sleeping or wakes you from sleeping at night. Other symptoms are general weakness and inability to use the shoulder, especially in the overhead position.

A. Rotator cuff tears do not heal on their own. However, symptoms of pain can decrease and the function of the shoulder can improve with physical therapy such that surgery may not be necessary. Many people function in our society with a rotator cuff tear with minimal or no pain and don’t even know they have a tear.

A. The first treatment option is a smart course of physical therapy to maintain motion in the shoulder and work towards increasing the strength power and endurance of the rotator cuff muscles. If this conservative management with a strong emphasis on a home exercise program, does not decrease pain and increase function, then surgical alternatives are often considered.

A. Patients realize they need surgery when the pain is so severe that they cannot function on a daily basis. This is especially true with the pain at night. Generally, this pain can get better with a short course of physical therapy. Perhaps 50% of the patients can get better with physical therapy and not have surgery.

A. Rotator cuff surgery is primarily done by arthroscopy, through a few small incisions. All damaged rotator cuff structures can be identified and repaired with specialized instruments and highly engineered sewing techniques that reattach the torn tendon(s) back to the humerus.

A. Depending on the strength of the repair of the torn rotator cuff tendons, I generally place the arm in an arm sling with a side pillow. Most often your shoulder can be moved immediately without contracting your shoulder muscles (passive motion – usually done by a therapist or the opposite arm). After 4-8 weeks, depending on the strength of repair, I will allow you to begin using your repaired muscles to elevate your arm.

A. This is an outpatient surgical procedure done with an arthroscope through very small incisions. This means less pain and a faster recovery time for you. It will probably be 2-3 months before you can fully raise your arm over your head comfortably. Full function for lifting, carrying, pushing, pulling and sports may take up to 6-12 months.

A. The rotator cuff is a collection of four muscles which power the shoulder. These muscles are important in keeping the shoulder in its socket, as well as providing the power to lift the arm. The rotator cuff can be torn as a result of trauma or can degenerate from years of overhead motion. By age 60, approximately 1/3 of all patients will have a rotator cuff tear. When rotator cuff tears are painful or cause limitations of function they can be addressed. The first line of treatment consists of physical therapy, anti-inflammatory medications, and steroid injections. If these measures fail then surgery can be considered.


INSTABILITY

A. Shoulder instability often comes from either a large traumatic event or many small (repetitive) traumatic events. For instance, a pitcher who throws for years can, over time, stretch out the shoulder capsule and cause instability. A tackle in football can cause the shoulder to traumatically dislocate. Some people are born with “loose collagen” and these patients can develop the pain of instability through simply activities of daily life.

A. Symptoms of instability are pain and weakness in the shoulder in certain arm positions. Often times, specific positions are avoided as you, the patient, know when the shoulder will come out of socket. This is often present when the arm is raised up behind the ear in the throwing position.

A. Generally speaking, shoulders with instability do not get better on their own. The damage is often mechanical in nature and you must undergo physical therapy to strengthen the muscles and stabilize the shoulder or possibly even proceed to a surgery to correct the damaged structures.

A. Treatment options for instability consist of a good course of physical therapy with a strong home program to strengthen the muscles about the shoulder as well as the many muscles connecting to the scapula.

A. If pains persist and instability patterns and instability events continue, including dislocations, then surgery must be undertaken to correct these mechanical problems in the shoulder. Not all physical therapy programs can prevent this.

A. Surgery is an outpatient arthroscopic procedure done through small incisions. The torn ligaments and capsule can be identified and repaired with sutures back to their normal positions at the glenoid.

A. After surgery I will place you in a sling and a pillow for comfort to alleviate the effects of gravity on the arm which can pull down on the repair. This will also stabilize your repair as you continue with your busy activities of everyday living. You can use your elbow and your hand in front of your body, between your belt buckle and your mouth. Advanced motions will come after the repaired tissue heals over several 4-8 weeks.

A. After surgery you will be in a sling and a pillow for 6-8 weeks to allow the ligaments and capsule reconstructions to heal. From that point you will advance with physical therapy and a home program to more extreme ranges of shoulder motion after several months time. Simple goals will be to return to sporting activities such as throwing between 3-4 months. Contact sports can begin in 3-4 months as well. Return to work in a non- lifting, pushing, pulling job can be within a week.


LABRAL TEARS

A. The labrum is the fibrous rim of cartilage surrounding the perimeter of the shoulder socket. It can commonly become torn with excessive motions about the ball and socket (glenohumeral joint). Traumatic shifts of the ball in the socket or repetitive motions such as throwing can cause tears to this tough rim of tissue.

A. Symptoms involve sensations of clicking and catching with certain motions in the shoulder. Often times they can become very painful.

A. The labrum does not generally heal on its own. The mechanical symptoms can increase over time and can become painful.

A. A conservative short course of physical therapy can be tried. However, these tears are generally mechanical in nature and often times require trimming or sewing with an arthroscopic surgical procedure.

A. You will need surgery if symptoms of pain continue. Often time these symptoms will not allow you to use your shoulder effectively in everyday activities or athletics.

A. Surgery is an outpatient arthroscopic procedure done through small holes in the shoulder. At that time, motorized instruments can trim and remove the mechanical tears in the labrum. Also highly engineered instruments can be used to sew the labrum back to the edge of the socket (glenoid).

A. Generally, you can immediately use your shoulder with motions keeping your arms and hands in front of your body. If the labrum is trimmed, you can quickly advance to as much shoulder motion as possible. If the labrum is sewn, you may have to restrict your motions until the reconstruction heals in 3-6 weeks.

A. Recovery and rehabilitation of labral tear will be quick if only trimming of the tear is done. If there is sewing involved, return to the extremes of motion and heavy lifting will be curtailed for several weeks. Throwing may not begin till 3-4 months.

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IMPINGEMENT / BURSITIS

A. Impingement occurs when the arm is elevated and the top of the arm (humerus) pinches underneath the acromion, the bone on the top of the shoulder. The bursa structure is a cushion between these two boney structures and as this gets pinched, it can become swollen and inflamed – that’s why it’s called bursitis. Often repetitive overhead motions, such as swimming, or lifting can bring on bursitis.

A. Symptoms are simply pain when you lift your arm. It is really when the arm goes overhead that pinching of the bursa is encountered.

A. It often times can get better with good shoulder mechanics, proper exercises, and anti-inflammatory medicines. Physical therapy and occasionally cortisone injections can help. Non-steroid anti-inflammatory drugs (NSAIDs) can help reduce the “-itis” of this bursitis.

A. Initial non-operative treatment will include physical therapy and a home exercise program. Ongoing, unrelieved pain may require surgery.

A. Persistent pain and failed attempts with physical therapy, injections, or anti-inflammatory medicine for longer than 2-3 months, generally requires surgical intervention. This is really about quality of life issues and reducing pain.

A. Surgery is outpatient arthroscopic surgery to trim any bone spurs underneath the acromion and remove the thickened painful bursal tissue. Removal of the bone under the acromion is called a subacromial decompression (SAD).

A. After this surgery a sling is used for comfort and this may be removed as soon you have more motion and less pain. Shoulder motion can be restored in 3-6 weeks and the pain is generally reduced as the surgical incisions heal up.

A. If the rotator cuff is not involved, the recovery is very quick. An exercise program is started right away and you can remove the sling as soon as you feel comfortable. You can move your hands and elbows in front of your body right away and progress to more extreme motions over time as your strength improves. You can return to work within a few days if you do not have to do a lot of lifting, pushing, and pulling. Return to sports can be anywhere from 6-12 weeks depending of the sport and the extent of the shoulder problems involved.


FRACTURES

A. Broken bones (fractures) are often very painful. The only way we can really diagnose a fracture is by x-ray.

A. Generally, if the fractured bone is not separated then surgery can possibly be avoided. If the bone is broken in many places or the bone fragments are separated then often surgery may be required to help correct the anatomy of the broken bone. Even if the fracture does not require surgery, a period of immobilization (cast) may be required.

A. Generally it takes 6-8 weeks for bones to heal and that’s how long you’ll be in a cast or a brace. This depends where the fracture is, the individual bone, and the amount of energy involved to create the fracture.

A. Recovery and rehabilitation after a fracture will depend on which bone is fractured. Fractures that involve the rotator cuff tendons can be slower to heal. Fractures that involve the shoulder joint can make the shoulder stiff.


AC JOINT PAIN (ACROMIAL CLAVICULAR JOINT PAIN)

A. A painful AC joint is usually caused by a stress or strain of the AC joint or arthritis in this joint. Occasionally, impingement and bursitis can mimic this pain. Lifting your arm across your body can increase this pain.

A. This can heal on its own. However, if arthritis is involved the AC joint can continue to be painful in everyday activities.

A. Treatment options for AC joint problems involve reducing the inflammation about the capsule or managing the symptoms of arthritis in the AC joint. This involves nonsteroid anti-inflammatory Drugs (NSAIDs), cortisone injections, or possibly surgery.

A. Occasionally these pains do not go away. If this pain persists over time surgical intervention may be required to remove the capsule surrounding the joint and a few millimeters of the end of the clavical bone: The idea is to remove the painful bone to bone contact, most commonly due to arthritis. This is called a Mumford procedure.

A. After surgery you can move your shoulder as much as possible. Pain will be your guide. The goal is to obtain full motion between 4-6 weeks after surgery. You can lift, push, and pull in the early days after the surgery.

A. A sling is used for comfort for 1-2 weeks if necessary and motion begins immediately. Return to work depends on the pain. Roughly 80% of the time there is minimal pain after 4-8 weeks. 10-15% of the time you can have intermittent symptoms of pain over time, especially with overhead activities.


CALCIFIC TENDONITIS

A. For uncertain reasons, the tendons about the body can accumulate areas of calcium. Depending on where this occurs it can become very painful. Commonly the rotator cuff tendons can get calcium bodies.

A. Symptoms of calcific tendonitis can involve painful bursitis and painful forward flexion impingement. Simple movements when using the shoulder can cause pain.

A. The causes of calcific tendonitis are uncertain.

A. Calcific tendonitis is treated in a conservative nonoperative fashion. Often cortisone injections or poking the calcified area with a needle can help remove the calcified structures. Over time, studies have shown that these calcified areas generally go away. If symptoms of pain continue, arthroscopic surgery can remove the calcified area with small motorized instruments.

A. Recovery from this outpatient procedure is generally quick if the rotator cuff is not severely involved. Return to work can be in days and return to rigorous activities can be within weeks. The calcification can recur, but generally this is not common.


NECK PROBLEMS

A. There are many nerves that come off of the cervical (neck) vertebral bodies that pass down in front of the shoulder heading towards the arm. Irritation of these nerves can refer pain to the shoulder.

A. Rotation of the neck or tilting of the neck can create your shoulder pain if these nerves are involved. There may also be numbness, tingling, weakness, and difficulty with motion/movement.

A. Treatment options are always conservative in nature with a strong course of core strengthening and physical therapy of the neck and trunk muscles. Specific scapular strengthening exercises are often important to consider as well. Sometimes anti-inflammatory medicines, muscle relaxers, and cortisone injections are given. Continued long lasting severe pain can lead to referral to a neck specialist.


DISLOCATED SHOULDER

A. A dislocated shoulder is usually a result of trauma. The most common type is an anterior dislocation, in which the humeral head (ball) moves in front of the glenoid (socket). The signs of dislocation are pain, inability to move / lift the arm, and a different contour of the shoulder compared to the opposite side. Shoulder dislocations occasionally self-reduce but often will require a reduction/relocation by a specialist. Reduction of shoulder dislocations will require medications to relax the muscles. Shoulder dislocations in the young are often re-occurring and require surgery to stabilize the joint. Dislocations in the elderly are often accompanied by a rotator cuff tear.


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