Multidisciplinary Shoulder Care

Frozen shoulder is a severely restrictive condition frequently caused by injury that, in turn, leads to lack of use due to pain. Intermittent periods of use may cause inflammation and adhesions to grow between the joint surfaces, thus restricting motion. There is also a lack of synovial fluid to lubricate the gap between the arm bone and socket that normally helps the shoulder joint to move. This restricted space between the capsule and ball of the humerus distinguishes adhesive capsulitis from the less complicated condition known as stiff shoulder.

Bursitis often occurs when tendonitis and impingement syndrome cause inflammation of the bursa sacs that protect the shoulder. The jelly-like sacs serve as a cushion to reduce friction between bones and soft tissues of the body. Bursae (plural of bursa) are located throughout the body near joints such as the hips, knees, shoulders, elbows and heels. Bursitis can be chronic (long-term), involving repeated flare-ups of pain, swelling and tenderness. While these attacks are usually temporary, over time they may lead to muscle deterioration and reduced range of motion in the affected joint.

Rotator cuff problems and tears are common among adults, and are a frequent source of pain and disability.

A rotator cuff injury such as a tear may happen suddenly when falling on an outstretched hand or may develop over time due to repetitive activities. Rotator cuff tears may also happen due to aging, with degeneration of the tissues.

Common symptoms of a rotator cuff tear may include:

• Recurrent pain, especially with certain activities.
• Pain that prevents you from sleeping on your injured side.
• Grating or cracking sounds when moving your arm.
• Limited ability to move your arm.
• Muscle weakness.

A rotator cuff may tear partially or fully. Partial-thickness tears do not completely sever the tendon from the shoulder.

In addition to a complete medical history and physical exam, diagnostic procedures for a rotator cuff injury may include the following:

• X-ray, which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
• Magnetic resonance imaging (MRI), which uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

Impingement syndrome is caused by the excessive squeezing or rubbing of the rotator cuff and shoulder blade. The pain associated with the syndrome is a result of an inflamed bursa (lubricating sac) over the rotator cuff, and/or inflammation of the rotator cuff tendons, and/or calcium deposits in tendons due to wear and tear. Shoulder impingement syndrome can lead to a torn rotator cuff.

For many people, self-care measures are enough to relieve shoulder impingement symptoms. But if self-care and other treatments haven’t worked, surgery may be an option. Surgery can help free up the joint space, allowing pain-free motion. Talk to your doctor to see if surgery is right for you.

Your shoulder joint is a ball-and-socket joint in which the rounded top of your upper arm bone (humerus) fits into a cup-shaped socket (glenoid) of the shoulder blade. Shoulder instability is a condition that occurs when the muscles, ligaments and tendons that surround the shoulder joint loosen and do not keep the ball in the socket. 

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Tendonitis of the shoulder is caused when the rotator cuff and/or biceps tendon become inflamed, usually as a result of being pinched by surrounding structures. The injury may vary from mild inflammation to involvement of most of the rotator cuff. When the rotator cuff tendon becomes inflamed and thickened, it may become trapped under the acromion. 

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A SLAP (superior labrum anterior and posterior) tear is an injury to a part of the shoulder joint called the labrum. The labrum is the cuff of cartilage that extends the socket part of the shoulder blade to better accept the ball end of the arm bone.

A SLAP lesion is a tear that occurs where the tendon of the biceps muscle meets the labrum.

Common causes of a SLAP tear include:

• Fall onto an outstretched hand.
• Repetitive overhead actions (throwing).
• Lifting a heavy object.

Symptoms of a SLAP lesion can include:

• A catching sensation, clicking or locking in the shoulder.
• Pain in the front or top of the shoulder.
• Increased pain with movement, especially with overhead activities.
• Decreased range of motion of the shoulder and arm.

Determining if pain is caused by a SLAP lesion is sometimes difficult because the injury often does not show up well on normal MRI scans. However a MRI scan with dye placed into the shoulder is often helpful to diagnose a labral tear. Sometimes, though, an actual diagnosis is made at the time of surgery when the orthopaedic surgeon has an opportunity to look inside the shoulder, most often during an arthroscopic surgical procedure. 

Biceps tenodesis surgery is a procedure to repair the biceps tendon, a long cord-like structure that attaches the biceps muscle of your upper arm to the elbow at one end and the shoulder at the other. At the shoulder end, the biceps tendon divides into two strands, called the long head and the short head. 

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Labral repair is a surgical procedure used to correct damage to the ring of cartilage (labrum) that surrounds the cup or socket in the shoulder joint for the end of the arm bone (humerus) to move smoothly and securely. This cartilage makes the shoulder joint much more stable, and allows for a very wide range of movements. In fact, the range of movements in the shoulder far exceeds any other joint in the body.

Labral repair is most commonly performed arthroscopically using a tiny video camera inserted through a small incision in the shoulder. The camera transmits images of inside the joint to a monitor in the operating room and helps the surgeon identify the problem. Small instruments are inserted through additional incisions to then repair or remove the damaged cartilage until healthy tissue remains. Next, small anchors are placed into the shoulder socket bone (glenoid). These anchors are what will re-attach the cartilage to the bone. Most labral repairs require 2-3 anchors, depending on the location and size of the tear.

This procedure is usually recommended when persistent pain and instability in the shoulder do not respond to more conservative methods, such as exercise and pain medication, and interfere with recreation and activities of daily living.

Our orthopaedic specialists will work with you to determine the right treatment for your rotator cuff injury. Treatments may include:

• Rest.
• Nonsteroidal anti-inflammatory medicines.
• Strengthening and stretching exercises.
• Ultrasound therapy.
• Corticosteroid injection.
• Surgery (for severe injuries).
   

Shoulder manipulation is a procedure where the arm is forcibly stretched in various positions to relieve stiffness and pain caused by frozen shoulder. In some cases, the manipulation may cause tearing in the shoulder joint. Motion is restored, but as the body begins to repair the area it lays down more scar tissue which can potentially cause more loss of motion and pain. This means the patient must undergo additional physical therapy to prevent further loss of motion.

In most cases, there is no actual surgery involved, meaning incisions (cuts) are not made when a manipulation is performed. After anesthesia is given, the surgeon will move the shoulder through a full range of motion in order to break up scar tissue to improve shoulder mobility.

The alternative to manipulation is arthroscopic release. It is usually performed on people who have a severe loss of mobility in the shoulder. After anesthesia is given, the surgeon inserts a small camera and other instruments through very small incisions in the shoulder. This allows the surgeon to see inside the shoulder and to remove any scar tissue surrounding the joint. A gentle manipulation follows. This will significantly reduce the risk of injury if the frozen shoulder has been present for some time. If necessary, other disorders within the shoulder can be addressed at the same time.

Surgery is usually recommended when more conservative methods, such as physical therapy or anti-inflammatory medications, fail to relieve pain and restore range of motion.

Shoulder replacement surgery is usually done when the shoulder joint is badly damaged and there is pain or loss of motion that has not responded to more conservative methods, such as activity modification or use of anti-inflammatory medications.

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