Orthopedic Shoulder and Elbow Surgeon. Engineer. Edmonds, Washington
This is a follow-up to my last post regarding rehabilitation from rotator cuff tendinitis and partial thickness rotator cuff tears. This is an evidence-based home treatment protocol for the same conditions from the MOON Shoulder Group. It is a well designed protocol that has been proven to be effective. More information about rotator cuff tendinitis can be found here.
Read MoreBelow is a copy of my preferred evidence-based nonoperative rehabilitation protocol for rotator cuff tendinitis and partial thickness rotator cuff tears.
Read MoreThis is part 2 of our discussion on shoulder arthritis. Previous posts include:
Pain is by far the most common symptom of arthritis of the shoulder. This pain is normally aggravated by activity and worsens over time. The pain may be felt as a deep ache or may be centered in the back of the shoulder. This pain also normally intensifies with changes in the weather. Night pain is also incredibly common with most shoulder problems.
Decreased range-of-motion is also very common with shoulder arthritis. This may be secondary to pain or may be from a tight shoulder capsule or bone spurs.
Please stay tuned for more posts on the diagnosis and treatment of shoulder arthritis.
Rotator cuff repair
This is part 1 of our discussion on rotator cuff repairs.
Previous posts on rotator cuff include:
Rotator cuff surgery is a very generic term that encompasses many different procedures. They can be as minimal as a debridement of the bursa and the rotator cuff with possible removal of any bone spurs called a “smooth and move” procedure. This procedure is normally reserved for partial rotator cuff tears or rotator cuff tears that are old or have poor tissue quality. If you have a complete tear of your rotator cuff with good tissue quality and desire a return to an active lifestyle, you may be candidate for a rotator cuff repair.
A rotator cuff repair is most commonly done by stitching the tendon back to its original site on the humerus. In active patients who have a old, complete tear with poor tissue quality, the options are more limited, unfortunately. Luckily, a new procedure called the superior capsular reconstruction may help restore some shoulder function that would otherwise be impossible.
This post is part 1 of my posts on shoulder arthritis.
Arthritis is the abnormal wearing down of cartilage in the joint. Cartilage is the smooth, protective layer that acts like a cap at the end of bones in joints. The complete cause of the most common type of arthritis, osteoarthritis, is still unknown. We believe that it is a combination of genetic and activity related factors. The other type of arthritis is called inflammatory arthritis and may include rheumatoid arthritis.
Arthritis in the shoulder is normally between the ball of the humerus and the socket of the shoulder blade. Patients can also get arthritis between the shoulder blade and the collar bone, called AC joint arthritis.
Stay tuned for my next posts about the diagnosis and treatment of shoulder arthritis.
Shoulder arthritis
This post is a continuation of our talk on rotator cuff tears. Today, we will be discussing the symptoms and diagnosis of rotator cuff tears. Previous posts included:
Nonsurgical treatment is usually based on avoiding activities that cause shoulder pain, nonsteroidal antiinflammatory medications, and extensive shoulder stretching at home or with physical therapy. Often times, the pain in your shoulder is secondary to shoulder stiffness. Once the stiffness has been resolved, the shoulder pain improves significantly. In the past, many physicians have recommended steroid injections into the shoulder. Many shoulder specialists, like myself, do not recommend this course of treatment often due to its negative effect on the rotator cuff tendon. Steroid injections can make the rotator cuff tendon weaker and more prone to more extensive tearing.
If you had a significant injury that resulted in a rotator cuff tear or you have not improved with extensive physical therapy and home exercises, minimally-invasive rotator cuff surgery may be an option for you. To learn more about rotator cuff surgery, continue reading here.
This post is a continuation of our talk on rotator cuff tears. Today, we will be discussing the symptoms and diagnosis of rotator cuff tears. Previous posts included:
The most common symptoms of rotator cuff tears are:
pain at night, especially if lying on the affected shoulder
pain when lifting or lowering your arm or with specific movements
weakness when lifting or rotate your arm
cracking or popping sensation when moving her shoulder in certain positions, especially overhead
Tears that happen suddenly, such as from a fall or when lifting something heavy usually cause intense pain. You may also notice that you are unable to lift your arm after this injury.
Tears that develop slowly due to overuse, usually begin by some vague pain in her shoulder that progresses to worsening pain and then significant pain and weakness.
Some rotator cuff tears, especially those that occur slowly over time, are sometimes not painful. These tears, however, may still result in some weakness and other symptoms.
Rotator cuff tears can be diagnosed with history and physical examination on most occasions. Sometimes, advanced imaging such as MRI or ultrasound can be used to confirm a diagnosis of a rotator cuff tear.
Stay tuned for the next post on rotator cuff treatment.
This is a continuation of my blog series on rotator cuff issues. Today, we will discuss what causes rotator cuff problems.
Rotator cuff problems can fall along a wide spectrum of issues. The most common is inflammation of the rotator cuff called rotator cuff tendinitis. Along with this issue is inflammation of the bursa sac called bursitis. Sometimes, the rotator cuff tears off of the humerus bone. This can range from a small, partial tear of the rotator cuff tendon to a complete tear of the rotator cuff tendon. Many times, complete rotator cuff tears begin with minor tendinitis that progress to partial tearing and then complete tear.
There are two main causes of rotator cuff tears: acute injury and degeneration.
Injury to your rotator cuff is usually caused by lifting something very heavy with a jerking motion. This can tear the rotator cuff tendon off of the humerus bone.
Location of rotator cuff pain
Degenerative tears are by far the most common type of rotator cuff tears. These tears are often caused by wearing down of the tendon slowly over time. This type of tear usually starts with tendinitis and progress to partial thickness tears and complete tears. These can be due to repetitive stress or just wear over time.
Stay tuned for more information about rotator cuff tears. More information can be found here.
Many people hit the gym to get their beach body where they’d like it to be before the summer, but there are sometimes issues with pain or inflammation that can get in their way.
Biceps tendonitis is the technical term for irritation or inflammation in your upper biceps tendon, which attaches your biceps (the muscle located at the front of your upper arm) to your shoulder bones. Tendons are tough strips of connective tissue which connect muscles to bones and let you move your arms, legs, and other body parts, and your biceps muscle has three of them: two that attach it to your shoulder bones and one that attaches it to your radius, one of your two forearm bone, at your elbow.
What are some of the causes for a bicep tendon injury?
Biceps tendon damage is most often simply the result of wear and tear due to normal daily use. Tendons age just like everything else in our bodies, and as we age they tend to weaken and degenerate just from being used every day over a lifetime. This slow degeneration can be accelerated by overuse or repeating the same motions over and over.
What are the symptoms of a bicep tendon injury?
If you tear your biceps tendon, the most obvious symptom will be pain—sudden and severe pain. Depending on where the tendon is injured, you may feel this in your upper arm or at the elbow. You may feel or even hear a popping sound when the tendon tears.
Other signs that you might have torn your biceps tend are:
A sudden, sharp pain at your shoulder or in your elbow as the tendon tears
Bruising of your upper arm in the injured area
Weakness in your shoulder or your elbow as the muscle becomes detached
Difficulty turning your arm and hand between palm-up and -down positions, as the detached muscle is unable to do its work
The front of your upper arm may appear misshapen if the tendon is torn completely. Muscles, when properly attached, are stretched like rubber bands. When the tendon tears, it no longer holds one end in place and the muscle recoils, forming a bulge in your arm.
While surgery may be necessary to repair a torn biceps tendon, many people are able to function normally without a surgical repair. The appropriate treatment depends on the type of injury and its severity, and in many cases symptoms can be relieved by the same treatments used for tendonitis. Tears that occur at the elbow require surgical repair more often than those at the shoulder.
Some surgical procedures can be done arthroscopically, using small incisions rather than a single large one, although open surgery has very good results and is the one that I prefer.
Surgical repairs for a biceps tendon injury may include:
Reattaching the remaining tendon to the bone. This procedure is called a biceps tenodesis.
The rotator cuff
A common condition that I see and am asked about in clinic is rotator cuff tears.
Rotator cuff problems are some of the more common and frustrating issues that patients can deal with throughout their lives. Rotator cuff issues can weaken your shoulder and make activities of daily living, like combing your hair or getting dressed painful and difficult to do.
Your shoulder is made up of three bones:
your upper arm bone, called the humerus,
your shoulder blade, called the scapula, and
your collar bone, called the clavicle.
Your arm is partially kept in your shoulder socket by the rotator cuff. The rotator cuff is a group of four muscles that come together to form tendons that cover the head of your humerus. The rotator cuff attaches to the humerus and allows you to lift and rotate your arm.
On top of your rotator cuff, you have a lubricating sac called the bursa. The bursa allows your rotator cuff to freely glide when you move your arm. Sometimes, the rotator cuff or the bursa become inflamed and painful.
shoulder bursa
Stay tuned for more information about rotator cuff tears. More information can be found here.
https://www.ncbi.nlm.nih.gov/pubmed/31743037?dopt=Abstract
I am routinely asked about platelet rich plasma (PRP) treatment for rotator cuff tears. PRP is obtained from a patient’s blood and is then injected into injured tissue like rotator cuffs. Many physicians perform this procedure (I do not), but the effectiveness has not been well established at the time of this blog. The above article looked into the effectiveness for rotator cuff tears. Their conclusion that “significant improvements in PRP-treated patients were noted for multiple functional outcomes, but none reached their respective minimal clinically important differences” shows that the PRP has yet to show any functional improvements for rotator cuff tears. I encourage patients to have frank discussions with their physicians about the potential risks and benefits of this procedure before proceeding.
When people typically think of a joint replacement they will think of a knee or hip. However, shoulder replacements, though less common, can have a resounding effect on the quality of life of the individual.
Shoulder joint replacement is a safe, effective procedure to help with painful conditions of the shoulder that cannot be adequately managed with medications or therapy.
Why are shoulder replacement procedures performed?
Your shoulder is a ball-and-socket joint that’s comprised of three bones: the upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle). The ball, or head, of your upper arm fits into a shallow socket in your shoulder blade. When your shoulder is functioning properly, a thin, smooth tissue called synovial membrane makes fluid that lubricates the cartilage, allowing your shoulder to move smoothly and easily without much friction. The muscles and tendons that surround the shoulder provide support, and all these structures working together allow the shoulder to rotate through a greater range of motion than any other joint in the body.
Conditions such as arthritis can cause joints to lose their cartilage covering, and when you move, bone will move on bone without adequate protection. The result can be very painful, and you may experience a limited range of motion that hampers your ability to accomplish your daily activities.
What are the different types of shoulder replacement procedures?
Shoulder replacement surgery replaces the ball and sometimes the socket with man-made parts. Often the ball is replaced with metal and the socket is replaced with plastic. The components can be held in place with cement, or they can be made of material that lets new bone grow into the joint component over time, holding it in place.
Hemiarthroplasty – the ball part of the head is replaced with an artificial joint that has a stem to extend into the shaft part of the bone. It’s usually used for fractures but is also often used for shoulders affected by arthritis.
Shoulder resurfacing – a different type of hemiarthroplasty that requires the removal of less bone. Instead of removing the ball part of the joint, a metal cap is simply placed over it.
Total arthroplasty – this replaces both the ball and socket and is usually used for specific types of arthritis. Your doctor will take into consideration your age, how badly worn the natural joint is, and the condition of the tendons around the joint. A total arthroplasty will sometimes be performed using a resurfacing component.
Reverse shoulder arthroplasty – artificial components are fitted in reverse, with the socket to the upper arm bone and the ball to the shoulder blade. It’s usually only performed on patients with severe arthritis and extremely poor rotator cuff tendons around the joint. It’s sometimes be used if a patient has both a severe joint fracture and poor tendon function.
I, as your surgeon, will determine the location, type, and extent of your shoulder problem before recommending the type of joint replacement that would be most suitable in your particular case.
Are you a candidate for shoulder replacement surgery?
The decision to have shoulder replacement surgery should be made in cooperation with you, your family, your family doctor, and your orthopedic surgeon
Pain in the shoulders can significantly impact a patient’s quality of life and ability. Luckily, there are plenty of options, both surgical and non-surgical, that can alleviate this pain. If a surgical option seems prudent for your situation, you can ask these questions to ensure you are informed prior to the operation:
As with many other shoulder surgeons, it is common to practice a conservative approach to surgery, attempting to seek other options before resorting to surgery. Understanding these options, like general pain management techniques or therapies, can better inform that patient on the wide array of options for regaining their quality of life. Even if surgery is necessary, the patient will be informed on other options at the very least.
A common question is whether avoiding surgery will compromise the long-term outcome. This is a case-by-case decision and must be considered carefully by both the patient and physician, but there is a lot of evidence that can be used to help predict this. For instance, with a partial rotator cuff tear the risk of tear progression is low and attempting conservative treatment for several months does not typically affect the long-term outcome. Conversely, an acute rotator cuff tear (one that occurs after a trauma such as a fall) typically responds better to being repaired within a few months rather than waiting several months to a year.
The recovery from shoulder surgery can be lengthy and again varies from patient to patient depending on a number of factors. Patients should ask and understand how long they will be in a sling, when they can drive, when they can return to work, when they can return to sporting activities, and when they can expect complete pain relief.
A patient considering shoulder surgery should have a good understanding of the risks of the surgery. These can vary considerably. An arthroscopic cuff repair, for instance, has an anticipated complication rate of about 1%. Conversely, the complication rate after a shoulder replacement may be 5 to 10%. Additionally, while volume is important as noted above, complications rates can vary between surgeons.
Getting answers to these questions should help you make the right decision for you. Making sure you’re comfortable with your surgeon and your procedure, as well as understanding recovery expectations are all important for the success of your procedure.
The group of muscles and tendons that surround, stabilize and allow movement at the shoulder joint are the rotator cuff muscles. Because of this, any surgical procedure on the shoulder will likely have some involvement with your rotator cuff muscles. No matter the reason for your shoulder surgery, here are some general tips to help maximize your recovery.
It is important to insure that the muscles that have recently been operated on are supported and allowed to heal with minimal strain. Wearing a sling or some sort of standing support will allow for this throughout the day and sleeping with a pillow to support the affected side at night will help.
The rotator cuff muscles will take time to heal. Initially you should avoid putting any strain at all on your shoulder. After some time however, it’s important to stick to the physical therapists recommended exercises to slowly and gradually re-build the muscles.
Of course pain will be more significant immediately after the operation as compared to a few weeks out. To manage this, you can rely on prescription or over-the-counter medications as well as inflammation management practices like cold compresses. In addition, wearing your sling should help reduce shoulder pain and reduce the likelihood of unnecessary strain or damage to the muscles and tendons during the recovery period.
Consult with your physical therapist or physician as to when you can begin to resume normal activities with your post-operative shoulder. For example, from about 6 weeks you usually will be able to start using your shoulder for gentle tasks such as washing and dressing while at 12 weeks you will be thinking about using your arm for other moderate activities, such as swimming.
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You can experience pain in your shoulder for a variety of reasons, many of which are issues that are minor and shouldn’t worry you. Your shoulder joint is covered in a tissue that is tough and lubricates the joint articulation (where the bones in your shoulder meet) called cartilage. When your cartilage is healthy and functioning properly, you are able to experience full range of motion with little to no pain. However, as we age or when we experience an injury in the shoulder, the cartilage can wear thin or become damaged. This damage can cause pain and stiffness which will limit your range of motion in the shoulder. When you begin to experience pain or stiffness in your shoulder, try simple pain relief techniques like stretching, ice, and/or heat. If pain persists, it may be time to review your options with a shoulder specialist.
The deltoid
Shoulder injuries are very common with sports and exercise. 2 out of 3 people will experience a shoulder injury or problem at some point in their lives. Deltoid exercises are very common with many who lift weights, however, the anterior deltoid normally gets most of the attention. The deltoid actually consists of 3 main heads: the anterior, middle, and posterior. Imbalance in the 3 heads of the deltoid can lead to injuries. A study conducted by the University of Wisconsin LaCrosse evaluated proper deltoid exercises to see which were most effective.
To determine which exercises are most beneficial for activating shoulder muscles, researchers compiled a list of the 10 exercises most often performed by both recreational lifters and athletes and most commonly prescribed by trainers.
Barbell upright row
Battling ropes
Bent-arm lateral raise, great for the medial deltoids
Cable diagonal raises
Dips
Dumbbell front raise
Dumbbell shoulder press, tops in training for the anterior deltoids
Push-ups
Seated rear lateral raise, excellent for the posterior deltoids
45-degree incline row, excellent for the medial and posterior deltoids
Following the testing these exercises on 16 athletes, researchers compiled and evaluated the data. The conclusions were:
For targeting the anterior deltoid, the dumbbell shoulder press elicited significantly higher muscle activation than any other exercise tested.
For the medial deltoid, two exercises came out on top: the 45-degree incline row and the bent-arm lateral raise.
For the posterior deltoid, researchers found that the seated rear lateral raise and the 45-degree incline row both provided the greatest muscle activation for the back of the shoulder.
For the most high yield workout, you are best served starting with weakest rear deltoid with either the 45-degree incline row or the seated rear lateral raise followed by the dumbbell shoulder press to target the front of the shoulders.
Exercise is very important both physically and mentally, but always needs to be done the right way. I hope that this info will add to your workouts.
Dr,. Andrew Pastor
Q: I have been suffering from worsening shoulder pain and stiffness for several months. I finally had to stop exercising or playing sports because of the pain. The pain is waking me up at night and it's difficult to raise my arm above my head. I don’t recall injuring my shoulder. What could the problem be?
A: This is a question that I am asked on a daily basis. There are many possible causes of your shoulder pain.
The shoulder is a very complex joint that is vulnerable to overuse injuries and arthritis. It is actually the most mobile joint in the body.
The most common causes of shoulder pain are tendinitis/bursitis, arthritis, and rotator cuff tears.
The shoulder is actually comprised of two joints. The acromioclavicular (AC) joint is between the tip of the scapula (shoulder blade) and the clavicle (collarbone). The glenohumeral joint is between the humerus (upper arm bone) and the scapula.
The shoulder joint has a much more shallow socket called the glenoid (on the shoulder blade) than the deep hip socket.. Surrounding the glenoid is an O-ring made of cartilage, called the labrum. The labrum deepens the socket and adds stability. The four rotator cuff muscles and tendons stabilize the shoulder joint in the socket as well as rotate the shoulder. There is a fluid-filled spongy tissue known bursa sac that lubricates and cushions this joint space above the rotator cuff. The biceps muscle attaches to the shoulder in two places and helps control motion at the shoulder and elbow. The strongest muscle in the shoulder is the deltoid which help rotate, flex and lift your arm.
The shoulder joint
Injuries or inflammation of any of these structures can cause shoulder pain, stiffness and diminished range of motion.
In your case, in the absence of an acute injury, overuse of your shoulder (especially repetitive overhead activities at your job or with exercise) and aging may result in inflammation of the rotator cuff (tendinits), bursa (bursitis), and gradual deterioration and eventually tearing of the rotator cuff.
Inflammation in any of these areas almost always cause night pain, especially if you sleep on the affected side. Chronically inflamed shoulders may develop scarring in the shoulder over time that eventually completely immobilize the shoulder joint, which is known as adhesive capsulitis or frozen shoulder.
Osteoarthritis, which is the wearing down of cartilage in the shoulder joint, is another common cause of shoulder pain, especially if you had an old injury that damaged your cartilage. Osteoarthritis may also cause night pain, weakness and limited range of motion.
A torn labrum may cause pain, locking or clicking, or the feeling that your shoulder will dislocate.
There are other diseases that can cause shoulder pain like a herniated cervical disc, but your history doesn’t really support this.
Depending on your history and physical examination, your doctor may want to do X-rays, an MRI, or an ultrasound for more specific diagnostic information.
Treatment options include applying ice or heat, non-narcotic pain medication, TENS (transcutaneous electronic nerve stimulator), physical therapy (including a home exercise program to continue stretching and strengthening and prevent recurrence).
I recommend activity modification by refraining from any aggravating repetitive activities, but you must maintain the range of motion in order to prevent stiffness. Gentle range of motion activities can almost never make your condition worse. .Ask your physical therapist or doctor how much you can use it and don’t immobilize the joint or wear a sling unless specifically told to do so. I hope this helps!
Andrew Pastor
A study that was presented at the American Academy of Orthopedic Surgeons has demonstrated that transcutaneous electrical nerve stimulation may reduce the pain scores and opioid use after rotator cuff repairs. In this study, 37 patients were randomized to use either an active or a sham TENS unit during the first week after a rotator cuff repair.
Electrical stimulation for pain control was first used in ancient Rome. The first modern, patient wearable TENS unit was patented in the United States in 1974. It was initially used for chronic pain patients but its use has expanded to other areas.
TENS unit
Following arthroscopic rotator cuff repair, the use of a TENS unit during the first postoperative week was associated with significantly lower pain scores and opioid pain medication use when compared to patients who received the sham TENS unit.
I have used the this treatment as part of my shoulder pain protocol after rotator cuff repair surgery with good results. I continue to research ways to decrease postoperative pain and improve the overall outcomes of my patients after shoulder surgery. The study is encouraging and may provide an inexpensive and safe way of improving pain control after surgery.
As anyone who has ever had shoulder pain will tell you, sleeping can be very difficult. I hear this concern daily in my shoulder clinic and often times this is the biggest complaint after a shoulder injury or shoulder surgery...
Read MoreCould artificial muscles be an answer for chronic rotator cuff tears? This is a question that I couldn't help but ask myself while reading this fascinating article. The rotator cuff is a collection of 4 muscles and tendons that allow us to raise our arms. As many know, chronic (old) rotator tears are a very difficult problem to treat and can lead to severe disability in patients.
Shoulder specialists have been trying for years to determine the optimum treatment for chronic rotator cuff tears. Our current treatment for old rotator cuff tears is evolving and may include a simple "clean out" of the joint, placing a graft where the rotator cuff tendon was (a superior capsule reconstruction) or a reverse shoulder replacement. No one solution achieves return to full function due to the fact that rotator muscles atrophy and are no longer functional.
Artificial muscles may allow us the ability to transplant and replace the atrophied rotator cuff muscles and regain significant function. Although this research is very exciting, I would be remiss to say that this artificial muscle research is still in it's infancy and has not, to my knowledge, been proposed for use in shoulder surgery, so stay tuned.
I will continue to research this and other treatments and devices here and on my upcoming website the orthopedicfuturist.com.