Anatomy and Function of the Shoulder
The shoulder joint is considered one of the most complex joints in the body. It consists of three bones: the scapula (shoulder blade socket), clavicle (collar bone) and humerus (upper arm bone).
Although the shoulder is the most moveable joint in the body, it is unstable because the ball (the humerus) is larger than the socket (the glenoid) that holds it. To maintain stability, the bones of the shoulder are held in place by muscles, tendons, and ligaments. Tendons are tough cords of tissue that attach muscles to bone, and ligaments attach bones to each other for stability.
Shoulder Conditions and Treatment Options
Major causes of chronic shoulder pain are largely related to age and overuse. With age often comes arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease. Osteoarthritis is an age-related “wear and tear” type of arthritis, where the cartilage cushioning the bones of the knee wears away. When the bones rub against each other, it causes pain and stiffness in the joint. Rheumatoid arthritis is an autoimmune disease in which the synovial membrane becomes inflamed or thickened. This chronic inflammation can damage the cartilage, leading to pain and stiffness. Post-traumatic arthritis can follow shoulder injury or fracture. The cartilage may become damaged and lead to shoulder pain and stiffness over time. Conditions such as bursitis and tendonitis can cause shoulder pain. Participation in sports or manual labor increase the risk of common shoulder injuries such as; dislocation, fracture, separation, sprains, strains or tears.
Arthoscopic Stabilization (Bankart Repair)
The most common form of shoulder ligament injury is caused when the shoulder is push back too far with great force. This allows the head of the humerus to dislocate. If it does not heal properly, the shoulder dislocations will recur. To restore stability, a surgical repair requires that the torn tissue be sewn back to the rim of the socket. Your surgeon may choose to do this using an open procedure, which involves an incision at the front of the armpit, or an arthroscopic procedure, involving two or three small punctures. This determination will be made after consulting with you about the specifics of your injury.
Recovery from this procedure will involve bracing the shoulder with a sling and supporting the shoulder with pillows while sleeping for some weeks. The shoulder should be kept immobile after the procedure, even during the activities of daily living. Occupational therapy will help you find ways of dressing, cooking and doing other daily tasks using your other arm. Your physician and physical therapist will determine when it is safe for you to use your shoulder and resume sports and leisure activities at a measured pace. You may be unable to drive for some weeks after your surgery. It is very important that you make arrangements to have some assistance in traveling to your follow up appointments and therapy visits.
Biceps Tendon Rupture
The upper end of the biceps muscle has two tendons that attach it to bones in the shoulder. This tendon may be susceptible to partial or complete tearing due to a sudden injury or overuse. A hard fall on an outstretched arm, lifting something too heavy or repetitive overhead lifting can lead to fraying of this tendon that may proceed to a tearing. A complete rupture of the tendon may be obvious, as it causes a visual deformity of the bicep, accompanied by pain. A partial rupture may be less visible, but shoulder pain when tightening your bicep muscle is a strong indicator. A biceps tendon tear may be accompanied by other conditions, so it is very important to let your doctor know if you have any other pain so that a comprehensive treatment plan can be developed for you. Diagnosing your condition may involve the use of X-ray or MRI images.
For many people, a small tear may resolve over time. In addition, if the damage is minor, nonsurgical treatments such as ice, anti-inflammatory medications, rest and physical therapy may be sufficient to promote healing and restore movement to your shoulder. When nonsurgical treatment is not sufficient or complete recovery of shoulder strength is required, surgery may be the best option. Several new procedures have been developed that repair the tendon with minimal incisions. The goal of surgery is to re-anchor the torn tendon back to the bone. After consultation and examination, your doctor will recommend treatment options that are best for your specific case.
After surgery, your shoulder may be temporarily immobilized with a sling. Physical therapy is frequently used to improve flexibility and range of motion in your shoulder. Strengthen exercises will gradually be added to your rehabilitation plan.
Rotator Cuff Tear
The rotator cuff is a network of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm. When one or more of these tendons is torn, the tendon no longer fully attaches to the head of the humerus. Tears may be partial or complete, they may happen suddenly, when you fall on an outstretched arm or lift with a jerking motion, or they may happen gradually, as the tendon degenerates with use. If you have a degenerative rotator cuff tear in one shoulder, there is a greater risk for a tear to develop in the other shoulder, even if you do not currently have pain in both shoulders. Degenerative rotator cuff tears can be the result of repetitive stress and overuse caused by sports or routine chores, age-related lack of blood supply or bone spurs, also known as shoulder impingement. Diagnosing your condition may involve the use of X-ray or MRI images.
For about 50% of patients, nonsurgical treatment relieves pain and improves function in the shoulder. However, shoulder strength does not usually improve without surgery. Nonsurgical treatments may include rest, avoiding activities that cause shoulder pain, strengthening exercises, physical therapy and steroid injection. Continued use of the shoulder without treatment may cause the size of the tear to increase. If your symptoms have lasted 6 – 12 months, your tear is larger than 3 cm, you have significant weakness or loss of function in your shoulder or your tear was caused by a recent, acute injury, surgery may be a good option for you. Your surgeon may recommend an open procedure, a mini-open procedure or an all arthroscopic procedure, depending on the specifics of your condition.
After surgery, therapy progresses in stages. Initially, you will need to immobilize your shoulder in a sling to allow the tendon to heal. You may need to avoid using your arm for 4 to 6 weeks, so it is important to have assistance in place for driving and activities of daily living. A physical therapy regimen, beginning with passive exercise and gradually incorporating active exercise and strengthening will take place 4 to 12 weeks after your surgery. Most patients can expect a full recovery 4 to 6 months after surgery. Your commitment to following the recommendations of your doctor and your physical therapist is key to a successful rehabilitation. In patients 65 and older, patients who smoke, patients with poor tendon quality, incidence of large or massive tears or patients who do not comply with rehabilitation instructions, it may not be possible to restore the shoulder to full strength and mobility after surgery.
Arthroscopy is a procedure that your surgeon may use to inspect, diagnose and repair problems inside your shoulder joint. During shoulder arthroscopy, your surgeon inserts a small camera, into the joint, using very small incisions. The camera displays pictures on a screen and your surgeon uses those images to guide miniature surgical instruments. Minimizing the incisions needed for procedures results in less pain and shorter recovery times than the larger incisions needed for standard, open surgeries. Arthroscopy is commonly used for rotator cuff repair, bone spur removal, removal or repair of the labrum, ligament repair, removal of loose cartilage or inflamed tissue and repair for chronic shoulder dislocation. Nerve release, fracture repairs and cyst removals may also be done arthroscopically.
While arthroscopic procedures allow for faster and easier recovery than standard procedures, it is still important that you follow your doctor’s instructions when preparing for your procedure. If you are generally healthy, your arthroscopy will most likely be performed as an outpatient. Most shoulder arthroscopy is performed using a nerve block, to numb the shoulder and arm and most procedures take less than an hour. However, the specifics of your procedure will be unique to your personal needs and circumstances.
After surgery, plan to have someone drive you home and stay with you for at least the first night. You can expect some pain and discomfort for at least a week after surgery, perhaps more, if you’ve had a complex procedure. You will most likely need a sling or brace to immobilize your shoulder. A gradual exercise plan and physical therapy regimen will likely play an important role in your recovery from surgery. Your surgeon will develop a customized rehabilitation plan, based on the surgical procedures required for you. Your ability to recover flexibility, mobility and strength in your shoulder will be directly affected by your participation in your rehabilitation plan.
Shoulder Joint Replacement
The shoulder is a ball and socket joint. The head of the humerus bone forms a ball that fits into the glenoid socket. In shoulder replacement surgery, the damaged parts of the shoulder are removed and replaced with artificial components. Treatment options include replacement of just the head of the humerus bone (ball) or replacement of both the ball and the socket (glenoid). Conditions that commonly lead patients to consider joint replacement include osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, severe fractures, arthritis caused by a severe, long-term rotator cuff tear, blood supply disruption to the bone, and a failed previous shoulder replacement surgery.
Your doctor may recommend shoulder replacement surgery if you have severe shoulder pain that interferes with the activities of daily living, moderate to severe pain when resting, loss of motion or strength in the shoulder, and/or a failure to substantially improve after receiving nonsurgical treatments, such as; anti-inflammatory medications, cortisone injections, or physical therapy. There are many types of shoulder replacements surgeries. After examination and consultation, your doctor will determine which one is right for you.
A total shoulder replacement replaces the head of the humerus with a highly polished metal ball attached to a stem that will be either press-fit or cemented into your humerus, along with a plastic socket that is implanted with bone cement to replace the glenoid socket. In cases where the glenoid socket is healthy and undamaged or is severely weakened, just humerus head is replaced with a ball and stem. For patients who are young or very active, resurfacing the humerus head and applying a cap-like prosthesis may be the best option. Due to the conservative nature of this procedure, bone is preserved to allow for a total shoulder replacement at a later time, if necessary. In cases where completely torn rotator cuffs result in severe arm weakness, severe arthritis accompanies rotator cuff tearing or a previous shoulder replacement failed, a reverse total shoulder replacement may be indicated. In reverse total shoulder replacement, the socket and ball are switched. A metal ball is attached to the shoulder bone and a plastic socket is attached to the humerus. This allows the patient to use the deltoid muscles instead of the rotator cuff to lift the arm.
In any case, shoulder replacement surgery will require a careful, well-planned recovery. Making simple changes in your home before surgery can make this recovery easier. It will be difficult to reach up to high shelves or cupboards for several weeks. For the first few weeks, you will need assistance with daily tasks like dressing, bathing, cooking and laundry. If you do not have help at home, you may need a short stay in a rehabilitation facility immediately after surgery. Physical therapy will begin shortly after surgery to strengthen the shoulder and improve flexibility. You will need a sling to support and protect your shoulder, and refrain from driving for 2 to 4 weeks. It is important to follow your doctor’s prescription for physical therapy and home exercise carefully. Exercise is important for regaining strength, but early overuse of the shoulder may result in severe limitations in motion of the joint. In most cases, a full recovery of function and range of motion can be expected over time, but you may have to forego contact sports and repetitive heavy lifting indefinitely after shoulder replacement.