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SHOULDER SURGERY
The shoulder is one of the most essential and versatile joints in the human body. If your shoulder’s movement is in any way impaired, physical therapy alone often isn’t enough to relieve the distress. Expert shoulder surgery may represent a more permanent option.
Shoulder surgery comes in many forms, and can be tailored to treat a variety of symptoms. Your experienced San Diego orthopedic surgeon will walk you through every step of the process, from imaging and diagnosis through shoulder surgery and postoperative care.
Dr. Robert Afra is widely recognized as one of the nation’s leaders in the field of shoulder surgery. Dr. Afra was the Chief of Sports Medicine in the UCSD Department of Orthopedic Surgery, and today runs one of the most respected shoulder surgery clinics in San Diego. With access to cutting edge technologies and an experienced technical team, Dr. Afra is proud to offer the finest orthopedic surgical care in Southern California.
We have helped hundreds of patients from across the country achieve lasting relief from a broad array of shoulder injuries and symptoms, including:
- Rotator cuff tear
- Subacromial bursitis/ rotator cuff tendinitis
- AC joint arthritis
- AC Joint Injuries
- Biceps tendinitis/ biceps tendon tear
- Labral tear
- SLAP Tear
- Shoulder osteoarthritis
- Frozen shoulder
- Shoulder instability
- Little leaguer’s shoulder
If you’d like to schedule your own shoulder surgery consultation today, please contact us here to learn more about the many good options available.
Introduction of Shoulder Joint:
The human body is composed of many joints, such as the elbows, knees, and hips. While every joint is important for movement and range of motion, the shoulder is one of the most important joints in the body.
The shoulder contains a ball and socket type of joint. The ball (humeral head) and socket (glenoid fossa) joint is covered by different muscles, bands of connective tissue-tendons, labrum, and ligaments. These muscles play a crucial role in maintaining accurate movement of the shoulder joint, along with providing maximum mobility to the body.
Shoulder injuries frequently occur due to repetitive motions, muscle overuse, and overhead movement. Activities like tennis, cricket, golf, swimming, and weightlifting can aggravate the condition. Shoulder injuries can also be sustained while doing day to day activities like lifting, cleaning, hanging curtains, and gardening.
The shoulder contains a ball and socket type of joint. The ball (humeral head) and socket (glenoid fossa) joint is covered by different muscles, bands of connective tissue-tendons, labrum, and ligaments. These muscles play a crucial role in maintaining accurate movement of the shoulder joint, along with providing maximum mobility to the body.
Shoulder injuries frequently occur due to repetitive motions, muscle overuse, and overhead movement. Activities like tennis, cricket, golf, swimming, and weightlifting can aggravate the condition. Shoulder injuries can also be sustained while doing day to day activities like lifting, cleaning, hanging curtains, and gardening.
Warning Signs of a Shoulder Injury:
- Pain or stiffness in the shoulder area
- The joint slides or pops from the socket
- A popping sound
- Weakness
- Swelling
- Inflammation
- Restricted movement
Untreated pain in the shoulder area can cause even more problems over time.
Types of Shoulder Injuries:
Shoulder injuries involve the muscles, ligaments, and tendons more than bones. Those who use their muscles repeatedly are more prone to develop shoulder injuries.
While there are many different types of shoulder injuries and tears that can occur, the most common types of injuries are:
- Rotator cuff tears
- Instability
- Impingement
- Labral tears
- SLAP lesion tears
- Subacromial bursitis
- Bankart lesions
- Biceps tendinitis
Rotator Cuff Tears:
The rotator cuff is composed of four major muscles: the supraspinatus, infraspinatus, subscapularis and teres minor. The tendons of these muscles attach to the humerus (upper arm bone) with the scapula (shoulder blade) which is essential to lifting the arm.
The rotator cuff muscles play a very important role to stabilize the shoulder joint and assist in overhead activities. When the tendons in the rotator cuff fray and possibly tear, their attachment to the humerus weakens causing pain and limited mobility.
The rotator cuff wear and tear can be diagnosed imaging studies such as Ultrasound or MRI.
Rotator cuff tears are more common in the people who are above 50. As patients age, the blood supply to the rotator cuff decreases and that is why it becomes more prone to injury. Lifting, falling and repetitive arm activities are common causes of a rotator cuff tear.
Symptoms may include pain, weakness, inflammation and tenderness in the shoulder, particularly while doing overhead activity. Patients typically will complain of pain with overhead activities, pain reaching behind them, and pain sleeping on the shoulder.
Neglected rotator cuff tears can become problematic over time. The size of the tear can increase with time, as more and more of the muscle fibers tear. Eventually the muscle pulls away from its native attachment site. Because the torn muscle is no longer exercised the same way, the muscular tissue changes in two ways: the muscle loses its bulk (muscle atrophy) and the muscle is replaced by fat tissue (fatty infiltration). Both these changes progress over time. Studies show that rotator cuff repairs are more successful when there is less muscle atrophy and fatty infiltration. Additional risk factors for failure of rotator cuff repair are: female gender, >65 years old, superior migration of the humeral head, diabetes, amount of retraction, fatty infiltration, and muscle atrophy.
The rotator cuff muscles play a very important role to stabilize the shoulder joint and assist in overhead activities. When the tendons in the rotator cuff fray and possibly tear, their attachment to the humerus weakens causing pain and limited mobility.
The rotator cuff wear and tear can be diagnosed imaging studies such as Ultrasound or MRI.
Rotator cuff tears are more common in the people who are above 50. As patients age, the blood supply to the rotator cuff decreases and that is why it becomes more prone to injury. Lifting, falling and repetitive arm activities are common causes of a rotator cuff tear.
Symptoms may include pain, weakness, inflammation and tenderness in the shoulder, particularly while doing overhead activity. Patients typically will complain of pain with overhead activities, pain reaching behind them, and pain sleeping on the shoulder.
Neglected rotator cuff tears can become problematic over time. The size of the tear can increase with time, as more and more of the muscle fibers tear. Eventually the muscle pulls away from its native attachment site. Because the torn muscle is no longer exercised the same way, the muscular tissue changes in two ways: the muscle loses its bulk (muscle atrophy) and the muscle is replaced by fat tissue (fatty infiltration). Both these changes progress over time. Studies show that rotator cuff repairs are more successful when there is less muscle atrophy and fatty infiltration. Additional risk factors for failure of rotator cuff repair are: female gender, >65 years old, superior migration of the humeral head, diabetes, amount of retraction, fatty infiltration, and muscle atrophy.
Rehab Alternatives Following Rotator Cuff Surgery
Rehabilitation after arthroscopic shoulder surgery is crucial to recovery. Patients who do not receive adequate therapy are less likely to recover their full range of motion. Most patients who undergo rehab also experience decreased shoulder pain and improved strength.
The conventional method is immobilization of the shoulder for four to six weeks before rehabilitation is begun. A different school of thought is that patients benefit from earlier, more aggressive therapy. Most authorities call for an individualized approach, taking into account people’s conditions and other factors.
Advocates of early immobilization believe that tissues require healing time before they are stressed. Studies have produced conflicting evidence. Research involving rats indicated that early, aggressive rehab enhances the strength of surgical repairs. A study of rats failed to reveal the same results.
Patients sometimes suffer new rotator cuff tears during their rehab. Those undergoing therapy for repairs of large tears are especially vulnerable. Some therapists are concerned that starting rehab too soon, or doing it too strenuously, might heighten the risk. While this may seem logical, no studies have produced data proving a connection between aggressive rehab and the likelihood of recurring tears.
Early, aggressive rehab typically features the use of passive-motion devices, which permit patients to move their arms and shoulders without exerting any effort. Proponents of early therapy cite research suggesting that it results in less shoulder pain and stiffness. Patients in one study also reported greater improvements in range of motion than those who began therapy later. In another trial, early rehab enabled patients to regain more function in their shoulders. Still, as one researcher noted, “no definite consensus exists” among authorities that the two methods produce significantly different outcomes.
Whichever approach is employed, accepted protocols are followed. Physical therapists know when, and for how long, to carry out treatments and exercises. They weigh biological and biomedical factors in designing individual plans. Patients are guided through three stages of recovery: the initial phase, featuring considerable shoulder pain and inflammation; the “proliferative” period, a time of healing as new cells grow; and the “maturation and remodeling” phase. Some studies have attempted to determine whether active rehab or passive motion is better during each of the stages. Unfortunately, the evidence either way is not conclusive.
In monitoring the progress of patients receiving rehab, therapists use tests created by the American Shoulder and Elbow Surgeons, and the University of California-Los Angeles. Other measurements are the Constant score; the Simple Shoulder Test; and the Disabilities of the Arm, Shoulder and Hand score. The tests assess patients’ range of motion, as well as the extent to which their shoulder function is restored.
In deciding whether to pursue early and aggressive rehab, or start later with a more cautious approach, surgeons and therapists consider individual factors. The types of therapy, and when they are administered, vary according to patients’ ages and medical conditions. For some people, the tissues at the point of their repairs are too fragile for strenuous rehab. Others can start using passive-motion devices soon after surgery. Specially designed treatments are recommended for patients who sustain recurring rotator cuff tears.
The conventional method is immobilization of the shoulder for four to six weeks before rehabilitation is begun. A different school of thought is that patients benefit from earlier, more aggressive therapy. Most authorities call for an individualized approach, taking into account people’s conditions and other factors.
Advocates of early immobilization believe that tissues require healing time before they are stressed. Studies have produced conflicting evidence. Research involving rats indicated that early, aggressive rehab enhances the strength of surgical repairs. A study of rats failed to reveal the same results.
Patients sometimes suffer new rotator cuff tears during their rehab. Those undergoing therapy for repairs of large tears are especially vulnerable. Some therapists are concerned that starting rehab too soon, or doing it too strenuously, might heighten the risk. While this may seem logical, no studies have produced data proving a connection between aggressive rehab and the likelihood of recurring tears.
Early, aggressive rehab typically features the use of passive-motion devices, which permit patients to move their arms and shoulders without exerting any effort. Proponents of early therapy cite research suggesting that it results in less shoulder pain and stiffness. Patients in one study also reported greater improvements in range of motion than those who began therapy later. In another trial, early rehab enabled patients to regain more function in their shoulders. Still, as one researcher noted, “no definite consensus exists” among authorities that the two methods produce significantly different outcomes.
Whichever approach is employed, accepted protocols are followed. Physical therapists know when, and for how long, to carry out treatments and exercises. They weigh biological and biomedical factors in designing individual plans. Patients are guided through three stages of recovery: the initial phase, featuring considerable shoulder pain and inflammation; the “proliferative” period, a time of healing as new cells grow; and the “maturation and remodeling” phase. Some studies have attempted to determine whether active rehab or passive motion is better during each of the stages. Unfortunately, the evidence either way is not conclusive.
In monitoring the progress of patients receiving rehab, therapists use tests created by the American Shoulder and Elbow Surgeons, and the University of California-Los Angeles. Other measurements are the Constant score; the Simple Shoulder Test; and the Disabilities of the Arm, Shoulder and Hand score. The tests assess patients’ range of motion, as well as the extent to which their shoulder function is restored.
In deciding whether to pursue early and aggressive rehab, or start later with a more cautious approach, surgeons and therapists consider individual factors. The types of therapy, and when they are administered, vary according to patients’ ages and medical conditions. For some people, the tissues at the point of their repairs are too fragile for strenuous rehab. Others can start using passive-motion devices soon after surgery. Specially designed treatments are recommended for patients who sustain recurring rotator cuff tears.
Frozen Shoulder:
Adhesive capsulitis, commonly known as frozen shoulder, is a painful condition. It causes stiffness that can worsen to the point that moving the shoulder becomes difficult.
Frozen shoulder is most frequently diagnosed in patients between 40 and 60 years of age. It is seen more often in women than men.
Connective tissue called the shoulder capsule surrounds the joint. When the capsule thickens and tightens, inflammation occurs. Inflexible adhesions develop, limiting the shoulder’s range of motion.
The first sign of adhesive capsulitis is shoulder pain that gradually becomes more severe and limits mobility. Patients describe the initial pain as a dull ache, generally in the outer shoulder and possibly in the upper arm. The discomfort increases over time, with the most extreme pain occurring during arm movements. This stage usually lasts between six weeks and nine months.
Next comes the “frozen” stage, during which pain levels may vary but the stiffness is constant. Regular, every-day activities can become challenging during this four- to six-month period.
The third stage, “thawing,” features range of motion slowly improving. Within six months to two years, patients often regain strength and mobility. For some, full shoulder function returns.
Frozen shoulder is most frequently diagnosed in patients between 40 and 60 years of age. It is seen more often in women than men.
Connective tissue called the shoulder capsule surrounds the joint. When the capsule thickens and tightens, inflammation occurs. Inflexible adhesions develop, limiting the shoulder’s range of motion.
The first sign of adhesive capsulitis is shoulder pain that gradually becomes more severe and limits mobility. Patients describe the initial pain as a dull ache, generally in the outer shoulder and possibly in the upper arm. The discomfort increases over time, with the most extreme pain occurring during arm movements. This stage usually lasts between six weeks and nine months.
Next comes the “frozen” stage, during which pain levels may vary but the stiffness is constant. Regular, every-day activities can become challenging during this four- to six-month period.
The third stage, “thawing,” features range of motion slowly improving. Within six months to two years, patients often regain strength and mobility. For some, full shoulder function returns.
Causes:
Frozen shoulder is a bit of a mystery. It does not seem to result from any particular activity or occupation. However, there are some factors that make some people more susceptible to the condition. They include:
1. Diabetes: For reasons researchers have been unable to determine, 10-20 percent of patients diagnosed with diabetes develop frozen shoulder;
2. Hypothyroidism, hyperthyroidism, Parkinson’s disease and cardiac disease;
3. Immobilization: A long period of shoulder immobilization is sometimes necessary following surgery or a fracture. To prevent frozen shoulder from developing, patients are advised to begin moving their shoulders as soon as possible after sustaining an injury or undergoing surgery.
1. Diabetes: For reasons researchers have been unable to determine, 10-20 percent of patients diagnosed with diabetes develop frozen shoulder;
2. Hypothyroidism, hyperthyroidism, Parkinson’s disease and cardiac disease;
3. Immobilization: A long period of shoulder immobilization is sometimes necessary following surgery or a fracture. To prevent frozen shoulder from developing, patients are advised to begin moving their shoulders as soon as possible after sustaining an injury or undergoing surgery.
Diagnosis:
A doctor discerns whether a patient has frozen shoulder by conducting a physical examination. The arm is moved in all directions to assess the shoulder’s degree of flexibility and the patient’s level of pain. The passive range of motion (when someone else moves the shoulder) is compared with the active range (when patients perform the movements on their own).
Diagnostic imaging tests are necessary to ensure that a patient’s pain and stiffness are not caused by another disease or condition. An x-ray might show that the discomfort is due to arthritis, while an MRI could reveal a torn rotator cuff.
Diagnostic imaging tests are necessary to ensure that a patient’s pain and stiffness are not caused by another disease or condition. An x-ray might show that the discomfort is due to arthritis, while an MRI could reveal a torn rotator cuff.
Treatments:
For more than 90 percent of patients, the symptoms of frozen shoulder eventually subside. The process can last as long as three years. During this time, several types of treatments are administered. They include:
1. Physical therapy, featuring exercises designed to limit pain, build shoulder strength and enhance mobility;
2. Non-steroidal anti-inflammatory medication to combat pain and inflammation; and
3. Steroid (cortisone) injections in the shoulder joint to reduce swelling.
Physical therapy may take place at a medical facility or in a patient’s home. They entail stretching and other movements that are helpful in restoring range of motion. Heat may be applied to loosen the shoulder before exercise. Among the types of workouts are:
1. External rotation, passive stretching performed while standing in a doorway. The arm is bent at a 90 degree angle, so it can extend to the doorjamb. While keeping the hand there, the patient rotates the body and holds this position for 30 seconds. Multiple repetitions follow.
2. Forward flexion, in which patients lie on their backs with legs straightened. They stretch the arm on their “good” side over the head, hold it for 15 seconds, lower the arm and relax, then repeat the movement.
3. Crossover arm stretch, the gentle pulling of one arm across the chest just below the chin just short of the point at which pain begins. This position is held for 30 seconds, after which the patient relaxes and then repeats the exercise.
1. Physical therapy, featuring exercises designed to limit pain, build shoulder strength and enhance mobility;
2. Non-steroidal anti-inflammatory medication to combat pain and inflammation; and
3. Steroid (cortisone) injections in the shoulder joint to reduce swelling.
Physical therapy may take place at a medical facility or in a patient’s home. They entail stretching and other movements that are helpful in restoring range of motion. Heat may be applied to loosen the shoulder before exercise. Among the types of workouts are:
1. External rotation, passive stretching performed while standing in a doorway. The arm is bent at a 90 degree angle, so it can extend to the doorjamb. While keeping the hand there, the patient rotates the body and holds this position for 30 seconds. Multiple repetitions follow.
2. Forward flexion, in which patients lie on their backs with legs straightened. They stretch the arm on their “good” side over the head, hold it for 15 seconds, lower the arm and relax, then repeat the movement.
3. Crossover arm stretch, the gentle pulling of one arm across the chest just below the chin just short of the point at which pain begins. This position is held for 30 seconds, after which the patient relaxes and then repeats the exercise.
Surgery:
When physical therapy, medications and other treatments are insufficient, surgery may be needed to stretch and release the stiffened joint capsule.
The main surgical procedures are:
1. Manipulation of the shoulder, while the patient is anesthetized, in which the doctor forces the shoulder to move in various directions, resulting in greater range of motion; and
2. Arthroscopy, in which tiny medical instruments inserted into the joint through small incisions are used to cut through tight parts of the capsule.
After surgery, patients typically receive physical therapy for six weeks to three months. This is key to recovering function and mobility. Following therapy, most patients report that their pain is either gone or diminished. They usually have improved range of motion, though some degree of permanent stiffness is common.
For more details please see: Adhesive capsulitis
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