fred jackosnShoulder injury comes in a variety of flavors.  Sometimes it develops insidiously from wear and tear; and sometimes it comes for acute shoulder injury.  The Buffalo Bills have been severely bitten by the injury bug as of late. Not only have they lost running back Fred Jackson to a groin injury, they have also lost fellow backfield mate C.J. Spiller to injury, in the same game no less. While Fred Jackson is likely to return in about four weeks, C.J. Spiller is likely done for the season. C.J. Spiller got tripped up from behind and fell hard onto his left shoulder at the tail end of a 52-yard run. He immediately reached for his left collarbone.

fred-jackson-shoulder-injuryThe clavicle, more commonly known as the collarbone, connects the arm to the body and is located between the rib cage and shoulder blade.  As with the case of C.J. Spiller, broken clavicles are typically caused by a direct blow to the shoulder. A broken clavicle can cause extreme pain, sagging shoulder, inability to lift arm, grinding sensations, deformity, bruising, and swelling.Diagnosing a broken clavicle can typically be done via a physical examination; however, x-rays are taken to determine the location and severity of the break. Occasionally an orthopedic physician will also order a CT scan as well to get a better look at the broken bone.This injury can heal completely witho

broken-shoulder-collar-boneut surgery as long as the bones are not out of place. Non-surgical treatment typically involves the use of an arm sling and pain medication at first. Once the pain has been reduced and the bone begins to heal, gentle shoulder and elbow exercises can be used to prevent stiffness and weakness. Eventually, after follow-up x-rays reveal that the bone has completely healed, you can start doing more strenuous exercises.If the bones of the clavicle are out of place and not properly aligned, surgery may be required to assure proper healing. The orthopedic surgeon will manipulate the bones to get them into proper alignment. Once aligned, plates, screws, or pins can be utilized to hold the bone in place while it is healing. Pins are removed after healing, while screws and plates are typically kept in unless there is discomfort associated with them. As with any surgical procedure, there can be complications such as infection, bleeding, pain, hardware irritation, and nerve damage. Following successful surgery the recovery is much the same as the non-surgical method of treatment.

shoulder bone fracture



Shoulder injury in a young athlete is usually a result of overuse, barred a distinct traumatic event. One of the types of overuse shoulder injuries that results in severe shoulder pain is called acromial apophysiolysis. Pediatricians often diagnose the condition in young baseball pitchers.

baseball-pitcher-shoulder-injuryIncomplete fusion and tenderness of the acromion is responsible for the shoulder injury, according to the Radiological Society of North America. The acromion forms the bone at the top of the shoulder. It actually consists of four bones that join during a person’s teen years.

In its online journal “Radiology,” the RSNA described the results of a study which found that “young baseball pitchers who throw more than 100 pitches per week are at risk” of suffering acromial apophysiolysis. Some sustain rotator cuff tears and other shoulder injuries, as well.

Another study, also posted at, concluded that acromial apophysiolysis is characterized in part by edema (too much watery fluid accumulating in body cavities or tissues).acromial apophysiolysis shoudler injury

Patients 25 years of age and younger were found to be most susceptible to “superior” shoulder pain  due to the shoulder injury. Researchers confirmed that pitching “is a risk factor (because) it predisposes the patient to the development of an osacromiale and rotator cuff tears after age 25 years.”

The study is titled “Acromial Apophysiolysis: Superior Shoulder Pain and Acromial Nonfusion in the Young Throwing Athlete.” The authors were Johannes B. Roedl, MD, PhD; William B. Morrison, MD; Michael G. Ciccotti, MD; and Adam C. Zoga, MD.

“We kept seeing this injury over and over again in young athletes who come to the hospital at the end of the baseball season with shoulder pain and edema at the acromion, but no other imaging findings,” Roedl, a radiologist, said in a news release. “We believe that, as a result of overuse, edema develops and the acromion bone does not fuse normally.”

The research took place at Thomas Jefferson University Hospital’s Department of Radiology in Philadelphia. It involved 2,372 patients between 15 and 25 years of age who had undergone MRIs to diagnose the cause of their shoulder pain. The imaging tests detected edema of the acromial apophyses in 61 (2.6 percent) of the cases.

“Association of acromial edema with incomplete fusion, pitching and clinical findings was determined in the study group, and in an age- and sex-matched control group,” the researchers wrote.

The patients included men and women, most of whom were baseball pitchers. Roedl said they were chosen for the study because “among high school athletes, pitching is the most common reason for shoulder injury.”

Forty percent of one group of study participants had thrown more than 100 pitches per week, compared with 8 percent in the other group. All the patients were diagnosed with acromial apophysiolysis.

According to, baseball pitchers are not the only athletes at risk. The shoulder injury also happens to those who play softball, tennis, golf, handball, volleyball and other sports that require throwing or hitting an object. Even weight lifters and yoga practitioners are vulnerable.

The best advice for avoiding acromial apophysiolysis and other overuse shoulder injuries is to practice moderation. The shoulder joint needs time to rest and heal. When the arm starts to hurt, it is time to take a break.

The American Academy of Orthopedic Surgeons recommends that pitchers reduce the number of times they throw a ball in a game. The organization supports pitch-count limits set by the USA Baseball Medical Safety Advisory Committee.

Strengthening exercises, and stretching and warming up before workouts, are helpful. Ice and anti-inflammatory medication reduce swelling and discomfort.

If you or your child are faced with unabating shoulder pain, contact our nationally recognized sports medicine physicians at Orthopedic Surgery San Diego.


Baseball pitchers, tennis players and others whose activities entail repeatedly reaching above their heads are vulnerable to a relatively rare condition called suprascapular neuropathy. It causes shoulder pain and dysfunction.

As Dr. Dana P. Piasecki and associates noted in a review article for the journal of the American Academy of Orthopaedic Surgeons, the Suprascapular Neuropathy results from the stress that arm stretching and rotating movements place on the shoulder. The suprascapular nerve is injured by excessive stretching, kinking and friction.

The nerve extends from the neck to the back of the shoulder, in a narrow passageway through bones and ligaments. The nerve can become compressed, or entrapped, at several points. Ganglion cysts and masses of soft tissues are sometimes responsible, though much of the time the compression is an overuse injury resulting in Suprascapular Neuropathy.

Retracted rotator cuff tears can cause Suprascapular Neuropathy in older patients. Nearly one-third of the time, suprascapular nerve injury is associated with shoulder dislocations or humerus fractures, according to the article.

More than 80 percent of those with suprascapular neuropathy report pain and spinal weakness. Patients have described the discomfort as a dull, ocassionally burning, ache in the shoulder that sometimes extends to the neck and arm. Reaching across the torso, or rotating the shoulder, may be particularly painful.suprascapular-neuropathy

Most patients who undergo nonsurgical treatment for Suprascapular Neuropathy enjoy reduced pain. They regain shoulder function by modifying their physical activities, taking anti-inflammatory medication and receiving physical therapy.

For others, “muscle bulk and motor strength may be irreversibly lost” due to atrophy, Piasecki et al noted. Surgery might be necessary to allow for shoulder function to return. The procedure typically involves widening the spinoglenoid or suprascapular notch, points at which the nerve tends to sustain injuries. This can be done as open surgery or arthroscopically.

A study by Kim et al, involving 31 patients, found that the procedure produced long-term pain relief and restored strength in more than 90 percent of the  Suprascapular Neuropathy cases. In another study, arthroscopic suprascapular notch decompression significantly helped all 10 patients. Surgeons sometimes perform open spinoglenoid decompression while arthroscopically repairing related labral tears.

In research featuring patients with spinoglenoid notch entrapment resulting from ganglion cysts, all six participants reported that they no longer felt any pain after undergoing decompression surgery. Another study showed that the procedure resulted in significant nerve recovery, pain relief and restored function for patients diagnosed with suprascapular neuropathy and large rotator cuff tears.



Although the goal of performing rotator cuff repair surgery is to alleviate the pain and weakness, there is no guarantee that the rotator cuff will heal.  If it does heal, there is no guarantee that it won’t retear.  Patients specifically at risk of failure to heal/retear are: older than 65 years, larger size tears, the tissue has undergone muscle atrophy and/or fatty infiltration, diabetic, smoker, and noncompliant with rehabilitation restrictions.


Nine times out of 10, patients experience significantly less shoulder pain after undergoing arthroscopic surgery to repair rotator cuff tears. The procedure also, in nearly all cases, improves the range of motion of the arm and shoulder. Patients generally recover full use of their shoulders.

However, some report continued pain, stiffness and weakness. The degree to which they can rotate their shoulders and move their arms may not be not any better than it was before the operation. When this happens, doctors identify the problem as failed rotator cuff syndrome. Elderly patients, those with diabetes and people who smoke are particularly vulnerable to the condition. Careful diagnosis is required to ensure that a patient does not have superior labral anterior-posterior lesions, rather than a rotator cuff tear. Each condition produces similar shoulder pain.


The syndrome is characterized by an “incompetent” rotator cuff. That typically means the tendons did not heal adequately after surgery. The term also can refer to new tears in the rotator cuff sustained during patients’ recovery. People who have had large tears repaired are more vulnerable to subsequent tears.

Other ways that rotator cuffs are rendered incompetent include cervical spine disease and a nerve condition called suprascapular neuropathy. Athletes and workers who repeatedly and strenuously extend their arms overhead are susceptible to subacromial impingement, which compromises the rotator cuff. Another cause of ongoing discomfort is a type of arthritis.

The best treatment for failed rotator cuff syndrome depends upon the cause. The primary options are revision repair, non-anatomic repair, tendon transfer and arthroplasty. Synthetic materials, or tendon tissues from other parts of the body, are used to create a bridge reconnecting the cuff’s torn segments. This method is known as a “tension-free” repair because tissues do not have to be pulled together, as when they are reattached with stitches. Another technique entails implanting scaffolds (natural or artificial supports) to hold tissues in place.

Tendonesis, which can be performed arthroscopically or as open surgery, enables some patients to regain shoulder function. For seniors, surgeons tend to suggest biceps tenotomy, which takes less time than tendonesis and requires shorter rehabilitation.


Tendon transfers are not recommended for the elderly, for patients experiencing post-surgical stiffness or for those with nerve injuries. However, the procedure can help young, physically active patients with weakness and limited range of motion but little pain. Patients diagnosed with degenerative glenohumeral arthritis, as well as older people who have had repeated cuff tears, sometimes undergo total shoulder replacement (arthroplasty). Hemiarthroplasty is the replacement of just the humerus portion of the shoulder joint.

In one study, researchers spent eight years following 20 people with repaired rotator cuffs who had sustained re-tears. In most cases, the new tears stopped growing. The patients did not report increased shoulder pain or additional loss of movement. These results suggest that surgery is not always required when a re-tear occurs. For patients who do need further treatment to find relief for their symptoms, surgeons can suggest a variety of possible solutions.

If you have been told you have a rotator cuff problem, call to schedule an appointment with our expert sports medicine surgeons at Orthopedic Surgery San Diego.


NFL quarterback, NHL goalie, MLB starting pitcher, and NBA point guard are generally considered the most important positions in the major U.S. sports. A position that is arguably as important is the major league closer. The closer is responsible for whether a team wins close games. A majority of major league games are decided by only 2 runs or less. It is easy to see the importance of a quality closer. Unfortunately for the San Diego Padres, closer Joaquin Benoit has been sidelined off and on by ongoing shoulder pain. He has missed a number of games over the course of the season due to the shoulder pain. Benoit has described a pain fluctuates. That he will feel good for a couple of days but then the inflammation will return. The cause of this pain has not been diagnosed but there are some acute shoulder tears that may be attributing to Benoit’s discomfort.

A SLAP tear is a tear in the top part of the labrum. The labrum is a strong, fibrous tissue that stabilizes the shoulder joint. The labrum acts to deepen the shoulder socket and allows a stronger fit between the upper arm bone, the shoulder blade, and the collarbone. A SLAP tear occurs in both the top-front and top-back portion of the labrum and is often caused by repetitive shoulder motion such as constantly hurling MLB sized curve balls and sliders. When a SLAP tear is present, the patient may experience shoulder pain, decreased strength, decreased range of motion, and unusual and uncomfortable feelings that the shoulder is catching, locking, grinding, or popping out of it’s joint. For major league pitchers there will also likely be a decreased in their pitch velocity.
A partial thickness rotator cuff tear is an incomplete tear of the rotator cuff. The rotator cuff connects the upper arm to the shoulder blade and is essential for shoulder strength and lifting of the arm. A partial tear in the rotator cuff would include damage to the soft tissue of the rotator cuff but would not be severed and would not be disconnected from the upper arm or shoulder blade. When the rotator cuff is torn, a patient will likely experience shoulder pain, shoulder weakness, difficulty lifting and rotating arm, and a crackling sensation in the shoulder. For major league pitchers lifting and rotating the arm is an essential part of the pitching motion. A partial thickness rotator cuff tear can cause tremendous amount of pain and a decrease in pitcher productivity.
For these acute injuries the suggested initial treatment is rest, anti-inflammatory medications, and physical therapy to restore the strength, flexibility, and range of motion. If non-surgical treatment is not sufficient and problems persist or worsen then the next step would be to review surgical options. At this point Joaquin Benoit is experiencing discomfort bad enough to miss some games, but team doctors do not believe that surgery is needed just yet. Time will tell whether he can overcome this nagging shoulder injury or if he will need to have the shoulder repaired via surgery. Call to schedule your appointment with our top notch sports medicine specialists at Orthopedic Surgery San Diego.


Many of the kids playing pop warner or teens playing high school football in the Carlsbad and North County area may have sustained shoulder injuries or neck pain, similar to Pro NFL players.  St. Louis Rams officials described Rodger Saffold’s recent shoulder problem as a “stinger,” a term familiar to people who play contact sports.

Saffold suffered the injury in his left shoulder during training camp, ESPN reported. It took nearly a month for symptoms to subside to the point that the offensive lineman was ready to return to action.  This is unusual.

Technically called a brachial plexus injury, a stinger afflicts about one in two college football players. Wrestlers, gymnasts, snow skiers and martial-arts enthusiasts also are vulnerable. A stinger can occur when a collision or fall causes the shoulder and head to snap in opposite directions. It also may result from the head being forced to the side, or from blunt-force trauma of the collarbone.

Such violent movements and impacts compress and excessively stretch nerves in the neck and shoulder, causing an electric stinging sensation that may extend to the arm and hand. Some patients describe the pain and discomfort as “burning” or “tingling.” Others feel weak or numb in the shoulder or arm. Neck pain can be an indication of another type of injury or disorder.

Many experience the symptoms for only a few seconds or minutes. Others need treatment for several days or weeks. Sometimes, there is a nerve injury that continues to cause shoulder pain and weakness. People who have had one stinger are more likely to suffer more of them. Each time it happens, the joint gets weaker and nerves sustain additional damage.

Nerves function like electrical cables in the spinal canal, allowing the brain to send messages to the muscles. Nerves that branch from the spine, where it meets the neck, form the brachial plexus (a bundle of nerves). All the nerves that permit a person to feel and move the arm travel through the cord.

Most patients get stingers on one side of the body, though full contact with another person or an unmovable object can injure both shoulders. In some cases, people have stingers on both sides because of spinal-cord damage.

Treatments for the pain and burning include resting the shoulder and arm, alternating applications of ice and heat, and taking anti-inflammatory drugs. When the discomfort continues longer than several weeks, medical tests are needed to diagnose the problem. There might be nerve damage that cannot heal on its own.

Doctors study patients’ medical histories, and conduct physical exams, to diagnose stingers. They determine the extent to which the brachial plexus has been stretched, and evaluate nerve function and reflexes. More tests are ordered if a patient appears to have a cervical spine injury. Diagnostic methods include x-rays, MRIs and EMGs.  It is important the player seek medical attention so that a doctor can unmask any latent anatomic risks that puts a player at risk.

Some patients wear cervical collars to take pressure off the nerves until they can recover. Doctors often give cortisone to reduce the swelling. They advise patients to refrain from strenuous activity until the pain is gone, full range of neck motion returns, and testing has confirmed there is no nerve damage. Strengthening neck muscles and improving posture can help prevent recurrences.

Surgery becomes necessary when a herniated disk or bone spur compresses and injures a nerve. Without the procedure, a patient is likely to continue experiencing severe pain and weakness.  Let our Orthopedic Surgery San Diego award winning orthopedic sports medicine specialists evaluate you to help you maximize your recovery.


Separated Shoulder Injury Sidelines Another Athlete……

Whether a soccer player in Carlsbad, mountain biker in San Diego,  or an ice hockey player on the ice, shoulder injury such as a separation are a dime-a-dozen but need to be taken seriously.  Pittsburgh Steelers’ rookie Martavis Bryant is the latest professional football player to suffer an AC joint sprain, commonly known as a shoulder separation.sports-shoulder-injury

The wide receiver could miss much of the season, depending upon the extent of the damage in his shoulder, ESPN reported.The source of the shoulder pain resulting from such a shoulder injury is the acromioclavicular (AC) joint, between the shoulder blade (scapula) and collarbone (clavicle) on the top of the shoulder. The scapula and clavicle form the joint socket, which holds the rounded end of the arm bone (humerus). A shoulder separation happens at the point where the shoulder blade (acromion) attaches to the clavicle.

Falling on a shoulder while the arm is extended is often responsible for an AC joint separation. This shoulder injury can happen while playing sports, or when riding a horse or bicycle.  Extraordinarily common with mountain bikers going over the handle bars.  A collision or direct blow to the shoulder also may cause this shoulder injury.


The impact of falling or getting hit damages ligaments that stabilize the joint. When the ligaments under the clavicle tear, a separation of the collarbone and wingbone occurs. The wingbone shifts into a lower position, producing a bulge above the shoulder.

The severity of AC sprains varies. In some cases, people feel only slight shoulder pain, along with some swelling and bruising. More serious shoulder injuries involve additional pain and physical deformity. The more a joint is distorted, the longer it takes for the patient to recover.

Shoulder separations are classified in six categories, based on the degree of damage. A Type 1 separation, in which the bones are not forced out of alignment, is only an injury to the capsule that surrounds the AC joint. Patients feel pain, but typically recover quickly.

A person with a Type II separation also has an injured AC joint capsule, as well as a partially torn coracoclavicularone ligament (which supports the clavicle). The injury is often characterized by a small bump. A Type III sprain is similar to a Type II separation, but more extensive. The bump on the top of the shoulder is pronounced.shoulder-injury-types

A less common diagnosis, Type IV shoulder separation, features a clavicle that has been forced behind the AC joint. In a Type V separation, the end of the clavicle punctures the muscle above the joint, causing a large bump. A Type VI separation is rare. It involves the clavicle being pushed down, below the corocoid (a section of the scapula).


Treatments for AC joint separations include rest, ice and medication. Patients often wear slings, and refrain from intense physical activity, until the pain subsides and normal joint mobility returns. Most people, even those who suffer deformities, regain shoulder function. Some continue to experience pain, because the AC joint has been misshapen in a way that causes bones to rub together. Cartilage damage and arthritis also can cause persistent pain.


If a patient’s condition does not improve, surgery is an option. A common procedure entails trimming the end of the collarbone to prevent it from irritating the shoulder blade.  Dedicated shoulder surgeons like the award winning doctors at Orthopedic Surgery San Diego can perform even more cutting edge procedures that reconstruct the damaged shoulder ligaments.  To correct deformities, orthopedic surgeons reconstruct the ligaments that support the bottom of the collarbone.  Call Orthopedic Surgery San Diego for an appointment to discuss your injury.


Shoulder pain.  It can plague us all, even the great ones!  There is very little debate over who the NFL’s greatest wide receiver of all time is. Jerry Rice is the best there ever was. But did you know that Jerry’s football DNA has been passed on to a son, Jerry Rice Jr.? That is correct. He is an incoming rookie wide receiver.  With some experience at my old alma mater, UCLA.   He was set to potentially follow in his father’s footsteps until an unfortunate injury. Jerry Rice Jr. suffered a significant shoulder injury when he landed awkwardly on it during practice. The diagnosis: a labrum tear.

The labrum is a fibrous cartilage that is located in the shoulder joint. The shoulder joint is one of the most common examples of a ball and socket joint. This joint is where the shoulder blade cavity (glenoid cavity) and upper arm bone (humerus) meet and form the respective ball and socket. The labrum acts as a joint stabilizer that both deepens the socket and sucks the humerus into the socket.

If the labrum tears, the shoulder can become unstable. Labrum tear causes decreased range of motion, decreased strength, and pain. In addition, severe labrum tears tend to cause abnormal shoulder joint interactions such as grinding, locking, popping, and catching. While these interactions sound like a set of trendy new dance moves, they can be painful and quite discomforting.

There are a number of different types of labrum tear; the main types are SLAP tears and bankart tears, but these also has a set of sub-categorizations based on the severity of the tear. A SLAP (Superior Labrum Anterior and Posterior) tear involves the top of the shoulder and essentially involves the disconnection of the labrum from its ball and socket attachment points. A SLAP tear is usually diagnosed in terms of severities from type 1 to type 4. Type 1 is a partial tear where the edges of the labrum fray but do not become completely detached. Type 2 is the most common and does involve a complete detachment of the upper labrum from the socket. Type 3 is where the tear from the socket causes the labrum to actually folds over itself between the ball and socket. Type 4 is where the tear actually extends to the bicep tendon. The bankart tear involves the front of the shoulder. The reverse bankart tear involves the back of the shoulder.

Treatment can involve anything from rest followed by rehabilitation to arthroscopic surgery.  In the case of type 1 SLAP labrum tears the typical treatment would just be rest, anti-inflammatory medications, and rehabilitation if needed. Most large tears will require surgery, which will involves trimming, repair or reattachment. After successful surgery, recovery time involves using a sling for approximately a month followed by anywhere from a month to three months of rehabilitation to regain complete strength and range of motion.

In the case of Jerry Rice Jr., his torn labrum did require surgery and it is considered season ending. But if he has half of the heart that his father had, you can bet that Jerry Rice Jr. will have a bright future in the NFL.


Frozen shoulder, otherwise known as adhesive capsulitis, is a painful and paralyzing shoulder condition. Although it can take weeks or even months to fully develop, most people find the initial symptoms concerning enough to seek help.

The simple truth is that this is a terrible ailment that can take upwards of a year to resolve.  Patients with diabetes and/or hypothyroidism, especially women, are particularly vulnerable to this problem.  It may start as a result of a simple slip and fall or other seemingly insignificant shoulder injury.  The pain is extraordinarily high and profoundly limits life style.  Often times the patients find that they cannot sleep through the night, they have pain reaching behind them for hygiene or dressing, and they have pain reaching overhead.

But what kind of help is considered the most effective course of treatment? I have written before about the vast benefits of shoulder exercises for orthopedic pain, and about the growing consensus that pain relief can be covered at home nearly as well as it can at the hospital or clinic. Now researchers have found good evidence that simple exercise can be a “drug” all its own.  In this study exercise was used as a treatment measure in various settings.  After dividing patients with frozen shoulder into three groups – some patients were placed in an exercise class; a second group were to perform individual physical therapy; a third group were to perform individual home exercises.  Researchers found the most dramatic improvement among the group exercisers:

They discovered improvement in the exercise class group from a mean Constant Score of 39.8 at baseline to 71.4 at 6 weeks and 88.1 at 1 year, as well as a significant improvement in shoulder symptoms in the Oxford and Constant scores compared to the individual physiotherapy or home exercises alone groups.

This is a good sign that getting out of the house and remaining active can help to “thaw” a frozen shoulder, and may also prevent further recurrence of the problem. If you’d like to learn more about the latest advances in shoulder pain management, please contact my San Diego orthopedic shoulder surgery offices today.


Orthopedic shoulder surgery can be an effective remedy for acute injury or for chronic pain and stiffness, but it’s a tool of last resort. Given the time commitment and lengthy recovery period, most patients would much rather try other strategies to avoid time in the OR.

The Web abounds with stories of shoulder pain sufferers who sought pain relief without medical interventions. This latest from the Los Angeles Times does a nice job of covering the full menu of options available to people in most cities. The highlight for me? This quote, which describes the basic problem of postures and inactivity that have become a national epidemic:

“What we are doing today does not support our eons of evolution,” said Heath Reed, a licensed massage and yoga therapist who practices in Phoenix. “There is no way our biology can keep up with technology. The lack of movement at all is our first problem. The secondary problem is our dysfunctional movement.”

I encourage you to read the full piece for a nicely balanced discussion of various interventions such as massage, exercise, physical therapy and Rolfing. Some additional tools to consider include Alexander technique and Feldenkrais.  And when you’d like to get checked out by an expert San Diego orthopedic surgeon, contact my offices today.

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