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:

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.

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

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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.

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.

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 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.


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.


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.


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

Shoulder Instability:

Instability occurs when the shoulder joints shift or are forcefully pulled from its normal position due to injury or a severe jerk. Instability can result in the dislocation of the shoulder joint. Individuals suffering from instability will experience pain and weakness while lifting their arms.


Impingement transpires when the shoulder muscles rub excessively against the top part of the shoulder blade, called the acromion. Repetitive or excessive overhead shoulder movement is responsible for impingement. Medical care is required immediately for pain and inflammation in the shoulder. Left untreated can result in a more serious injury.


Labral Tear:

While the shoulder is a ball-socket type of joint, the socket of the shoulder joint is too shallow to hold it tight on its own. To compensate, the joint has a ring of cartilage around the socket called the labrum. This helps to forms a deeper cup for the ball portion of the humerus. The tear can occur from long term activities, a sudden jerk to shoulder joint, or a fall can cause wear and tear in this labrum.

labral tear

SLAP Lesion Tear:

SLAP – stands for Superior Labrum from Anterior (front) to Posterior (back) direction. This indicates a tear in the labrum above the middle of the glenoid fossa. An injury such as this is common in those who play sports using repetitive overhand motion, such as baseball, golf, and tennis. The torn labrum (seen at the top of the shoulder socket) is where the biceps tendon is attached to the shoulder. Patients with this type of tear can have difficulty in lifting the arm, or feel pain and weakness. For more details please check: superior labrum anterior to posterior (SLAP) tear

Subacromial Bursitis:

The bursa is a small pouch located between bones and muscles. It contains fluid that helps cushion the joints, provide smooth gliding, and reduces friction. Bursitis occurs when the bursa becomes irritated or inflamed. The subacromial bursa assists the rotator cuff in overhead activities. Bursitis mostly occurs secondary to any shoulder injuries like impingement, calcium deposits, or overuse of the muscles.

Bankart Lesion Tear

The Bankart lesion is a tear of the labrum below the middle of the glenoid fossa (socket). This is caused by repeated shoulder dislocations. It is one of the most common causes of instability of shoulder joint. This kind of tear also occurs with overstretching. Symptoms with a Bankart lesion tear sense instability or dislocation, pain and a catching sensation in the shoulder.

Acromioclavicular Joint Injuries:

The acromioclavicular (AC) joint is located at the top of the shoulder. The joint, called the acromion, is formed where the collarbone, known as the clavicle, meets the shoulder blade, or scapula. Cartilage can be found between the two bones. The AC is a bony joint and can be felt about 3 to 4 centimeters from the end of the shoulder. Out of all types of shoulder dislocations, 12% involve the AC joint. Males are 5 times more likely to have a shoulder injury to the AC joint than females. Those under the age of 35 are more prone to developing this type of injury due to participating in higher risk activities and sports. AC joints are most often ligament tears, but can also result in sprains, fractures, and separations of the joint.


The AC joint is usually injured during direct contact with the shoulder and a hard surface, such as falling onto pavement or gymnasium floor. It can also occur during contact sports such as football, basketball, rugby, hockey, and other activities where tackling, falls, and hard hits are common. AC joint injuries can also occur from just falling on an outstretched arm. Injuries to this joint cause athletes to seek medical attention more often than for other injuries. AC joint injuries are graded I to 6 by severity. Grade I is the most common and is usually a partially torn ligament or sprain. Grade 2 is a partial dislocation of the joint and a complete tear of the AC ligament. A Grade 3 is a complete shoulder separation. Grades 4-6 are uncommon and are caused by serious injuries such as a car accident or fall from a significant height.

Signs and Symptoms

Those suffering from an AC joint injury will feel pain around the end of the collarbone, which can be widespread and hard to pinpoint, or can be localized. Pain and swelling can worsen with movement and the range of motion decreases. Tenderness or bruising often occurs with an AC joint injury, and occasionally a bump or deformity can be seen at the top of the shoulder.


Treatment depends on the severity of the injury. For a Grade 1 injury or a strain, an initial RICE (rest, ice, compression, elevation) treatment along with a sling is tried. The doctor will often prescribe an NSAID (non-steroidal Anti-Inflammatory Drug) such as Motrin or Ibuprofen, or possibly prescription pain medication. If the injury is not too severe, movement of the shoulder is recommended to maintain mobility. If RICE, over the counter medicine, and motion does not lessen the pain, cortisone shots are the next step. These are done in the doctor’s office, who will usually only give one or two before surgery is recommended. If the joint has been completely separated, it will remain unstable and usually requires shoulder surgery. Due to the location and every day usage of the joint, most types of injuries will eventually result in arthritis as the cartilage wears away. For AC Joint Dislocation please check: Acromioclavicular Joint Dislocation

Biceps Tendinitis:

Biceps tendinitis is the inflammation of the long head tendon of the biceps muscle. Biceps tendinitis is mainly caused by degeneration of the tendon from activities like repetitive overhead movement, jerk, over stretch, and past injury. Inflammation can be felt in the bicipital groove. This injury is commonly accompanied by rotator cuff tears or SLAP (superior labrum anterior to posterior) lesions. The chief complaint of patients with biceps tendinitis is usually a deep, throbbing pain in the anterior side of shoulder.

Subacromial structures1 253x300 1

How Surgeons Position Patients for Shoulder Surgery

Patients who undergo arthroscopic shoulder surgery are generally placed in one of two positions on the operating-room table. Orthopedic surgeons either have them lying down or sitting up. The lateral decubitus position essentially means the patient is lying on his/her side during the surgery. This position is used for most arthroscopic shoulder procedures. One of the advantages of having patients lie flat is that little medical equipment is required. The patient tends to have less blood loss in this position because of manipulative techniques that the anesthesiologist can employ while the patient is in this position. The beach chair position essentially means that the patient is sitting up during the surgery. This position is used for most open shoulders procedures (surgeries that require a relatively larger incision). Each method has its pros and cons, as well as potential complications. For the lateral decubitus position, there tends to be less blood loss as previously described. In addition the risk of stroke and vision complications are significantly less common in this position. Access to certain parts of the shoulder (especially posterior) is much more readily approachable. For beach-chair patients, the advantage is that the anatomy is upright and so easier for a nonspecialized surgeon to appreciate and understand. The operating-room table is prepared with a bean bag and sheet. Medical staff use the sheet to lift and place a patient on the table, ensuring that the operative side of the shoulder is facing upward. Suction is applied to the bean bag to get the torso into the right position. Padding supports the head, ankles, hips, elbows and wrists; and a safety strap holds the patient in place. The anesthesiologist and other staff rotate the table to make the shoulder accessible to the surgeon. The patient’s bottom arm is strapped to an arm board. The arm on the operative side is suspended with clamps, tape or an IV pressure bag extending from a boom over the patient. A nurse applies sterile drapes, and places a bear hugger on the lower extremities to keep the patient warm. During rotator cuff repair, a member of the surgical team provides constant traction, or pulling, on the arm. The lateral decubitus position is the simplest, because no devices are needed to hold the patient in the proper posture. However, many surgeons prefer the beach-chair method because it affords easier access to the front of the shoulder. Operating on a patient who is propped up in a sitting position requires the use of positioning devices. These supports allow the arm to be rotated and pulled during surgery. Most patients find this posture more comfortable than lying flat. To get patients into the beach-chair position, they are first placed on the table in the supine posture. The upper torso is lifted until the waist is bent at an 80 percent angle. Positioning devices hold the shoulder and head in place, while side supports prevent the torso from moving when the arm is manipulated. For some shoulder procedures, surgeons have patients placed in a hybrid posture known as La Jolla beach-chair position. The patient is propped up from a supine pose until the body is flexed at a 45-degree angle. The position is in between lying down and sitting up. A traction device and positioning equipment aid in maintaining the position. Surgeons and other medical staff are trained to identify the best positioning for a patient. The main factor is the nature of the procedure, though individual considerations also play a role in the decision.

beach chair position

lateral decubitis position


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