SHOULDER

Do you have pain in your shoulder or arm? Does the pain bother you when you lay down to sleep? Is it painful to rotate your shoulder joint, or do you have muscle weakness? Shoulder pain can develop over time from normal wear and tear, but it is often caused by overuse or repetitive overhead movements in sports.

Your shoulder is a complex ball-and-socket joint. It is surrounded by strong ligaments and tendons, including the rotator cuff. These supportive structures can be sprained or strained, causing weakness in the shoulder.

To determine exactly what is causing your symptoms, you need an orthopedic evaluation of your shoulder, including X-ray and possible MRI. Once a diagnosis is made, a Southeast Michigan Center for Orthopedic doctor will create a custom treatment plan.

If the doctor suspects you have a torn ligament or tendon, he may recommend shoulder arthroscopy. This minimally invasive surgical technique is used to both assess joint damage and repair it in a single procedure.

For minor injuries, shoulder rehabilitation includes limiting movement with a sling and managing the pain and swelling while it heals. In extreme cases of shoulder arthritis or injury, the doctors can perform a shoulder replacement.

Physical therapy can work to strengthen the shoulder muscles and stabilize the joint for long-lasting benefits, even after surgery. Keeping your shoulder strong will be essential for preventing re-injury if you intend to return to the activities that caused your shoulder pain in the first place.

Shoulder pain is an indication that something within the joint is inflamed or damaged. The pain will not go away without treatment, but that does not mean you need surgery.

The team of doctors at Southeast Michigan Center for Orthopedics have fixed many shoulders in their careers and will help you, too. Call (248) 792-9881.

Shoulder Impingement Syndrome - Shoulder Tendonitis

Shoulder impingement syndrome is a painful condition in the shoulder. It occurs when the tendons in the shoulder are irritated, inflamed or degenerated from repetitive overhead motions or structural abnormalities in the shoulder. Shoulder impingement syndrome is treated with activity modification, medication, and therapy. When non-surgical options fail, surgical treatment may be used to relieve symptoms and restore function.

ANATOMY

Your shoulder is composed of three bones. The humerus is your upper arm bone. The clavicle is your collarbone. The scapula is the shoulder blade that moves on your back. A prominent edge of the scapula, the acromion, forms the top of the shoulder.

The head of the humerus is round. It rotates in a shallow basin on the scapula called the glenoid. A group of ligaments, called the joint capsule, hold the head of the humerus in position. Ligaments are strong tissues that connect bones and provide stability. In other words, the joint capsule is responsible for holding your upper arm in place at your shoulder.

Four muscles at the shoulder form the rotator cuff of tendon that connects to the head of the humerus. The muscles allow the arm to rotate and move upward to the front, back, and side. A gliding membrane, the bursa, lubricates the rotator cuff tendons and reduces friction around them when they move.

You use your rotator cuff muscles whenever you perform overhead motions, such as lifting your arms up to put on a shirt or reaching for an item on a shelf. These motions are used repeatedly during sports, such as serving in tennis, pitching in baseball, stroking in swimming, and passing in football. Overhead motions may also be used for job duties, such as for construction.

CAUSES

Impingement syndrome usually occurs as a result of muscle imbalance around the shoulder that place increase stress on the rotator cuff tendons. Secondary impingement syndrome results from the rubbing or pinching of the tendons and bursa during repetitive overhead movements. Shoulder impingement syndrome occurs when the space beneath the acromion is too small for the rotator cuff tendons. The space may be too narrow because of structural abnormalities in the shoulder bones, bone spurs, or thickened tissues.

As the tendons and bursa rub together during movement, it causes friction, pain, and limited motion. Degenerated tendons can become painful. Tendons may develop tendonitis, and the bursa may develop bursitis. Both are painful conditions. Continued inflammation can cause the rotator cuff tendons to tear or detach from the top of the humerus.

SYMPTOMS

Shoulder impingement syndrome causes a generalized aching pain in the shoulder and upper arm. You may feel weakness and pain when you raise your arm for activities, such as combing your hair or putting on a shirt. Pain at night is typical and may interfere with sleep.

DIAGNOSIS

Your doctor can diagnose shoulder impingement syndrome by reviewing your medical history and examining your shoulder. X-rays are ordered to check for bone spurs or acromion abnormalities. A magnetic resonance imaging (MRI) scan may be used to show more detailed pictures of your shoulder, particularly the rotator cuff, the muscles and joint capsule.

TREATMENT

Treatments for shoulder impingement syndrome include rest from the irritating activity and ice packs or medication for pain and inflammation. Cortisone injections are often used. Physical therapy is very often used to regain motion and strengthen weakened muscles, thereby decreasing pain.

SURGERY

Surgery is recommended when non-operative treatments have provided minimal or no improvement of your symptoms. Surgery may be necessary to enlarge the space beneath the acromion to allow the tendons to glide freely, or to trim degenerated tendon. This can be accomplished with surgery to remove bone spurs and the undersurface of the acromion (acromioplasty), remove some of the bursa, and occasionally a small part of the clavicle. The surgery is typically performed arthroscopically.

During an open surgical repair, the surgeon makes a three or four inch incision over the shoulder to access the joint. Arthroscopic surgery is a less invasive surgical procedure. It uses an arthroscope and narrow surgical instruments that are inserted through small incisions. An arthroscope contains a lens and lighting system that allow a surgeon to view inside of a joint. The arthroscope is attached to a miniature camera. The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.

With arthroscopic technology, your surgeon will not need to open up your joint fully. The arthroscope can be used to remove bone spurs and excess bone. It can also be used to repair torn tissues.

RECOVERY

Arthroscopic surgery usually leads to less pain in the early post operative period. It has a reduced risk of infection, less blood loss, and less pain and stiffness because only small incisions are used and less surrounding tissue is affected or exposed. The recovery process is different for everyone, but typically it takes several months to recover from surgery with participation in rehabilitation therapy. Your doctor will let you know what to expect.

Shoulder Arthroscopy

Arthroscopic Surgery is a procedure that allows surgeons to see, diagnose, and treat problems inside a joint. The procedure, also called an Arthroscopy, requires only small incisions and is guided by a miniature viewing instrument or scope. Before arthroscopy existed, surgeons made large incisions that affected the surrounding joint structures and tissues. They had to open the joint to view it and perform surgery. The traditional surgery method carries a higher risk of infection and requires a longer time for recovery. In contrast, arthroscopy is less invasive. It has a decreased risk of infection and shorter recovery period. Today, arthroscopic surgery is one of the most common orthopedic procedures.

TREATMENT

Arthroscopic Surgery uses an arthroscope, which is a very small surgical instrument; about the size of a pencil. An arthroscope contains a lens and lighting system that allows a surgeon to view inside a joint. The surgeon only needs to make small incisions and the joint does not have to be opened up fully. The arthroscope can be attached to a miniature camera. The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.

Initially, the arthroscope was designed as a diagnostic tool for planning traditional open joint surgeries. A surgeon uses an arthroscope to diagnose joint conditions when physical examinations or imaging scans are not conclusive. The diagnostic accuracy of arthroscopy is highly precise. As the technology developed, special surgical instruments were created to use with the arthroscope. Now, it can be used to treat conditions as well. Like the arthroscope, the thin surgical instruments are inserted into the joint through small incisions. Some injuries or problems are treated with a combination of arthroscopic and open surgery.

CONDITIONS TREATED WITH ARTHROSCOPY

Although nearly all joints can be viewed with an arthroscope, it is used most frequently to treat six joints. These include the knee, shoulder, elbow, ankle, hip and wrist. Arthroscopy most commonly treats diseases and injuries that damage the bones, cartilage, ligaments, tendons, and muscles that make up a joint.

Bones are the hardest tissues in our body. They support our body structure and meet to form joints. Cartilage covers the ends of many of our bones. The cartilage forms a smooth surface and allows the bones to glide easily during motion. Disease and injury can compromise the cartilage and joint structure and disrupt their functions.

A condition called Chondromalacia can cause the cartilage to soften and deteriorate because of injury, disease, or “wear and tear.” The curved cartilage in the knee joint, called a meniscus, is especially vulnerable to tears during injury. An arthroscopic surgery can treat these conditions by shaving and smoothing out the cartilage. It can also remove abnormal growths from bones, such as calcium deposits and bone spurs.

Tendons are strong fibers that attach our muscles to our bones. They are tissues that do not stretch easily and are susceptible to tears under repeated or traumatic stress. Ligaments are strong tissues that connect our bones together and provide structural support. The ligaments are lined with Synovial Membrane called Synovium. The Synovium secretes a thick liquid called Synovial Fluid. The Synovial Fluid acts as a cushion and lubricant between the joints, allowing us to perform smooth and painless motions. Trauma and “wear and tear” from overuse can cause injury and inflammation to our tendons, ligaments, and Synovium.

Tendons in the shoulder and ligaments in the knee are frequently torn or impinged from trauma and overuse. An arthroscopy can repair tendons. Many ligaments and tendons can be repaired arthroscopically. Synovitis, a condition caused by an inflamed lining of a joint, can develop in the knee, shoulder, elbow, wrist, or ankle. Arthroscopy can treat synovitis by removing scar tissue or the inflamed synovium. A synovial biopsy, a tissue sample for examination, can be done via arthroscopy.

WHAT TO EXPECT

Arthroscopic surgery is usually performed as an outpatient procedure. In some cases, an overnight stay in the hospital may be needed. You may be sedated for the surgery or receive a local or regional anesthetic to numb the area, depending on the joint or suspected problem. Before the surgery, your surgeon will elevate your limb and apply a tourniquet, an inflatable band. This will reduce the blood flow to your joint during the procedure.

Your surgeon will make one or more small incisions, about ¼” to ½” in length, near your joint. Your surgeon will fill the joint space with a sterile saline (salt-water) solution. Expansion of the space allows your surgeon to have a better view of your joint structures. Your surgeon will insert the arthroscope and manipulate it to see your joint from different angles. If you are having another surgical procedure, your surgeon may make additional small incisions and use other slender surgical instruments. When your procedures are completed, your surgeon may inject your joint with medication to reduce pain and inflammation. Because the incisions are so small, they will require just a few stitches.

Your recovery time will depend on the extent of your condition and the amount of surgery that you had. Your surgeon will let you know what to expect. Your surgeon may restrict your activity for a short period of time following your surgery. It is common for people to return to work or school within a few days. In some cases, rehabilitation is recommended to mobilize and strengthen the joint. It usually takes a joint several weeks to fully recover.

BENEFITS OF ARTHROSCOPY

An arthroscopy can be a short procedure.  In some cases, it may only take minutes for the actual surgery. Because it is often a shorter procedure, a smaller amount of anesthesia is required and individuals need to be sedated for shorter amounts of time than with open joint surgery. Most people have the procedure as an outpatient and return to their homes in just a few hours.

Overall, an arthroscopy requires a shorter length of time for recovery than open joint surgery. It also has a reduced risk of infection and causes less pain because only small incisions are used and less surrounding tissue is affected or exposed.

Total Shoulder Replacement

The shoulder has a greater range of motion than any other joint in our body, but because it can perform so many movements, the shoulder is vulnerable to stress, injury, and arthritis. Arthritis is a major cause of shoulder pain.

Arthritis is a common disease that causes joint pain, stiffness, and swelling. It affects the cartilage in joints. Cartilage is a very tough, shock absorbing material that covers the ends of many of our bones. The cartilage forms a smooth surface and allows the bones in our joints to glide easily during motion. Arthritis can cause the cartilage to wear away. Loss of the protective lining can cause painful bone on bone rubbing.

Severe shoulder arthritis can be quite painful and can cause restriction of motion. While the symptoms of shoulder arthritis may be tolerated with some medications and lifestyle adjustments, there may come a time when surgical treatment is necessary. Shoulder replacement surgery, also called Arthroplasty, involves the replacement of the damaged bone and cartilage with metal and plastic implants. Shoulder Arthroplasty is a treatment option that can relieve pain and restore function. Very often, people tolerate their symptoms for long periods of time because the arm is not a weight bearing extremity. For this reason, arthritis of the shoulder is not as common as in the hip and knee. As such, most people know someone who has had a hip or knee replacement, but many people do not even know that shoulder replacement is an option.

ANATOMY

Our shoulder is composed of three bones. The humerus is our upper arm bone. The clavicle is what we call our collarbone. The scapula is the shoulder blade that moves on our back. A part of the scapula, called the acromion, forms the top of the shoulder. There are a total of four joints in our shoulder complex. The humerus and the scapula form the main shoulder joint, the glenohumeral joint.

The glenohumeral joint is not a true ball-in-socket joint like the hip, but it is similar in structure. The top of the humerus is round like a ball. It rotates in a shallow basin, called the glenoid, on the scapula. A group of ligaments, called the joint capsule, hold the ball of the humerus in position. Ligaments are strong tissues that provide stability. In other words, the joint capsule is responsible for holding our arm in place on our body.

Several ligaments connect our shoulder bones together. Tendons attach our muscles to our bones. Our muscles move our bones by pulling on our tendons. They move our arms to position our hands for a variety of functions. The shoulder also provides stability when our elbow flexes as we lift objects.

The Rotator Cuff tendons connect strong muscles to the humerus bone. These muscles allow the arm to rotate and move upward to the front, back, and side. A fluid-filled sac, called the subacromial bursa, lubricates the rotator cuff tendons allowing us to perform smooth and painless motions. We use the rotator cuff muscles to perform overhead motions, such as lifting up our arms to put on a shirt, comb our hair, or reach for an item on a top grocery shelf. These motions are used repeatedly during sports, such as pitching in baseball, serving in tennis, and passing in football.

CAUSES

Arthritis is a major cause of pain, stiffness, and swelling in the shoulder. Arthritis can occur for many reasons, including aging, “wear and tear,” injury, autoimmune disease, and inflammatory disease. There are over 100 different types of arthritis. Osteoarthritis, Post-Traumatic Arthritis, and Rheumatoid Arthritis are types of arthritis that frequently develop in the shoulder.

Osteoarthritis is the most common type of arthritis affecting some 21 million Americans alone. It tends to develop as people grow older. Osteoarthritis can result from overuse of a joint during sports or work. Post-Traumatic Arthritis can develop in individuals of all ages after a shoulder injury, such as a fracture.

Osteoarthritis causes the cartilage covering the end of the bones to gradually wear away resulting in painful bone on bone rubbing. Abnormal bone growths, called spurs, can grow in the joint. The bone spurs add to the pain and swelling, while disrupting movement.

Rheumatoid Arthritis is one of the most serious and disabling types of arthritis. Rheumatoid Arthritis can affect people of all ages, but most frequently occurs in women and those over the age of 30. It is a long-lasting autoimmune disease that causes the synovium to be inflamed and painful. It also causes joint swelling and deterioration. Tissues surrounding the joint may also become affected. Pain, stiffness, and swelling are usually ongoing symptoms, even during rest.

Some people that have had a rotator cuff injury for a long time may develop Rotator Cuff Tear Arthropathy. This condition results from the changes in the shoulder joint that occur because of the rotator cuff tear. Eventually, arthritis can develop, which leads to destruction of the joint cartilage.

Shoulder Replacement Surgery is also a treatment for Avascular Necrosis. This medical condition causes a lack of blood flow to the head of the humerus bone, causing it to die. Avascular Necrosis can be caused by several factors, including chronic steroid use, deep sea diving, severe fractures, sickle cell disease, and heavy alcohol consumption.

SYMPTOMS

A deep ache is the primary symptom of shoulder arthritis. In the early stages of arthritis, your shoulder pain may get worse with movement or activity. As time goes on, your shoulder pain may become continuous, even when you are resting. It may be severe enough to keep you awake at night and interrupts the ability to do everyday tasks such as putting on a belt or carrying groceries. Inflammation can cause your shoulder joint to also feel swollen and stiff.

Arthritis can make your joints feel weak or unstable. Your shoulder may feel like it “grinds” or “catches” when you raise your arm. You may have difficulty moving your arm. This can make it challenging to complete common activities, such as putting on your shirt or washing your hair.

DIAGNOSIS

Your doctor can diagnose arthritis by conducting a physical examination. You will be asked about your symptoms and level of pain. You may be asked to perform simple arm and shoulder movements to help your doctor assess your muscle strength, joint motion, and joint stability. Blood tests and other laboratory tests may identify what type of arthritis you have.

Your physician will order X-rays to see the condition of your shoulder bones and to identify areas of arthritis or bone spurs. Sometimes your doctor may order Computed Tomography (CT) scans or Magnetic Resonance Imaging (MRI) scans to get a better view of the bone and soft tissue structures. These imaging tests are also painless. They require that you remain very still while a camera takes images of your shoulder joint. CT scans provide a view in layers like the slices that make up a loaf of bread. MRI scans provide the most detailed images of the tendons and ligaments.

TREATMENT

Some cases of shoulder arthritis can be treated with non-surgical methods including pain relief and rest. Over-the-counter medication or prescription medication may be used to reduce pain and swelling. If your symptoms do not improve significantly with these medications, your doctor may inject your joint with corticosteroid medication. Corticosteroid medication is a relatively safe pain reliever.

Occupational or physical therapists can help you strengthen the muscles surrounding your shoulder joint. Your therapists may also apply heat treatments to help ease your pain and stiffness. They may recommend ways for you to do your daily activities, such as housework and meal preparation, in a manner that puts less stress on your joints.

SURGERY

Shoulder Arthroplasty is recommended when non-surgical treatments have provided minimal or no improvement of your symptoms. The goal of Shoulder Arthroplasty is to relieve pain and restore shoulder mobility. The surgery is performed as an inpatient procedure, and you may expect to stay in the hospital a day or two following your surgery. You will either require general anesthesia or a regional nerve block for the procedure. There are a few different types of shoulder replacement surgeries.

Total Shoulder Replacement Surgery is recommended for people with bone-on-bone Osteoarthritis and intact rotator cuff tendons. This is the most common type of shoulder replacement surgery. Your surgeon will make an incision, approximately six inches long, on the front of your shoulder joint. Your surgeon will replace the damaged head of the humerus with a highly polished metal ball. The metal ball may be surgically implanted in the humerus or attached with surgical cement, depending on the condition of the bone. The glenoid is replaced with a plastic socket.

In some cases, the surgeon may only replace the head of the humerus in a procedure called a Hemiarthroplasty. This procedure is used if the glenoid cartilage is in good condition.

A Hemiarthroplasty is commonly used to treat shoulder fractures.

A Reverse Total Shoulder Replacement Surgery is recommended for people with completely torn rotator cuffs, severe arthritis with cuff tear arthropathy, or prior failed shoulder surgery. Traditional total shoulder replacement would still leave these individuals with pain and the inability to lift their arms above their shoulders. In a Reverse Total Shoulder Replacement Surgery, the ball and the socket are switched. The metal ball is attached to the scapula, and the socket is attached to the end of the humerus. This allows the deltoid muscles, instead of the damaged rotator cuff muscles, to lift the arm above the shoulder.

Another form of replacement is resurfacing Arthroplasty when the cartilage is removed from the humeral head and a metal "cap-like" prosthesis is placed over it.

RECOVERY

Your shoulder will need several months to fully recover from the surgery. Your surgeon will restrict your arm movements for a short period of time following your procedure. You will wear an arm sling for some period of time after surgery. An occupational or physical therapist will help you gently move your arm starting on the first day following your surgery, or on the day of surgery.

Generally, Shoulder Arthroplasty rehabilitation takes from three to six months. You will gradually work to strengthen and increase the movement in your shoulder. Your recovery time will depend on the extent of your condition and the amount of surgery that you had. Your surgeon will let you know what to expect. Overall, most people achieve good results with shoulder replacement surgery. They experience an improved quality of life because of decreased pain and improved function.

Reverse Shoulder Replacement

Reverse shoulder replacement is an advanced newer surgical treatment that was approved by the FDA in 2004. A reverse shoulder replacement is a surgical procedure to replace a damaged shoulder joint with an artificial one. The new joint stabilizes the joint to allow pain-free movement and function.

A reverse shoulder replacement is used for people with certain complex shoulder conditions. In contrast to total shoulder replacement surgery (shoulder arthroplasty), the components of the artificial joint are placed in reversed positions to allow the deltoid muscle at the shoulder to raise the arm. Like traditional total shoulder replacement, physical therapy following the procedure helps to ensure the best outcomes.

ANATOMY

The shoulder joint has a greater range of motion than any other part of the body. Because the shoulder joint can perform so many movements, it’s structure of bones, ligaments, muscles, blood vessels, and nerves is more complex than other joints in the body. The shoulder joint’s structure and great range of motion make it vulnerable to injury.

The shoulder joint has three bones. The humerus is the bone in the upper arm. The clavicle bone is commonly referred to as the collarbone. The acromion is the bone at the top of the shoulder. The acromion is actually part of a larger bone, called the scapula (shoulder blade), which is located on top of the ribs on the upper back.

There are a total of four joints in the shoulder complex. The humerus and scapula form the main shoulder joint, the glenohumeral joint. The glenohumeral joint is not a true ball-in-socket joint like the hip, but it is similar in structure. The head of the humerus is round like a ball. During movement, the head of the humerus rotates in a shallow basin, called the glenoid, on the scapula. A group of ligaments, together called the joint capsule, hold the head of the humerus in position. Ligaments are strong tissues that provide stability. The ligaments in the joint capsule are responsible for holding the arm in place on the body.

Several ligaments connect the shoulder bones together. The tendons in the shoulder attach muscles to the bone. Your muscles move your bones by pulling on the tendons. The rotator cuff tendons connect strong muscles to the humerus bone. These muscles allow the arm to rotate and move upward to the front, back, and side, as well as overhead. A structure, called the subacromial bursa, lubricates the rotator cuff tendons and allows you to perform smooth and painless motions.

CAUSES

The purpose of a reverse shoulder replacement is to stabilize the shoulder joint and restore pain-free motion and function. People with multiple shoulder conditions, such as arthritis with a rotator cuff tear or vascular damage (avascular necrosis/osteonecrosis), may be candidates for reverse shoulder replacement. With significant degenerative shoulder conditions, the protective cartilage may wear away on the bones causing painful and limited movement or the rotator cuff tendons are so damaged that they contribute to pain and do not function properly. A reverse shoulder replacement may also be used for people that experienced an unsuccessful traditional shoulder replacement.

SYMPTOMS

Degenerative shoulder conditions can eventually destroy the structures in the shoulder joint. When the shoulder does not work at it should, pain and loss of motion can develop. In fact, reverse shoulder replacement can be a treatment option for people with very little or no shoulder motion, depending on the cause. Such factors can limit the use of the shoulder for functional tasks or recreational activities.

DIAGNOSIS

Your doctor can diagnose degenerative changes in the shoulder by conducting a physical examination. You should tell you doctor about your symptoms and level of pain. The examination will include performing simple arm and shoulder movements to help your doctor assess your muscle strength, joint motion, and joint stability.

X-rays help determine the condition of your shoulder bones and show abnormal bone growths (bone spurs), as well as loss of joint cartilage. Advanced imaging tests, such as a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan, may be ordered for a more detailed view.

SURGERY

A reverse shoulder replacement is recommended for people with a completely torn rotator cuff that cannot be repaired, severe arthritis with rotator cuff damage, or prior failed shoulder surgery. Traditional total shoulder replacement surgery would still leave these individuals with inability to lift their arm.

With a reverse shoulder replacement surgery, the position of the ball and socket in the joint are switched. The metal ball is attached to the scapula, and the artificial socket is attached to the end of the humerus. Such placement allows the deltoid muscle, instead of the damaged rotator cuff muscles, to lift the arm above the shoulder.

A reverse shoulder replacement is an inpatient procedure. To begin, your surgeon will make an incision on the front of your shoulder. Your surgeon will remove the damaged head of the humerus. The bone socket is exposed, and the damaged cartilage is removed. A base plate is secured to the glenoid with surgical screws. The artificial socket is inserted and secured on the humerus. The ball is inserted and secured on the glenoid. The wound is closed, and a soft dressing is applied.

RECOVERY

You will remain in the hospital for one or two days following your procedure. Some surgeons restrict shoulder movements for about three weeks. You will wear an arm sling for support.

Participating in physical therapy will help you gain motion, strength, joint stability, and coordination. At first, your therapist will help you gently move your arm. You will gradually work towards moving your arm independently. You will learn exercises to strengthen and increase the movement in your shoulder. You should be able to lift your arm above your shoulder. Eventually, your therapists will provide you with a home exercise program.

Recovery from reverse shoulder replacement surgery is individualized. It usually takes many weeks to recover from the surgery completely. Your doctor will tell you what to expect.