Shoulder Conditions

Shoulder bursitis, impingement syndrome, and rotator cuff tendonitis are different names used to describe the same problem. The shoulder bursa is a smooth layer between the rotator cuff tendons and the bones that lie on top of them. Anything that injures or irritates the rotator cuff will cause inflammation of the bursa, which is then called bursitis.

Repetitive lifting or activity, especially with the arm in the overhead or outstretched position can cause or exacerbate pain in the rotator cuff. This pain is usually referred to the lateral arm or deltoid muscle of the upper arm, and can cause pain with daily activities. Night pain is especially problematic, as it can be difficult or painful to lie on the affected shoulder, and will frequently cause loss of sleep and difficulty getting rest.

Spurring of the bone that lies on top of the rotator cuff has been implicated as an additional cause of shoulder pain, as it can cause compression or wear of the rotator cuff and “impinge” on the tendons.

Treatment

Treatment is directed at reducing the inflammation in and around the shoulder and rotator cuff. Medications such as anti-inflammatories (ibuprofen, naprosyn, Aleve, Advil, etc.) can help, as does Tylenol. To decrease pressure on the shoulder, avoid sleeping on the affected shoulder at night by putting a pillow under the injured shoulder or sleeping in a more sitting position.

You should also reduce activity with the shoulder and arm: limit the amount and weight of lifting with the arm, avoid overhead and outstretched positions of the arm, and use the arm predominantly at the waist level. Try to avoid reaching far behind you, such as reaching for a purse or briefcase in the backseat of the car.

In addition to medications and activity restrictions, exercises for the shoulder can help. Working directly with a physical therapist can be effective in strengthening both the larger muscles about the shoulder, neck and shoulder blade, in addition to the smaller muscles of the rotator cuff. Moist heat from a shower or bath can be beneficial, while ice can reduce swelling and inflammation. Use what feels best for your shoulder, although typically warm water helps the most.

A cortisone injection can be an effective way to treat bursitis. Cortisone is a potent anti-inflammation medication that is placed directly into the shoulder and around the rotator cuff. The injection itself should cause very little pain if performed by an experienced physician and can provide substantial relief of pain, although symptoms can reoccur.

Surgery

When time and treatment do not work, particularly in the face of worsening pain, surgery may be an option. The decision for surgery is based on pain, and only a patient can answer when it is time to proceed.

A patient can be a candidate for surgery based on failure to improve and continuous symptoms over time despite treatment, but only the individual knows how much the pain interferes with his or her life. Often this pain interferes with day-to-day, work, functional, and recreational activities in addition to sleep.

Surgery is performed arthroscopically using small holes around the shoulder and a scope about the size of a pen. Small instruments are placed into the shoulder using these holes or portals, and inflamed tissue is removed. The bursa, or gliding layer around the rotator cuff, is excised and bone spurs are removed to alleviate pressure or mechanical irritation of the rotator cuff tendons. The bone spurs will not reoccur, and the procedure can be very successful when done technically correctly.

Even though the procedure is an outpatient one, recovery can take time. Dr. Kaminsky recommends taking at least one week out of work, if not more, before returning to work on a limited or light-duty status. A sling can be used for support, and it can also prevent other people from bumping or grabbing the injured arm. Early use of the arm with light activities, in addition to physical therapy, can hasten recovery without causing inflammation to reoccur.

The rotator cuff is a series of four tendons deep in the shoulder that hold the ball into the socket and provide power and strength for the arm when reaching in the outstretched and overhead positions.

A tear of the rotator cuff can occur from an injury due to sports, a fall, or lifting. Aging and simple activities of daily living can also cause wear of the rotator cuff and eventual tearing. A tear can involve one or more of the tendons, and the biceps tendon may also be affected.

Once the rotator cuff is torn, pain is a frequent complaint. Night pain is especially common, and it is often difficult to lie on the affected shoulder or get a full night’s rest. Weakness of the arm will also occur, since the tendon is often detached from the ball of the shoulder and no longer has its normal function. Reaching out to the side or behind one’s body can be a painful experience, and reaching overhead can be problematic.

Treatment

Once the rotator cuff is torn, the tendon will not reattach to the bone where it inserts. Non-surgical treatment can reduce symptoms associated with a tear:

• Physical therapy exercises can strengthen the remaining intact rotator cuff and the other muscles around the shoulder.
• Pain relievers, anti-inflammatory medication, and cortisone injections can limit the inflammation and pain associated with a rotator cuff tear.
• Some patients find that heat, ice, or topical ointments can also be of help.
• Avoiding overhead activities and reducing repetitive or heavy lifting will minimize stress on the injured tissues.

Surgery

For most active and healthy people, surgery may be a consideration. Because the tear persists, weakness and pain can also persist. Many patients elect to have surgery after discussing their options with their surgeon. Surgery is directed at reattaching the torn tendon back to the bone where it belongs. The tendon is held there tightly with sutures or other implants while it heals over time.

However, rotator cuff surgery is a highly technical procedure with significant risks. Complications can include recurrent tear, stiffness, and pain. Recovery following surgery can take several months and will include physical therapy. Questions to ask your doctor include the number of shoulder surgeries that are performed each week and the number of rotator cuff repairs performed weekly and monthly.

An experienced shoulder surgeon will perform this surgery on a weekly basis and will perform hundreds of shoulder surgeries a year. An experienced surgeon will tend to keep complications at a minimum, avoid long surgery times, and likely have improved outcomes.

Be prepared to spend at least a week out from work to recover from surgery. Most patients start physical therapy at that time, and light activities are allowed, particularly at the waist level. A sling or brace is sometimes used to provide comfort and support to the arm as needed, but not to immobilize or restrain the arm.

Another question to ask your surgeon is whether he or she performs all-arthroscopic rotator cuff repairs and how many. This type of repair is a relatively newer way to reattach the rotator cuff tendon to the bone. The procedure is completed through several small holes and no incision is made. Most orthopedic surgeons perform shoulder arthroscopy but fewer perform arthroscopic rotator cuff repairs on a frequent basis.

Shoulder arthroscopy is a surgery in which a scope about the size of a pen is inserted into the shoulder joint to evaluate and treat shoulder conditions. The benefits of arthroscopic surgery can be substantial and include less pain after surgery, shorter recovery time, and an improved appearance.

Frozen shoulder, or adhesive capsulitis, is a condition in which the shoulder becomes very stiff and painful. It becomes difficult to place the arm in certain positions, and pain is a common feature. Many patients describe the pain as a constant, dull, toothache type of pain deep in the shoulder.

This problem often occurs without an injury and can persist for months or longer. Patients with diabetes are at higher risk of developing this problem, for reasons that are not entirely clear.

Patients with this problem describe difficulty with daily activities and find that a hot shower relieves some pain temporarily. Women often describe difficulty reaching their bra behind their back, and men describe difficulty reaching for their wallet in the back pocket or pulling a belt through belt loops in the back of pants.

Treatment

Treatment is directed at improving motion and alleviating pain. Physical therapy is often an integral part of treatment. Most patients should consider working with a therapist on a routine basis. Typically, as the motion or mobility of the shoulder improves, pain also improves.

Most patients respond well to a stretching program and the condition resolves. It is unlikely for the problem to reoccur. Pain medication or cortisone injections can provide some temporary relief.

Surgery

Surgery is reserved for those patients who do not respond to time and treatment. Patients who elect to have surgery do so because of the continuing symptoms and the difficulty of trying to perform everyday activities with pain.

Surgical options include a “manipulation” under anesthesia or arthroscopic surgery. A manipulation is a procedure in which the patient is put to sleep and the arm is forcibly moved to break up the tight tissue. This procedure can, however, cause the arm to break because of the force required to “manipulate” the shoulder.

The other option is arthroscopic surgery, in which a scope and small instruments are inserted into the shoulder joint to more precisely remove the tightened tissue and evaluate the remainder of the shoulder. Physical therapy is still required after surgery to maintain the improvements obtained at the time of surgery and to avoid recurrent stiffness.

The labrum is the cartilage that encircles the glenoid, or shoulder socket. The labrum serves as attachment points for ligaments of the shoulder, provides stability to the shoulder joint, and anchors the biceps tendon.

A labral tear can occur with injury, such as a forceful pull of the shoulder or from repetitive activity such as frequent throwing during baseball or softball. Labral tears can also occur with age. Certain types of labral tears have specific names such as a SLAP lesion (Superior Labrum Anterior Posterior). In this case, the socket cartilage is detached with the biceps tendon.

Pain with activity is a frequent complaint with a labral tear. In particular, overhead activity, and especially overhead throwing, becomes weak and painful. Some patients complain of a mechanical catch or popping sensation of the shoulder when the arm is placed in certain positions. Sleep can also be affected.

Treatment

Treatment can include surgical and non-surgical choices. Conservative treatment such as analgesics and anti-inflammatory medications can help with the pain and inflammation associated with a labral tear. Physical therapy can help strengthen the rotator cuff and muscles about the shoulder. Stopping sports and painful activities is also recommended as initial treatment.

Surgery

The decision to have surgery is based on several factors, including the extent and severity of the tear, the degree of pain, limitations of sports or activity, and failure of other treatments. The surgery is an arthroscopic procedure and is done on an outpatient basis. Small metallic or absorbable plastic anchors with sutures are placed into the rim of the socket. The sutures are then passed around the torn cartilage and tied. This secures the cartilage to the bone, and allows the tear to heal. Physical therapy is typically recommended after surgery.

Instability of the shoulder joint can be due to several causes. A common reason for an unstable shoulder occurs after a shoulder dislocation. When the ball dislocates from the shoulder joint, ligaments may tear and the lining of the shoulder joint – the capsule – stretches and cannot hold the shoulder joint in place. The ligament tear is often called a Bankart lesion.

Younger patients are more likely to dislocate the shoulder again than older patients. Shoulder dislocations can also cause other injuries to the shoulder, such as a rotator cuff tear.

Shoulder instability can occur from activities that stretch the shoulder joint repetitively, such as baseball pitching. Instability can also occur without an injury or sports. This type of instability is often called multidirectional instability, and these patients often are very flexible or “double jointed.” Instability can be very subtle and can be confused with other shoulder conditions.

Treatment

Treatment of shoulder dislocations and/or instability depends on the type and cause of the instability or dislocation, the age of the patient, and activity level, among other factors. Often, traumatic dislocations are treated surgically, while patients who develop instability without an injury are treated with an exercise program designed to control the shoulder with improved muscle balance and tone.

Although many procedures have been developed to tighten an unstable shoulder and repair torn ligaments, most of these procedures require an incision and may injure deep tendons. Newer arthroscopic repairs utilize only small holes around the shoulder, but can be technically demanding.

Make sure your doctor has extensive experience in these procedures, as complications from surgery can include over-tightening the shoulder, which can cause stiffness or continued sensations of pain or instability.

Arthritis is a common disease that causes joint pain, stiffness, immobility, and swelling. Arthritis is actually a term for a group of over 100 diseases that affect the muscle and skeletal system, particularly the joints.

Arthritis alters 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. Arthritis can be quite painful and disabling. Shoulder arthritis can often be treated by Dr. Kaminsky with minimally invasive surgery, with excellent improvements in pain and function. For those patients with more severe shoulder arthritis, Dr. Kaminsky offers total shoulder replacement surgery.