How the Shoulder Works

The shoulder is made up of three main bones: the collarbone (clavicle), the shoulder blade (scapula) and the upper arm bone (humerus). The purpose of the shoulder is to position the arm and hand in space.  Although the shoulder is often referred to as a “ball and socket” joint, in reality, it more closely resembles a golf ball sitting on a tee wrapped in muscles and tendons (the rotator cuff).  For this reason, the shoulder is the most mobile joint in the human body, allowing people to reach overhead, behind their back, across the body, and out to the side.  This freedom of motion makes it possible to throw a ball, swing a golf club or tennis racket, get dressed, perform personal hygiene, or reach for something on a high shelf.

While the unique evolutionary shape of the shoulder allows for this broad range of motion,  this often comes at a price of: instability, soft tissue injuries and fractures, or degenerative joint disease (i.e. arthritis).

At Palm Beach Hand to Shoulder, Dr. Veronica Diaz specializes in providing targeted care of the shoulder. Your consultation with her will involve establishing the cause of your symptoms or limitations. It will also include coming up with a tailored treatment plan that considers your activity demands and goals, the condition of your shoulder, and your general health status.

To schedule a consultation, please call (561) 746-7686 or submit an online appointment request.

Specific Shoulder Conditions:

Rotator Cuff Tears

Rotator cuff disease affects millions of people. The rotator cuff is important for providing stability and motion of the shoulder. It is comprised of four tendon-muscle units that wrap around (i.e. form a “cuff”) around the shoulder and allow movement of the shoulder. The spectrum of rotator cuff problems includes partial tears, complete tears amenable to repair, massive chronic tears that are no longer repairable, and rotator cuff tear arthritis. Symptoms of rotator cuff tears include:

• Shoulder pain while sleeping
• Loss of ability to participate in sports or fitness activities
• Pain and difficulty getting dressed (putting on a belt or getting in an out of a shirt)
• Pain and/or weakness while trying to lift the arm
• The loss of ability to lift the arm
• Pain and/or weakness while lifting or carrying items
• Pain or difficulty while styling hair, shaving, or putting on makeup
• Difficulty maintaining the shoulder in a position to pour something, difficulty eating
• Difficulty turning the steering wheel, closing the car door, or reaching across for a seatbelt 

Some rotator cuff tears occur after a distinct injury, but most rotator cuff tears are degenerative, meaning they develop gradually over time.  Studies have shown that up to 50% of people over the age of 60, whether they have symptoms or not, have a rotator cuff tear. Additionally, over the course of 5 years, many tears that were not causing pain or perceived functional limitations could become symptomatic.  The reason for this high incidence of rotator cuff tears is multifactorial.  One main reason is that as we age, the blood supply to the rotator cuff tendons diminishes, so the tendon is not able to recover from the stresses and strains placed on it through every day activity.  Certain patients have bone structure that can predispose to tears of the rotator cuff.  

Dr. Diaz helps hundreds of patients a year achieve reduced pain and better shoulder function with arthroscopic rotator cuff repair. The goal of arthroscopic rotator cuff repair is to reattach the torn tendon to bone.  This is accomplished through several small incisions around the shoulder and with special instruments that enable Dr. Diaz to insert “anchors” into bone, pass heavy rope-like suture through the torn tendon, and re-approximate the tendon to bone. 

Not all rotator cuff tears merit surgical repair.  Taken on a case-by-case basis, good results can be obtained in terms of pain relief and function with physical therapy, activity modification, and periodic follow up with Dr. Diaz to make sure the tear has not worsened.

For an animation of this procedure, please visit:

https://www.smith-nephew.com/education/resources/video/2016/september/double-row-rotator-cuff-repair-featuring-healicoil-multifix-s-ultra-and-firstpass-st/(opens in a new tab)

Some patients who have shoulder pain from rotator cuff tears that can no longer be repaired may be candidates for a minimally invasive technique to relieve their pain called the InSpace Balloon(opens in a new tab). Here is an Animation of InSpace Balloon(opens in a new tab).

Osteoarthritis

Osteoarthritis (degenerative arthritis), the most common form of arthritis, affects nearly 21 million people in the United States. It is defined by degradation of the cartilage that lines the joint (“wear and tear”). Age, genetics, activity level, occupation, and co-existing medical conditions play a role in the development of osteoarthritis. As the cartilage continues to wear down, the joint becomes inflamed. This can result in severe pain, limited mobility and strength, and sleep disruption. If non-surgical treatment options such as medication, physical therapy, dietary and lifestyle changes fail to provide relief, Dr. Diaz may recommend total shoulder replacement.

AC Arthritis

The acromiclavicular, or AC joint, is formed by the end of the clavicle (collar bone) and a part of the shoulder blade called the acromion (the bony “ceiliing” of the shoulder).  This joint is small and experiences tremendous stress with forceful activity above eye level, resulting in early degeneration.  Acromioclavicular arthritis results when there is loss of cartilage in this joint.  Laborers and weightlifters tend to be at risk for symptoms of AC arthritis.  AC joint arthritis is characterized by pain and swelling on the top of the shoulder. Pain from AC joint arthritis typically has exacerbations and remissions. Most people have symptoms while performing forceful overhead activity (overhead military press), reaching across their body, or sleeping on the affected shoulder. 

If nonsurgical management fails, surgery may be an option. Surgical treatment of painful AC arthritis involves removing a small portion of the end of the clavicle to eliminate pain from bone rubbing on bone at the top of the shoulder. Dr. Diaz mostly performs this operation arthroscopically, which carries the advantage of a quicker recovery, less risk of destabilizing the end of the clavicle, and no incision over the top of the shoulder where it can be sensitive from contact with clothing (bra) or bag straps. Most patients can resume their pre-surgical level of activity and most athletics by 6 weeks. If distal clavicle resection is combined with a reconstructive procedure, the restrictions for that procedure (ex: rotator cuff or labral repair), informs the recovery time, restrictions, and rehabilitation.

AC Separation

The AC joint can be separated if one lands hard on the point of the shoulder. Cyclists and football players are particularly at risk for this kind of injury. Many of these injuries can heal without surgery and will yield full painless function, even if there is some deformity to the shoulder.  Some patients have such severe displacement of the AC joint that an arthroscopically-assisted reconstruction of the ligaments that stabilize the AC joint is recommended.

Biceps Tears and Tendinitis 

One of the biceps tendons originates in the shoulder joint and travels between two of the rotator cuff tendons before passing into the front of the arm and connecting to the biceps muscle belly.  The long head of the biceps can be a considerable source of pain in shoulder conditions.  It is often seen in the presence of associated problems with the labrum and rotator cuff.

Subacromial Impingement (Bursitis)

The bony ceiling of the shoulder is a part of the shoulder blade or scapula called the acromion.  There is wide variability in the shape of the acromion from one person to the next.  Certain people are predisposed to inflammation in the space below the acromion (subacromial space) and above the rotator cuff.  This often manifests as pain halfway down the arm that is provoked by reaching behind one’s back or above the head.  Occupational or recreational pursuits that involve sustained eye-level or above motions can increase the risk of this condition, called impingement or bursitis.  

If the acromion is prominent towards the front or side of the shoulder, this may predispose to impingement.  Poor posture from muscle imbalance or from curvature of the spine as we age and lose bone mass can also increase the risk of this and other shoulder conditions.  Most cases of subacromial impingement can be managed with a high quality physical therapy or physician-directed home exercise program.  Some patients may benefit from a local injection to calm down the pain and inflammation.  Other patients may benefit from an arthroscopic procedure to remove inflamed tissue and smooth out the undersurface of the bony prominence.  This is especially true if there is a co-existing rotator cuff tear.

Clavicle Fractures

The collarbone serves as a strut for the arm, and is important for normal shoulder function.  Many fractures of the clavicle can be treated without surgery by immobilizing the shoulder in a sling until the fracture heals. Ice and oral pain medication are helpful for alleviating the pain.

Fractures, where the ends of the bone are widely separated or overlapped, may benefit from surgical repair with a plate and screws or a device that sits inside the clavicle.  This surgery realigns the fracture to ensure healing and preserve shoulder function.  

When you are prescribed a sling and no shoulder movement for treatment of a clavicle fracture, you are encouraged to come out of the sling to bend and straighten your elbow and to move your fingers as needed for activities of daily living (eating, toothbrushing) or tabletop activity (cutting food, writing, typing, mousing).  When x-rays show healing, the shoulder can be moved to position the hand in space.  Heavier use (household chores, yardwork, sports) should be avoided until I discuss that it is safe to resume this type of activity. Most clavicle fractures heal uneventfully.  Some fractures do not heal (nonunion) or heal with malalignment (malunion).

Rotator Cuff Deficiency and Cuff Tear Arthritis

Because the shoulder joint is stabilized by muscles and tendons rather than by bone, the shoulder has great flexibility, allowing us to position our hand in the space around us with great freedom. However, this great degree of motion has a trade off, as the stability of the shoulder is dependent upon the integrity of the four muscle-tendon units (supraspinatus, infraspinatus, teres minor and subscapularis) that comprise the rotator cuff. Most people with a painful rotator cuff tear can be treated arthroscopically. Chronic, massive tears of the rotator cuff are often irreparable and can result in cuff tear arthritis of the shoulder. The degenerated muscles lose their ability to keep the humerus centered on the glenoid, causing your arm bone to move upward and out of the socket. This prevents you from positioning your hand in certain ways that can affect reaching overhead, dressing, playing sports, turning a steering wheel, eating, etc. Cuff tear arthritis is often characterized by severe pain and limited mobility of the shoulder, and in most patients is reliably treated with reverse shoulder replacement.

Frozen Shoulder

In frozen shoulder, also known as adhesive capsulitis, the lining of the shoulder joint, called the capsule, becomes sequentially inflamed, thickened, and scarred. It most commonly affects people between the ages of 40 and 65, with women more commonly affected than men. Although frozen shoulder can be associated with a history of major trauma or prior shoulder surgery, many cases develop with no obvious cause.  Risk factors for developing frozen shoulder include diabetes, thyroid disease, and Dupyutren disease.

Patients typically present with pain without prior injury, or with seemingly minor injury. Night pain is fairly common, as is difficulty with activities of daily living like brushing one’s hair or getting dressed.  This pain is eventually accompanied by stiffness. Eventually, the pain quiets down and the shoulder “thaws” out, yielding recovery of motion.  Getting to that point requires diligence with a stretching program, correction of any thyroid problems or tight control of diabetes, and patience. 

The majority of patients with frozen shoulder will have successful treatment without surgery. Treatment for the reduction of symptoms from frozen shoulder may include physical therapy, oral anti-inflammatories, and injections of steroid +/- an injectable NSAID called toradol. Acupuncture has also been described, and meditation techniques and biofeedback may also be helpful.  Adhering to a low inflammation diet that is high in fiber and eliminates sugar-laden and processed or packaged food can be helpful.  In cases where recovery of motion is incomplete and recalcitrant to nonsurgical therapies, an arthroscopy of the shoulder for release of the scarred capsule combined with manipulation under anesthesia can yield improvement in pain and mobility.

The majority of cases resolve within 12-18 months, although some can take longer to show improvement. The shoulder community has not come up with a precise way to determine the length of disability from this condition. In patients with diabetes, frozen shoulder generally lasts longer and is more prone to recur. Frozen shoulder caused by trauma generally demands more intensive therapy and may not resolve on its own. 

Shoulder Instability and Labral Injuries

A labral tear results when there is injury to the ring of tissue that surrounds the glenoid. This cartilage acts as a bumper to stabilize the humeral head (ball) in the center of the glenoid (socket) and prevent dislocation. It can be torn with traumatic dislocations or with overuse injuries such as overhead sports. Initial treatment may consist of rest and activity modification accompanied by strengthening of the shoulder. If a course of nonoperative management fails, then surgical intervention is considered. 

Many overhead athletes or patients with early degenerative changes of the shoulder can develop painful tears of the top part of the labrum, called SLAP lesions. SLAP stands for superior labral anterior posterior, and refers to labral tears involving the origin of the biceps tendon. For patients under 35 with high athletic demands, repair of unstable SLAP tears 
is sometimes warranted. In patients 40 and older, most superior labral tears are degenerative and if patients do not improve without surgery, are best managed with debridement and disconnecting of the biceps from the labrum with a biceps tenotomy (allowing the disconnected biceps to heal on its own with scar) or tenodesis (reattaching biceps to upper arm outside of shoulder with an implant). 

Young patients with a shoulder dislocation or instability are susceptible to tears of the front and lower part of the labrum, called a Bankart lesion. If they plan on continuing to play sports where there is risk of their shoulder being forced out of socket (ex: participation in contact sports such as football, wrestling, or lacrosse, or other high risk activity such as surfing or wakeboarding), or if nonsurgical rehabilitation is unsuccessful, surgical repair is an option.

Adolescents or young patients engaged in activity that poses a high risk for recurrent instability often require a stabilization procedure for Bankart tears.  First-time dislocators can often be treated with a period of immobilization followed by physical therapy to strengthen the stabilizing muscles of the shoulder and prevent reinjury. Shoulder surgeons consider the following factors when recommending surgical stabilization vs a trial of non-surgical treatment:

• Age: the younger you are (< 20 years old), the more at risk you are for repeated dislocations if the shoulder is not surgically stabilized.
• Activity level: patients who participate in contact sports or activity that is at high risk for recurrent instability have a better chance of avoiding repeated dislocations with surgery.
• Collagen make up: Patients with more flexibility or "hyperlaxity" are more at risk for repeated instability
• Bone loss: When the shoulder dislocates, there can be injury to the bone on the socket and/or ball side of the joint, which makes the recommendation for surgical stabilization more likely.

Shoulder dislocation and the treatment for it can result in premature arthritis. When the shoulder is treated with surgical stabilization, it may mean losing some degree of external rotation (rotation of the hand away from the body).

Proximal Humerus Fractures

Fractures of the upper arm bone are common.  They can occur in elderly patients with poor bone quality after a fall onto an outstretched hand.  Ice, a supportive sling, and oral pain medication are helpful for alleviating the pain. Although the majority of these fractures can be allowed to heal on their own, some merit surgical repair or even shoulder replacement in severely displaced fractures in which a good result is not expected to be achieved with nonsurgical treatment.  

Proximal humerus fractures can also occur in younger patients who have sustained significant trauma, such as from road traffic accidents or sports. Early treatment consists of immobilization in a sling. The decision on whether to allow the fracture to heal with time or surgically repair it depends on the alignment and exact location of the fracture, patient goals and demands, and whether there was an associated dislocation of the shoulder.  These fractures can result in injury of the nerves that supply the arm.

When you are prescribed a sling and no shoulder movement for treatment of a shoulder fracture, you are encouraged to come out of the sling to bend and straighten your elbow and to move your fingers as needed for activities of daily living (eating, toothbrushing) or tabletop activity (cutting food, writing, typing, mousing).  When x-rays show healing, the shoulder can be moved to position the hand in space.  Heavier use (household chores, yardwork, sports) should be avoided until I discuss that it is safe to resume this type of activity. Some fractures do not heal (nonunion) or heal with malalignment (malunion). Many fractures may result in some loss of shoulder motion.  Recovery of motion can occur for up to a year after these injuries.

Preparing for Shoulder Arthroscopy

Thank you for choosing Palm Beach Hand to Shoulder for your care. I have put this information together with the patient scheduled for shoulder arthroscopy in mind.  Please review carefully to ensure the best possible outcome.

What is Shoulder Arthroscopy?

Shoulder arthroscopy is a minimally invasive procedure performed through several small incisions around the shoulder using a camera to visualize structures and special instruments to clean out, repair, or reconstruct injured or worn out structures.

What are the symptoms that can be helped by shoulder arthroscopy?

• Shoulder pain that leads to activity limitation or sleep disruption
• Pain when positioning the shoulder for activity above eye level, behind the back, across the body, or out to the side
• Weakness of the shoulder
• Feelings of giving way in the shoulder
• Painful clicking, popping, or catching

What are the conditions that can be successfully treated with shoulder arthroscopy?

• Rotator cuff tears                     
• Bursitis (Subacromial Impingement)     
• Labral tears                       
• Arthritis at the end of the collarbone (AC arthritis)
• Biceps tendinitis
• Shoulder separation or dislocation

What should I do to prepare for surgery?

Make alternative arrangements for transportation, dog walking, meal preparation, house cleaning, and heavy chores.  Pick out clothes that are easy to take on and off with limited use of one arm: an oversized shirt that buttons down the front, pants with an elastic waist, and shoes that are supportive and preferably without laces.

Unless otherwise instructed, hold any blood thinning medications for 5 days prior to surgery.

Do not eat or drink anything after midnight the night before surgery.  

Take a shower the night before surgery and scrub your operative shoulder, neck, upper back, underarm, and chest wall with surgical soap (4% chlorhexidine gluconate) followed by wiping the same area with a cloth soaked in 3% hydrogen peroxide.

What can I expect when I wake up from surgery?

You will wake up from surgery with a sling on your operated arm. For the first 12-24 hours after surgery, you may have limited control of the operated arm owing to the regional anesthesia or “block” that temporarily numbs and paralyzes the arm for pain control.

How do I sleep after surgery?

Getting comfortable for sleeping can be challenging after shoulder surgery.  Most patients recovering from shoulder surgery find it easiest to sleep in a recliner chair for up to several weeks after surgery.  An alternative is to sleep propped up in bed with multiple supportive pillows. The sling should be on for sleeping.

Will I need pain medication?

Most patients will require prescription medication for a few days after the regional anesthetic block wears off. You should discontinue the prescription pain medication as soon as your symptoms allow you to do so, with a goal of discontinuing them at 2 weeks.  Opioid medication can cause constipation.  Walk in a climate-controlled environment, stay hydrated, and eat a fiber-rich diet to avoid this problem.  If not medically contraindicated, taking an anti-inflammatory such as ibuprofen or naproxen in conjunction with or as a substitute for the prescription pain medication can be very effective for controlling pain with fewer side effects than the prescription medication.

How long do I have to be in a sling?

The answer to this depends on whether you are having a “clean up” or whether structures have to be repaired and/or reconstructed.  Patients just having a debridement or “clean up” will be allowed gentle use of their shoulder within a few days of surgery.  

If you are having surgery for rotator cuff repair, do not move your shoulder or discontinue the sling until I have instructed you to do so.  Remain in the sling at all times except to shower or to periodically bring your hand to your face for eating, brushing teeth, shaving, typing, etc. (i.e. “hand-to-face” or tabletop activity).  Your hand on the surgery side should remain in front of your face until instructed (wait for clearance from me before reaching out to the side or behind your back). When you are bathing you can bend forward at the hips and lower back and dangle your arm out of the sling to straighten out the elbow so it doesn't stiffen up on you and so that you can access your underam while bathing. 

How do I take care of the incisions?

The surgical bandage should be kept in place for at least 3 days after surgery.  Each small incision should then be kept covered with fabric band aids.  Do not get the incisions wet until you see Dr. Diaz at 2 weeks after surgery. Avoid sweating as this can lead to wound infection.  

Will I receive a cooling machine?

If you are interested in renting an ice machine that circulates ice water around your shoulder, please let my office know.  Whether you use an ice machine or a reusable pack/gel pad, ice is an excellent means of reducing pain and swelling in the shoulder.

Will I need therapy?

Most people undergoing shoulder arthroscopy benefit from physical therapy.  If you had a repair or reconstruction, the start of therapy will usually be 4-6 weeks after surgery.

When can I drive?

Criteria for resuming driving include no requirement for narcotic medication and discontinuation of the sling. You should ask Dr. Diaz before resuming driving after shoulder surgery. 

When can I return to work?

Patients with sedentary jobs may return to work as early as a few days after surgery with some modifications.  Patients whose job entails heavy lifting, repetitive loading, or above-eye-level activity with the operated shoulder will require anywhere from 3-4 months off from work unless arrangements can be made for modified job responsibilities (i.e. supervisory, desk/office work).

When can I resume athletics?

This depends largely on the procedure performed and the type of sport. For arthroscopy without repair, I clear most patients for full athletic activity at 4-6 weeks, depending on the circumstances.  If I performed a rotator cuff repair or other soft tissue reconstruction, it will be 3-5 months before you are allowed full athletic activity.

Please call the office or use the Patient Messaging Portal should you have any further questions.

Preparing for Shoulder Replacement

I have put together the information contained herein with the patient undergoing shoulder replacement surgery in mind. Be advised that each patient’s situation is unique and that this information is only intended to provide a general guideline and answer commonly asked questions.

BEFORE SURGERY 

Dr. Diaz’s office will arrange for bloodwork and medical clearance from your internist or cardiologist prior to surgery. You will also have a pre-operative appointment with the anesthesia team at the hospital the week prior to your procedure, and an appointment with me to review CT and MRI studies of your shoulder and answer any questions. 

1. Unless otherwise instructed, stop blood thinners and arthritis medication other than Tylenol for 5 days prior to surgery. 
2. Focus on good nutrition. I may have prescribed weight loss before considering you a candidate for shoulder replacement, but starting two weeks prior to surgery, do not lose any weight and try to maintain your weight after surgery. Patients with diabetes should focus on tight blood glucose control and notify their internist or endocrinologist if they are having difficulty managing their glucose levels. 
3. Take a shower the night before surgery and scrub your operative shoulder, neck, upper back, underarm, and chest wall well with the surgical soap provided followed by wiping the same area with a cloth soaked in 3% hydrogen peroxide. 
4. No eating or drinking after midnight the night before surgery. Be sure to take any blood pressure or thyroid medication as scheduled with a tiny sip of water. 
5. You may receive the sling before surgery. If so, put it in the car that you will take to the hospital the night before surgery and bring it with you to the surgical prep area. 
6. What to pack for your overnight stay at the hospital: 
   • A loose-fitting shirt that buttons down the front for ease of putting on and taking off Pants that are easy to put on and take off (ideally with an elastic waist)
   • Comfortable, supportive shoes that don't need laces tied 
   • Basic toiletries (toothbrush, brush, face cream)
   • Healthy snacks that don't require refrigeration 
   • Your cell phone and a charger
   • Reading glasses and hearing aids 

Do not bring any jewelry or valuable items other than your cell phone and your wallet (for your ID for registration)

THE DAY OF SURGERY 

When you arrive at the hospital, the preoperative team will start an IV and antibiotics. You will likely receive an arm block (regional anesthesia) that will numb and paralyze your shoulder temporarily. The effects could last anywhere from 6-24 hours after surgery. Sometimes the blocks are not 100% effective.

Depending on the severity of arthritis, patient size and overall health, and history of prior surgeries to your shoulder, most patients’ surgery will take between 1-2 hours. For the first 30 minutes before and after the actual surgery you are being placed under anesthesia and positioned for surgery, and being woken up. So to your family and friends it could be 3 hours between when they say goodbye to you and when they hear from me. Not all of that time is surgery. You will probably spend a couple of hours in the recovery area (PACU) before they take you up to your room or discharge you. 

If you aren't too nauseous or sleepy from the anesthesia, you should try to walk with someone's assistance or supervision the afternoon of surgery. This will keep your lungs well aerated and the blood circulating in your veins to prevent clotting. It will also help you feel more oriented.

As soon as you regain control of your arm, you should bend and straighten your fingers into a fist to keep them from getting stiff. You can also bend your elbow to bring your hand to your face or on a table surface for eating, brushing your teeth, texting on your phone, etc. No shoulder motion until you come to the office for an appointment.

AFTER SURGERY 

When can I go home after surgery? 

Most patients will be released from the hospital the day after surgery. Some patients may be able to go home the same day. 

Will I receive medication for pain? 

Yes. Discontinue the prescription medication as soon as your pain levels allow you to do so, with a goal of being off prescription pain medication by one week after surgery. 

How do I sleep after surgery? 

Most patients recovering from shoulder surgery find it easiest to sleep in a recliner chair for up to several weeks after surgery. An alternative is to sleep propped up in bed with multiple supportive pillows. The sling should be on for sleeping. 

Will I receive a cooling machine? 

If you are interested in renting an ice machine that circulates ice water around your shoulder, please let my office know. Whether you use an ice machine or a reusable pack/gel pad, ice is an excellent means of reducing pain and swelling in the shoulder. 

How do I take care of the incision? 

The cleanest bandage your shoulder will have is the one placed in the operating room immediately after the surgery, because it is placed in a sterile environment. Furthermore, this bandage has a water resistant cover that makes it easier to keep the incision dry while showering (so long as the operative shoulder is pointed away from the showerhead or a hand held wand is used). As long as the bandage remains clean and adherent, retain it for at least 7 days until the incision is partially healed before removing it. The hospital staff will provide you with replacement bandages. Do not get the incision wet until you see Dr. Diaz at 2 weeks after surgery. 

How long do I have to be in a sling? 

Remain in the sling at all times except to shower or to periodically bring your hand to your face for eating, brushing teeth, shaving, etc or periodically extend your elbow. Your hand on the surgery side should remain in front of your face until instructed. Do not move your shoulder or discontinue the sling until I have instructed you to do so. When you are bathing you can bend forward at the hips and lower back and dangle your arm out of the sling to straighten out the elbow to prevent stiffness and so that you can access under your arm for bathing. For anatomic total shoulder replacement, the sling is usually worn for 6 weeks to allow the front part of the rotator cuff (subscapularis) to heal after it is opened to expose the shoulder and then repaired. For reverse total shoulder replacement, the period of sling immobilization will last between 4-6 weeks. 

How much general activity is advised? 

Try to maintain light levels of activity in a climate-controlled environment. Walking around your home or in a cool environment with even footing will help prevent blood clots and constipation. Avoid sweating as this can lead to wound infection. 

How soon after surgery may I drive? 

Many patients want to know when they can resume driving after shoulder replacement surgery. This is contingent upon a variety of factors including duration of sling immobilization, manual or automatic transmission, etc. Generally, reaction time can be affected for up to 6 weeks following shoulder surgery, with variability from patient to patient. You should ask Dr. Diaz before resuming driving after shoulder surgery. You should begin with short, familiar distances and have a licensed driver in the passenger seat the first time you resume driving. 

When may I return to work or resume sports? 

Return to work or sports is dependent on a number of variables. Patients with sedentary jobs may be able to return as early as two weeks. Patients who have to use their arm for lifting, carrying, climbing, driving, or above eye level work will generally need 12 weeks of modified or no work. I generally allow patients to return to golf, tennis, and swimming between 4-5 months, but in select cases earlier. 

Please call the office or use the Patient Messaging Portal should you have any further questions. 

Frequently Asked Questions

What are some activities or risk factors that can lead to shoulder pain or dysfunction?

Shoulder injuries and dysfunction tend to be more common in people who perform repetitive overhead motion or weight bearing activities with their shoulders.  People engaged in overhead or racket sports, throwing athletes, and athletes participating in contact sports are at a higher risk for sholder injuries. Many of the sports that are popular in South Florida can lead to shoulder pain, including baseball, volleyball, tennis, golf, surfing, stand up paddleboarding, swimming, water polo, and gymnastics.  Patients who practice yoga and martial arts or participate in CrossFit or high intensity training are also susceptible to shoulder injuries. Shoulder injuries can affect athletes of all ages, including adolescent and collegiate athletes, professionals, weekend warriors, and the senior athlete.

Patients whose interests or occupations involve sustained above eye level activity or heavy lifting with their arms are also at risk.  There is also a genetic predisposition to certain shoulder conditions, and many are linked to medical diagnoses. For example, patients with high cholesterol are considered to be at higher risk for rotator cuff disease.  Similarly, diabetes, thyroid disease, and Dupuytren disease can all be risk factors for developing a frozen shoulder. 

What can I do to reduce my risk of injuring my shoulder joint?

If you are having symptoms of shoulder pain, limited mobility, or weakness, consider scheduling a consultation with a shoulder specialist like Dr. Diaz.  

If you are concerned about your shoulders and want to protect them, daily shoulder stretches and strengthening exercises as recommended by a physician may be helpful. These sorts of techniques are especially beneficial if you have a history of shoulder pain, as they can help prevent future injury.  Consulting with a shoulder specialist before engaging in any new fitness or shoulder conditioning program can help avoid injury or worsening of existing symptoms.  As a general rule, open chain exercises (ex: lifting free weights out to the sides) , strengthening that involves fast, uncontrolled, or jerky motions or excessive weight, or ramping up your exercise routine too rapidly can all lead to injury. Maintaining good posture and overall bone and joint health are also important for preventing shoulder pain and dysfunction. Adhering to a mostly plant-based diet that limits sugar and eliminates packaged, processed, or genetically modified foods, can also improve shoulder health and overall musculoskeletal health.

How soon after rotator cuff surgery can I drive?

I get asked by almost every rotator cuff repair patient how soon after surgery they can drive. I tell them short familiar distances in a car with automatic transmission after their first post op visit at 2 weeks, but this advice was based on expert opinion alone and not a scientific study. 

Now there is great news for patients having shoulder surgery for rotator cuff repair! A recent study showed that it is safe for patients to drive with a sling on as early as 2 weeks after rotator cuff surgery. The study measured driving performance in patients before and at different time points after rotator cuff surgery. The research team evaluated the patients' ability to park, turn, yield to oncoming traffic, make a U-turn, and merge onto the highway, among other measurements of 'driving fitness'. They found that rotator cuff surgery and the use of a sling did not negatively impact their driving ability as early as 2 weeks after surgery. 

This finding should come as a great relief to patients who keep putting off rotator cuff surgery because of concerns over not being able to drive, patients who live alone or with someone who works or doesn't drive, as well as patients who live in areas lacking in robust public transportation infrastructure. It gives patients peace of mind to drive as early as two weeks after their surgery, and means they don't have to rely on someone else or incur transportation costs to attend in-person therapy. 

Note: Patients should only drive if they feel comfortable doing so and only if they are not requiring prescription pain medication. It always helps to have another licensed driver in the passenger seat on the first attempt, in case one doesn't feel ready. It stands to reason that these findings apply to operating a vehicle with automatic transmission.   Remember: safety is always first. 

Can I take CBD gummies after rotator cuff surgery and will they help with pain?

Many of my patients are rightly motivated to avoid or limit the use of opioids after shoulder surgery. Opioids have obviously led to a devastating addiction and overdose crisis in our society, not to mention the nasty side effects of nausea, vomiting, and constipation. In this video, Dr. Michael Alaia, a fellow shoulder surgeon at NYU Langone, presents his group's research into the use of CBD in dissolvable form (to minimize loss of efficacy when metabolized by the gut when taken in swallowed form) after rotator cuff surgery. Patients who took CBD reported better pain control compared to those who were given a 'sugar pill' or placebo. CBD is a promising alternative to opioids for postoperative pain control.

Because shoulder conditions affect each individual differently, please contact us at (561) 746-7686 or submit an online appointment request form to schedule a consultation with Dr. Diaz.