Specific Shoulder Conditions

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.

Osteoarthritis (degenerative arthritis), the most common form of arthritis, affects millions of 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.

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 “ceiling” 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.

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.

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.

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).

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 Dupuytren 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. 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.

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.

Fractures of the upper arm bone are common. They can occur in mature patients with low bone density 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.

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 active patients 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 around the biceps tendon, which starts at the top of the labrum. Many SLAP lesions can be treated without surgery. They are sometimes identified by MRI but not the cause of shoulder pain and dysfunction. Some younger patients with traumatic SLAP lesions may require repair of the labrum to restore shoulder stability and function. Most superior labral tears are from overuse or chronic wear and tear. If patients do not improve without surgery, arthroscopic treatment may help. This often involves debridement or repair of the labrum +/- separating the biceps from the labrum with a biceps tenotomy (allowing the released 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).

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.