Shoulder Treatment

The shoulder is a ‘ball and socket’ type joint made up by the head of the upper arm bone (humerus) and the shoulder blade cavity (glenoid). In an unstable or ‘loose’ shoulder, the head of the humerus slips in and out of the shoulder glenoid (ball slips in and out of the socket). This could be caused by injuries to a number of structures including the labrum, glenohumeral ligaments, joint capsule or rotator cuff. Shoulder dislocations are very common. Certain individuals are at very high risk of re-dislocating, and recurrent dislocations can cause significant disability. Furthermore, when a shoulder re-dislocates, there can be additional damage to the ligaments and the joint surfaces which may increase the risk of arthritis later in life. New arthroscopic, surgical techniques can be used to repair and stabilize shoulders after they dislocate. In some high risk individuals, surgery may be the best option, even after only a single dislocation. Arthroscopic repair provides a more predictable outcome, minimizes pain, allows the surgery to be performed on an outpatient basis, and decreases the overall risk of complications.

A shoulder is considered “unstable” when it dislocates frequently or slips partially out of the joint. This is a condition known as subluxation. Shoulder instability is a very painful condition and results in limited motion and use of the arm because of the anxiety and worry that the dislocations can cause. This injury often prevents patients from participating in sports and other activities that they would otherwise enjoy.

If the injury is a more severe case and if minimally-invasive arthroscopic surgery will not repair the condition, then arthroscopic stabilization surgery will most likely need to be performed. Surgical shoulder stabilization can be performed through an arthroscopic procedure involvement the reattachment of loose or torn ligaments to the joint with the use of special implants called suture anchors. These anchors are used to relocate, hold in place and tighten injured joints. Once they are in place and the patient has begun a rehabilitation process, the sutures will eventually disintegrate.

For some patients, depending on their own individual shoulder instability, shoulder stabilization surgery can also help to repair shoulder tears of the biceps muscle tendon, a damaged or torn rotator cuff, or help to tighten the shoulder capsule.
Shoulder arthroscopic stabilization surgery typically takes 1-2 hours. You will wake up in the Steadman Clinic’s recovery room so that we can observe you for about an hour.

After Surgery
Here are some recommendations and what to expect once you arrive home after your arthroscopic shoulder stabilization surgery:
* After arthroscopic stabilization surgery, it is crucial that the arm remain immobile for a period of time. Therefore, we will put an immobilizer on our patients. This helps to protect the amount activity you place on your arm which decreases the chance for a new injury or injury to the repaired joint.
* Following shoulder stabilization surgery, we ask that you do not lift any heavy objects and that you get plenty of rest. There will be a period of complete shoulder immobility (no motion) while the joints heal. This will need to continue for a period of 3-6 weeks until we evaluate your shoulder.
* You will be instructed to do pendulum type exercises on your own. Pump your hand and move your wrist and elbow to keep the blood circulating and prevent stiffness.
* Our office will provide you with a special cold pack and we recommend using this to help control pain. Please protect your skin by using a small cloth or thin towel so that you can avoid burning or other skin irritations.
* Our office will prescribe pain medication to help you combat the pain you will be experiencing the first few days. Take this post-surgery pain medication, as prescribed, and use your cold pack to help with additional pain relief. In some cases, we will offer a pain pump to our patients. This is a small device that will be filled with numbing medicine that is attached to a catheter that we will place in the shoulder at the time of surgery. If you are using a pain pump, there will be a little button to push that will release the medication to help relieve the pain. This button can be pressed every 4-6 hours. This pump should be removed within 72 hours following shoulder surgery.
* In the hours following your arthroscopic surgery, please keep the post-operative dressing clean and dry. Unless it becomes wet or too tight because of swelling, leave the bandages in place for at least 2 days. REMOVE YOUR BANDAGES 2 days after your surgery. Cover your incisions with Band-Aids to keep from snagging the sutures on clothes. You may shower then, but try to keep the incisions dry for the first 10-14 days. Do not wet your incisions directly (bathing or swimming) until at least 2 weeks post-op.
* The sutures are absorbable and do not need to be removed.
* No bathing, soaking or swimming until the incisions are completely healed (7-10 days).
* Be in the care of a responsible adult.
* Abstain from drinking alcoholic beverages and from smoking.
* You may eat a regular diet, if not nauseated. Drink plenty of non-alcoholic, non-caffeinated fluids.
* You will be required to visit our office for a post-operative visit within 10 days from shoulder stabilization arthroscopic surgery. We will evaluate the surgery site, discuss your progress, and put in place a rehabilitation program.
* Following this surgical procedure, please call our office if you are experiencing continued, intense shoulder pain, or if you have a temperature greater than 101 F. Numbness, a deep tingling, excessive drainage or excessive bleeding from the surgical site are symptoms you will need to notify us about because they may represent a problem with the site.

Rehabilitation Following Shoulder Stabilization Surgery Dr. Nasef has specific guidelines for patients who have undergone arthroscopic surgery. These guidelines are broken down into various shoulder rehabilitation phases. Please refer to the Patient Information section on this website to view a complete and printable version of the rehabilitation program. Depending on the extent of your injury and surgery, the rehab guidelines may vary. These are simply protocols for all patients who have had arthroscopic shoulder surgery.

Snapping scapula is a syndrome that causes pain and mechanical catching and grinding symptoms around the shoulder blade (scapula). Using minimally-invasive arthroscopic surgery, the problem can be treated and cured. This procedure, which is not widely available, removing bone spurs and inflamed tissue to restore full painless motion. Recovery is typically quick, and sometimes can even be within a few days from the procedure.

This is a new technique that has been developed for the treatment of recurrent shoulder instability in the setting of ‘end-stage’ shoulder instability. A transplanted tendon (from another part of the body or from a cadaver) is used to make new ligaments and cartilage which then act to prevent dislocation and stabilize the chronically unstable shoulder. This is a salvage procedure that serves as a promising alternative to shoulder fusion for patients with severe shoulder instability.

Surgery is usually always recommended if instability cannot be treated using physical therapy. The current surgical procedures optimize stabilizing the shoulder while minimizing loss of motion.
A Bankart-type capsulolabral reconstruction surgery is the most common surgery performed on patients with chronic instability. This procedure can be performed as an open procedure or by using an arthroscopic technique. If the problem is in fact due to the inferior shoulder ligament tearing away from the labrum within the shoulder, then a Bankart repair can be performed to fix this ligament. Arthroscopically, the torn labrum is repaired and the stretched-out anterior shoulder capsule is made to lie on top to make it smaller. This procedure is successful approximately 80-95% of the time in eliminating recurrent dislocations.
If the shoulder instability is chronic and in the setting of ‘end-stage’ instability, then capsulolabral reconstruction can be performed. This is a new technique that has been developed using a transplanted tendon (from another part of the body or from a cadaver) to make new ligaments and cartilage, which then act to prevent dislocation and stabilize the chronically unstable shoulder. This is a salvage procedure that serves as a promising alternative to shoulder fusion for patients with severe shoulder instability.
A loose capsule is more difficult to repair arthroscopically and may need to be looked at through open surgery.

After Surgery 
Following either arthroscopic or open operative repair and stabilization, the patient will wear a sling for about 6 weeks so that the repaired labrum can continue to heal to the glenoid. Sutures will assist in this healing process. The following guidelines are recommended:
* Apply ice to the incision site to help combat pain; protect your skin with a light cloth to avoid burning the skin.
* Wear your sling or brace until Dr. Nasef specifies that you can remove it. You may take off the sling to dress or bathe, but be careful not to move your arm.
* Keep your arm immobile.
* For pain management, Dr. Nasef can prescribe a pain medication. Please take as prescribed and follow the precautions listed for the drug. You also may take over-the-counter medicines for pain.
* Do not remove your sutures-they will disintegrate by themselves. Follow the incision site care instructions that are given to you after your surgery.
* If excessive pain, swelling, nausea, fever, numbness or trouble breathing takes place, please call our office immediately.
* Physical therapy, as prescribed by Dr. Nasef, should begin using exercises that stress range of motion for about 8 weeks after surgery, or until full strength is regained.
* Overhead sports may resume about 3 months following surgery.
* Patient can resume contact sports after 6 months.

Historically, most collarbone fractures have been treated without surgery and have simply been allowed to heal. New studies, however, have shown that in many instances patients do better with surgical treatment. Specially-designed plates and pins are now available to fix collar bone fractures properly so that the bone heals in its original position. In such instances, surgery will provide a more predictable outcome in terms of shoulder motion and strength.

This technique uses minimally-invasive, keyhole surgery to repair torn rotator cuff tendons. Arthroscopic rotator cuff repair is not only less-invasive but also decreases the risks of post-operative complications, such as muscle injury, stiffness, or infection. ‘Double row’ refers to the way the tendons are repaired — with two rows of sutures. While more technically challenging for the surgeon, ‘double row’ creates a more secure repair. This type of surgery is therefore not only less painful but also sturdier, with a better potential for healing of the torn tendons.

A double-row arthroscopic rotator cuff repair is a highly successful shoulder surgery that can ultimately improve the overall quality of the rotator cuff restoration process.
The double row arthroscopic procedure is a newer technique in arthroscopic surgery and has become increasingly popular due to improved instruments, surgeon skill and comfort level. Dr. Nasef performs the double row arthroscopic surgery on patients who have a more severe rotator cuff injury or when this type of repair is need to provide a cure for their specific tear.
This technique uses minimally-invasive, keyhole surgery to repair torn rotator cuff tendons. Arthroscopic rotator cuff repair is not only less invasive, but also decreases the risks of post-operative complications such as muscle injury, stiffness, or infection.
Double-row repair refers to an anatomic restoration of the original rotator cuff ‘footprint’ (the exact size, shape and makeup of the rotator cuff). A single-row arthroscopic rotator cuff repair surgery, while effective for many patients, does not re-establish the normal footprint anatomy. The double-row technique uses keyhole surgery to repair the tendons to their natural anatomy using a double-row of sutures rather than just a single row.
While more technically challenging for the surgeon, ‘double row’ creates a more secure repair and is less painful for the patient who will have an overall better potential for healing of the torn tendons.

Although many collarbone, shoulder and upper arm area fractures can be healed and repaired non-surgically, there are surgical options to treat these injuries. New studies have shown that in many instances-especially in cases where the collarbone has been fractured-patients do better with surgical treatment to repair a fracture. Fracture fixation surgery consists of specially-designed plates and pins that are inserted and put in place to fix the broken collarbone or other nearby area that has suffered a break. Surgical fixation for a fracture promotes anatomic healing and allows the bone to heal in its original position. In more and more instances, this surgery has proven to provide a more predictable outcome in terms of shoulder motion and strength.
During the surgery, the patient is seated in a slanted chair and given a local anesthetic. A titanium plate will be used to bridge the fracture site and stabilize the fragments. Plate position is critical to ensure correct and comfortable post-operative healing. In addition, plate fixation allows earlier mobilization and rehabilitation. Once the surgery has been performed, the patient will be required to wear a sling for 6 weeks.After Surgery 
In contrast to a shoulder separation where it takes much longer to heal from torn and damaged tendons, after fracture fixation surgery or clavicle fixation surgery, the bone will normally be healed within 2-3 months. In almost all cases, the patient can return, for the most part, to daily activities. The most important element in the recovery process is to rest the injured bone and slowly regain full, painless, range of motion.
Remember these guidelines:
* Apply ice to the incision site to help combat pain; protect your skin with a light cloth to avoid burning the skin.
* Wear your sling or brace until Dr. Nasef specifies that you can remove it. You may take off the sling to dress or bathe, but be careful not to move your arm.
* Keep your arm immobile.
* For pain management, Dr. Nasef can prescribe a pain medication. Please take as prescribed and follow the precautions listed for the drug. You also may take over-the-counter medicines for pain.
* Do not remove your sutures-they will disintegrate by themselves. Follow the incision site care instructions that are given to you after your surgery.
* If excessive pain, swelling, nausea, fever, numbness or trouble breathing takes place, please call our office immediately.
Rehabilitation Following Fracture Fixation Surgery
Dr. Nasef has specific guidelines for patients who have undergone fracture fixation. These guidelines are broken down into various shoulder rehabilitation phases. Depending on the extent of your injury and surgery, the rehab guidelines may vary. These are simply protocols for all patients who have had arthroscopic shoulder surgery. Dr. Nasef will provide these guidelines during pre-operative procedures.

Surgery Options
Arthroscopic surgery for the shoulder can vary from each condition. Below, are two surgeries that affect the AC joint and a snapping scapula:
Arthroscopic AC Surgery
If there is continued pain and limited function at the AC joint, or an uncomfortable amount of pain associated with overhead activities (such as throwing, lifting and reaching), a minimally invasive procedure known as arthroscopic shoulder surgery can be performed. During this out-patient procedure (also called the “Mumford” procedure), the end of the collarbone (the clavicle) is removed through several tiny incisions. Once inside the shoulder, the clavicle is repaired and fixed back to its proper position. This technique is very successful for painful joints (weightlifters, arthritis, or minor separation) and full range of motion is quickly re-established within days of the procedure.
Arthroscopic Treatment of Scapulothoracic Bursitis (Snapping Scapula)
Arthroscopic procedures can vary and can help treat other symptoms and conditions. For example, if you are experiencing ongoing shoulder popping and instability associated with a snapping scapula (shoulder blade) then arthroscopic surgery can treat and cure the shoulder related pain and mechanical catching and grinding symptoms in the shoulder blade region. This particular procedure, which is not widely available, involves removing bone spurs and inflamed tissue to restore full painless motion. Recovery is typically quick, and sometimes can even be within a few days from the procedure.

After Surgery
Following your arthroscopic shoulder surgery you will be allowed to do moderate activity, however, there are also some things that we recommend that you NOT do. It is crucial that you understand the healing process and that you participate in your post-operative recovery so that you do not injure or damage the tissues that were repaired during surgery. Below is a checklist of what to expect.
* It is normal to have swelling and discomfort in the shoulder for several days and up to a week following your arthroscopic shoulder surgery. Apply ice bags or use the cryocuff you were given to control swelling. Ice should be applied 20-30 minutes at a time, every hour or so. Use a thin cloth to avoid burning the skin. Icing is most important in the first 48 hours, although many people find that continuing it lessens their post-operative pain.
* If you had a nerve block during arthroscopic shoulder surgery, the local anesthetic may keep your shoulder numb for several hours. You will be given a prescription for pain medication when you are discharged from the hospital. If you do not tolerate it well, call our office and we will try another one. Many patients find that lying down accentuates their discomfort. You might sleep better in a recliner, or propped up in bed.
* In the hours following your arthroscopic shoulder surgery, please keep the post-operative dressing clean and dry. Leave the bandages in place for at least 2 days. REMOVE YOUR BANDAGES 2 days after your surgery. Cover your incisions with Band-Aids to keep from snagging the sutures on clothes. You may shower then, but try to keep the incisions dry for the first 10-14 days.
* The sutures are absorbable and do not need to be removed.
* After your arthroscopic shoulder surgery, we would like to see you back in the office within 10 days. If you don’t have your first post-operative visit scheduled, call our office to make one.
* Start your post-operative rehabilitation/physical therapy right away. Your physical therapy program is key to a successful outcome. It should be started the day after surgery. A separate prescription will outline the protocol.
* Be in the care of a responsible adult.
* Abstain from drinking alcoholic beverages and from smoking.
* You may eat a regular diet, if not nauseated. Drink plenty of non-alcoholic, non-caffeinated fluids.
* Plan to take a few days off work.

Rehabilitation Following Arthroscopic Shoulder Surgery
It is important to follow the arthroscopic rehabilitation regime that is set forth by Dr. Nasef and by your physical therapist. Arthroscopic shoulder surgery is a partnership between the doctor and patient. The results of the surgery are most effective when a post-operative rehabilitation program involving physical therapy and shoulder exercises are implemented daily. We have put together some guidelines for patients who have undergone arthroscopic surgery. These guidelines are broken down into various shoulder rehabilitation phases. Please refer to the Patient Resources section on this website to view a complete and printable version of the rehabilitation program.

Minimally-invasive shoulder fracture repair is a surgical procedure used to treat and fix a broken bone within the shoulder region. New minimally-invasive techniques allow shoulder fractures to be fixed percutaneously (through the skin) with only tiny incisions and limited internal hardware such as screws and sutures. Such repairs preserve the blood supply to the fractured bone fragments, which hastens healing and minimizes the risk of late complications. Minimally-invasive shoulder fracture repair surgery, if it is an option, is many times preferred by both the doctor and the patient because it does not require tearing or cutting through the muscle layers. As a result, overall pain after the procedure has been performed is decreased.

After surgery
* Apply ice to the incision site to help combat pain; protect your skin with a light cloth to avoid burning the skin.
* Wear your sling or brace until Dr. Nasef specifies that you can remove it. You may take off the sling to dress or bathe, but be careful not to move your arm.
* Keep your arm immobile.
* For pain management, Dr. Nasef can prescribe a pain medication. Please take as prescribed and follow the precautions listed for the drug. You also may take over-the-counter medicines for pain.
* Do not remove your sutures-they will disintegrate by themselves. Follow the incision site care instructions that are given to you after your surgery.

The reverse shoulder replacement is used to treat chronic massive rotator cuff tears that have weakness and arthritis. This revolutionary type of joint replacement changes the geometry of the shoulder joint such that the ball (upper end of humerus) becomes the socket through a new specially engineered implant and the socket (also known as the glenoid) becomes the ball also through a new specially designed implant called the glenosphere. Hence, the name”reverse”. This type of replacement is generally reserved for patients over 70 or those in whom there are no other reasonable options to reconstruct the shoulder.

Certain degrees of osteoarthritis of the shoulder can cause bony deformations called osteofytes. There is growing evidence, supported by Dr. Nasef’s own surgical experience and clinical research that these bony deformations can cause severe neural pain by entrapping nerves which run alongside the shoulder joint. One of these nerves is the axillary nerve which innervates several shoulder muscles. Often a release of this nerve is performed, after treating the osteoarthritis.

Every rotator cuff injury will have its own set of circumstances and could require varying treatment options. The rotator cuff healing response technique is a procedure that uses the body’s own stem cells and bone marrow to help repair damaged rotator cuff tendons. It was initially introduced into the medical field to help patients who heal slower and take longer to recover from such acute rotator cuff injuries. The best way to accelerate healing and reduced risk of re-injury is to use the bodies own natural healing system. The rotator cuff healing response arthroscopic technique uses tiny “microfracture” holes in the bone; the blood clot from the bone that releases blood captures the end of the injured muscle and eventually reattaches the ligament back to the bone. No sutures are needed with this repair technique so patients have rapid recoveries. The procedure eliminates pain and results in dramatic improvements in shoulder function. In addition, the rotator cuff “healing response” technique has many advantages including a much shorter recovery period and less cost, and because it is less invasive, the chances for osteoarthritis to set in later are greatly reduced.

This is a novel technique that uses the body’s own stem cells and bone marrow to help repair damaged rotator cuff tendons. No sutures are needed with this repair technique so patients have rapid recoveries. The procedure eliminates pain and results in dramatic improvements in shoulder function.

The shoulder joint acts as a ball and socket joint allowing people the greatest range of motion in this area over any other part of the body. Shoulder arthritis occurs when the cartilage in the joint begins to wear away allowing the protective lining to disappear. On-going and sometimes constant pain, inflammation and swelling are the result of shoulder arthritis. Patients suffering from advanced shoulder arthritis and who have tried more conservative shoulder treatments such as medication, physical therapy and in some cases, arthroscopic surgery-without relief-may be candidates for anatomic shoulder replacement surgery.

Surgical Treatment:
Anatomic Total Shoulder Replacement
Anatomic total shoulder replacement surgery is a joint replacement procedure most commonly performed on patients suffering from extreme arthritic conditions. Anatomic total shoulder replacement surgery replaces the damaged bone and cartilage with a plastic or metal implant. A metal ball is used to replace the humeral head, while a polyethylene cup becomes the replacement of the glenoid socket. Once in place, patients will feel alleviation from the intense and ongoing pain they were once used to.
The indication for a total shoulder replacement is pain which will not respond to non-operative treatment. Although arthritis is usually the primary condition that leads to a total shoulder replacement surgery, other abnormalities may also benefit from the procedure such as severe fractures and other degenerative disorders. The primary goal of total shoulder replacement surgery is to alleviate pain while improving motion, strength and function.

Reverse Shoulder Replacement:
A relatively new technique is a reverse shoulder replacement which was designed for individuals who are not candidates for a total shoulder replacement because of two underlying conditions-a torn rotator cuff and shoulder arthritis (sometimes caused by the torn cuff). Similar to a total shoulder replacement, the reverse shoulder replacement also uses a metal or plastic ball and socket device, but the ball is placed on the shoulder blade, and the socket is placed on top of the arm bone. The name “reverse shoulder replacement” was given to this procedure because it is the reverse of the body’s normal anatomy.
Joint Preservation and Cartilage Restoration Procedures for the Shoulder (CAM Procedure)
An alternative to arthroscopic surgery is joint preservation and cartilage restoration for joint replacement shoulder surgery. In cartilage restoration, the shoulder joint tissue is, in essence, regrown or transplanted from donated tissue. For some patients, arthroscopy only provides temporary relief because of other underlying factors and damage to the cartilage. In cartilage restoration of the shoulder, the injured tissue is replaced with healthy cartilage from either the patient’s own body or a donor cadaver. Which biologically restores the joint. The procedure, while less common, has positive results for patients who are candidates.

After Surgery
Therapy may or may not begin immediately upon leaving the hospital after your shoulder replacement surgery. You will be instructed if you can do pendulum exercises on your own and you may see a therapist in the hospital for therapy. This depends on the type of surgery you have. You can use your arm from the elbow down but no active motion of the shoulder until ordered by us. We will review this with you on your first visit after surgery.

Tendon transfer surgery can only be performed on patients who meet the following criteria:
* The patient must be physically healthy, active with functional loss of strength related to muscle loss
* The shoulder joint must be relatively healthy and in good condition with no signs of arthritis, osteoarthritis or other ailments present.
* The patient must have healthy, strong bones
* There must be a fair cross-sectional area and bulk of muscle tendons to be adequately transferred
* Patients must understand the rehabilitation period for a tendon transfer. Since this is typically that last effort we can make in hopes of salvaging the shoulder tendon, a strict rehab program will need to be administered and followed carefully.

After Surgery
For Rotator Cuff Repairs:
The tendon repair needs 4-6 weeks to heal so active motion of the shoulder is not permitted during this time. Therapy will usually begin after your first visit to us and will be passive motion performed by the therapist. In some cases we will allow you to go in a pool and do motion under water where your arm will be weightless. You will need to wear your sling for 4-6 weeks. After this period you will begin a program of active motion and, eventually, strengthening.
For Tendon Transfers for Massive Rotator Cuff Repairs or Shoulder Winging
These are highly specific procedures that are tailored to the individual situation. Most are immobilized for at least 6 weeks while the transferred tendon heals. After this period you will begin a program of active motion and, eventually, strengthening.

If the rotator cuff tears and fails to heal or if it re-tears after surgery, the tendons can retract and get to the point where they no longer can be repaired. In such situations, a ‘tendon transfer’ procedure can be performed. This is a technically challenging procedure that is only performed in certain setting but it can restore strength and function and decrease pain in young patients with these types of injuries.

This technique uses minimally-invasive, keyhole surgery to repair torn rotator cuff tendons. Arthroscopic rotator cuff repair is not only less-invasive but also decreases the risks of post-operative complications, such as muscle injury, stiffness, or infection. ‘Double row’ refers to the way the tendons are repaired — with two rows of sutures. While more technically challenging for the surgeon, ‘double row’ creates a more secure repair. This type of surgery is therefore not only less painful but also sturdier, with a better potential for healing of the torn tendons.

Using special techniques the body’s own (autologous) tissues can be used to accelerate healing. The most common method is to concentrate plasma from the blood which can then be injected around the site of injury to enhance the body’s own natural healing cascade. This technique is called PRP (platelet rich plasma) or ACP (autologous conditioned plasma) and is beginning to be used widely in athletes and weekend warriors alike to speed recovery.