Shoulder Injuries and Treatments

AC Joint Injury :

If you place your finger at the top of your shoulder, you will feel a prominent “bump.” This bump is called an AC (acromioclavicular) joint. The AC joint is held together by ligaments and has cartilage (also referred to as meniscus) that is located inside the joint and covering the ends of the bones.
Injuries of the AC joint are quite common. They can result from a hard fall or from a traumatic event. An AC joint injury can result in a severe shoulder sprain or a shoulder separation, which occurs when the collarbone (the clavicle) separates from the shoulder blade (the acromion). These are also referred to as dislocations. An AC joint injury is measured in varying grades. For example, a Grade I injury will bring mild shoulder pain because the AC joints are simply stretched. A higher grade injury will represent itself in a partial shoulder ligament tear or a full shoulder ligament tear, or a shoulder separation.

Symptoms

Symptoms of an injured AC joint will range from mild tenderness and swelling resulting from a shoulder sprain to intense, sharp shoulder pain that is the cause of a complete shoulder separation. In a higher grade shoulder injury, a popping sensation will often be heard and prominent shoulder bruising will take place on the skin.

Treatment Options

Treatment for a lower grade AC joint injury will usually consist of plenty of rest followed by the possible use of pain medications and a shoulder sling.
For more advanced AC joint shoulder injuries, shoulder instability and frequent separations and dislocations can occur on a daily basis. This condition causes men and women to lose time at work and the activities they enjoy, creates anxiety about when the instability will next occur and can lead to early arthritis or permanent damage to the shoulder joint if left untreated. In these more advanced cases, surgery will be required. There are numerous AC joint shoulder surgery techniques offered by us :

Arthroscopic Surgery

The arthroscopic AC repair procedure is a minimally-invasive surgery performed when three small incisions are made so that the clavicle which is the joint that has been separated can be fixed back into its proper position. Surgery involving arthroscopic AC repair is performed on an outpatient-basis and full range of motion is quickly re-established within days of the procedure.
Arthroscopic Stabilization Surgery for Shoulder Separations
Arthroscopic stabilization for shoulder dislocations often referred to as open shoulder (traditional) surgery is considered when the episodes of instability are occurring frequently, prohibit the individual from performing overhead activities or partake in sports, and interferes with normal daily routines. Once all other therapies have been exhausted, arthroscopic stabilization surgery is often the next step. Arthroscopic stabilization 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

Dislocated Shoulder and Shoulder Instability
Shoulder instability is condition that occurs when the muscles, tendons, bones, and ligaments that surround the shoulder do not work together to secure and maintain the ball (proximal humerus bone) within the socket (glenoid). When this happens, the shoulder is said to be unstable and the joint may either slide partially out of place which is known as a shoulder subluxation or it may slide completely out of place, which is called a shoulder dislocation.
When athletes suffer a blow directly to the shoulder, or when someone suffers trauma to the shoulder area either from a fall or an accident, shoulder instability can result. Instability can be a frustrating condition afflicting the patient until the condition is properly diagnosed and treated. Patients with shoulder instability will often complain about an uncomfortable sensation that their shoulder is about to “pop” or “slide” out of place. Sometimes it is more subtle however and pain may be the only manifestation of the condition. This condition usually affects the following distinct groups of patients:
– Patients who have had prior shoulder dislocations: Those patients who have had prior shoulder dislocations will often experience future dislocations, or recurrent instability. Age does play a crucial role in recurrent dislocations. When younger patients (35 years of age or younger) sustain a traumatic dislocation (from an injury), shoulder instability will follow in the vast majority of patients. In very young patients, those less than 20, the risk of suffering a second dislocation is almost 100 percent! On the other hand, older people (40 years of age and older) who experiences a traumatic dislocation will only have a 10% chance of developing chronic instability in future years, but they have an increasing risk of tearing the rotator cuff when the shoulder dislocates and that injury in of itself may need treatment.
– Athletes: Athletes who participate in overhead activities such as basketball, swimming, gymnastics, and tennis may have continuing symptoms of a loose shoulder or experience multidirectional instability (slipping or dislocating in more than one direction). This is a condition that develops from loose ligaments and a stretched shoulder capsule. While a complete dislocation may not occur, it causes pain, weakness, and diminished function such that it may prevent athletes from playing their sports.
– Genetic causes: Some patients are born with double-joints or have connective tissue disorders that may lead to loose shoulder joints. This can lead to shoulder instability and dislocations.

Recurrent Shoulder Dislocation:

First time Shoulder Dislocation

Symptoms :

The symptoms associated with shoulder instability and shoulder dislocations include:
– Extreme pain in the shoulder region
– Apprehension (fear that the shoulder will come out)
– Restricted motion
– Popping or a sliding sensation
– Unusual shoulder position-for example, the shoulder may hang down and forward and appear “limp”
When a shoulder dislocation occurs, some individuals are experienced and might be able to “pop” their shoulder back into place (called a reduction). This is a very painful situation to be in and many times, to return the dislocated arm back to its socket, a visit to the ER will be required.
Once a shoulder reduction has been performed, Dr. Nasef will be able to determine the exact cause and root of the shoulder instability and the risk of recurrent dislocations with his physical examination and routine X-rays. Some times the X-ray might show a “bony Bankart” which is a fracture of the front, lower portion of the shoulder socket that occurs after a dislocation. This fracture-which is the most common cause of recurrent instability for young adults after an injury-indicates that the ligaments in the front of the shoulder are no longer attached to the glenoid. Another common finding is a Hill Sachs fracture, which is an indentation or impression fracture on the ball of the upper arm (proximal humerus) that occurs when it impacts the socket during the dislocation. These findings are frequently only part of the problem and additional tests such as an MRI are usually required to fully determine the extent of the damage.

Treatment :

– Non-Surgical

Often times, patients who suffer from shoulder instability and shoulder dislocations can begin a structured shoulder physical therapy rehabilitation program using exercises to help strengthen the shoulder joint. Physical therapy with ongoing strengthening moves will often help maintain the shoulder in proper position. Athletes typically benefit the most from physical therapy for shoulder instability. Cortisone injections and anti-inflammatory medications are also used to help treat the condition and minimize pain.

– Surgical

There are surgical options for shoulder instability if therapy is not an option, or if it fails. Depending on the cause of the instability, arthroscopic surgery is the most preferred option.
Bankart-Capsulolabral Reconstruction
A Bankart-type capsulolabral repair surgery is the most common surgery performed on patients with chronic instability who opt to have surgery. This procedure can be as an open procedure but Dr. Nasef usually performs it arthroscopically (which is the preferred method). This is among the most frequent type of surgery that Dr. Nasef performs. If the shoulder instability is chronic and is in the setting of ‘end-stage’ instability, then there are options such as bone grafting procedures and soft tissue grafting procedures which can be used to restore stability to the shoulder joint. Capsulolabral reconstruction is one technique that Dr. Nasef has helped develop. This is a technique in which a transplanted tendon (from another part of the body or from a cadaver) is used to make new ligaments (capsule) and cartilage (labrum), which then act to prevent dislocation and stabilize the chronically unstable shoulder.

Labral and Slap Tears
When the labrum, which is an important type of cartilage that surrounds the glenoid (the socket of the shoulder), is injured or torn, it is referred to as a labral tear. While the glenoid itself has a moderately flat surface, the labrum’s contour deepens the socket and gives the glenoid a concave shape, enhancing stability of the shoulder. The solid, firm, yet flexible fit of the humerus (the bone that extends from the shoulder to the elbow) within the glenoid permits the immense range motion that a healthy shoulder is able to exhibit.
A labral tear, which is quite common, is usually caused from falls when the arm is stretched out or from repetitive work or sports activities (throwing, swimming, overhead lifting). A SLAP tear (Superior Labrum Anterior to Poterior) is a special type of tear in the labrum that occurs at upper part of the labrum where the long head o the biceps tendon attaches to the glenoid. These types of injuries are particularly common on athletes who participate in overhead sports. Such as tennis or baseball. An injury in this area can be extremely painful, and in severe cases can even cause the biceps tendon to rupture.
When evaluating an individual who is suspected to have either a labral tear or a SLAP tear, it is important to determine if the labral tear is associated with any type of pre-existing instability to the shoulder. If instability is involved, then some type of shoulder stabilization procedure will need to take place first. X-rays will rule out any precursors or underlying problems that might exist such as an impingement or a fracture. If instability is not an issue or at the root of the problem, surgery can be directed to the labral tear itself.

Symptoms :

The primary symptom of a labral tear is pain in the area of the injury-most commonly-at the back on top of the shoulder or deep inside the shoulder. The pain usually is intense and may be associated with mechanical symptoms such as clicking or catching. Shoulder stiffness can also be a sign of or associated with a labral tear. In throwers, there is a specific type of tightness of the posterior capsule called GIRD (glenohumeral internal rotation deficit) that may also need treatment. Labral tears involving the bicep tendon anchor (SLAP tears) can make using the biceps painful such that even performing small activities such as using a screwdriver can be painful or difficult.

Treatment :

Much can be done to help individuals who suffer from labral or SLAP tears and the first approach usually consists of icing, physical therapy exercises, anti-inflammatory medications and rest. Some labral tears can become asymptomatic (painless) and therefore may not need further treatment.

Recurrent Shoulder Dislocation:

First time Shoulder Dislocation

If the conservative approach to managing these tears is not effective, surgery may be required to repair or remove the torn part of the labrum. These are almost exclusively treated with arthroscopic surgery. Arthroscopic shoulder surgery is the standard treatment for most labral injuries, even those associated with instability, GIRD, rotator cuff tears, or biceps problems. The majority of these can be treated with simple debridement (removal of abnormal, damaged, or excess tissue) although sometimes detachment and repair of the biceps tendon (biceps tenodesis) is the preferred method of treatment. Dr Nasef has performed several hundred of these procedures.
In certain painful and unstable SLAP tears, in which the bicep anchor is detached, the labrum will need to be repaired (labral or SLAP repair). This requires meticulous surgery so as not to create too much stiffness in the shoulder. Sutures and anchors are used to firmly re-attach the labrum to the bone of the glenoid. Rehabilitation after surgery is critical and most people can resume full activities by 3 months, although overhead sports may take a bit longer.

Rotator Cuff Injuries
The rotator cuff located within the shoulder is made up of tendons and muscles. These shoulder elements connect the upper arm bone with the shoulder blade and they are in place to help hold the ball of the upper arm bone firmly to the shoulder socket. All of these biological functions come together to create the greatest range of motion of any joint in the human body.
Rotator cuff injuries are very common. They can occur when any irritation or damage affect the rotator cuff muscles or tendons. Many activities can lead to this type of injury including falling, lifting, repetitive overhead arm activities and degeneration of the rotator cuff tendon. The incidence of rotator cuff damage increases with age.
There are 3 distinct rotator cuff conditions:
– Tendinitis
– Bursitis
– Strain or Tear
Tendinitis occurs when the rotator cuff tendons become inflamed due to overuse or overload. Athletes will often find themselves with this condition if they are involved in daily or routine overhead sports such as tennis or basketball. Bursitis is an inflammation that occurs when the fluid-filled sac (bursa) between your shoulder joint and rotator cuff tendons become irritated. This can also be a cause of overhead activity or overuse of the shoulder muscle. If the first two conditions are not dealt with, a person could experience a strain or tear in the rotator cuff region, which will require a more drastic treatment approach.

Symptoms :

The most common symptoms associated with a rotator cuff injury are sharp shoulder pain and shoulder tenderness. Everyday activities such as scratching your head, putting on a shirt, laying down on the affected side and carrying a moderately light object will create pain over regular use of the arm. There will be an overall weakness in your arm and this weakness and pain will create anxiety that will prompt you to keep our shoulder inactive.

Treatment :

1yr after Arthroscopic Rotator Cuff Repair

2Wks after Rotator cuff repair in a patient that also performed bilateral Knee replacements with us years ago:

– Non-Surgical

Rotator cuff injuries are very common problems and can many times be healed without treatment. If a patient has a mild rotator cuff injury, it is important to keep the hurt shoulder inactive with plenty of rest. Apply ice daily and use an anti-inflammatory medicine to help with any swelling and pain.
If the shoulder does, in fact, require surgery, minimally-invasive arthroscopic surgery can usually repair the milder degree rotator cuff injury. In the event arthroscopic surgery does not work or is not recommended due to a more severe rotator cuff injury, there are other options that will treat the condition.

– Surgical

‘Double-Row’ Arthroscopic Rotator Cuff Repair:
For patients who have significant injuries to the rotator cuff, or who are experiencing recurrent shoulder problems and defects after open and/or arthroscopic surgery has been performed, a double-row arthroscopic rotator cuff repair might be recommended. The double-row arthroscopic repair technique typically improves the overall quality of the rotator cuff restoration process. ‘Double row’ refers to the way the tendons are repaired-with a double row of sutures rather than just a single row.
Rotator Cuff ‘Healing Response’ Technique :
The rotator cuff healing response technique is a novel procedure that uses the body’s own stem cells and bone marrow to help repair damaged rotator cuff tendons. This arthroscopic procedure involves making 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.
Tendon Transfer for Failed Rotator Cuff Repair:
Sometimes, open or arthroscopic rotator cuff surgery fails to work. In a massive rotator cuff tear good results can occur through a tendon transfer. A tendon transfer is a surgical procedure by which a tendon and its muscle are moved from one location to another. This procedure is completed so that lost function of the shoulder can be replaced. This procedure requires technical skill from the surgeon and is more of an undertaking than basic rotator cuff repair surgeries; it is often a last step or salvage surgery.

Bicep Tendon Injuries
The biceps is the muscle located on the front of the upper arm-just under the shoulder. It is a strong muscle in the upper arm region that helps you to rotate your arm, lift things and twist your elbow. The biceps tendons attach the biceps muscle to bones in both the elbow and the shoulder. If these tendons become torn, either through a fall, a sports related injury or from extreme wear and tear, strength in the upper arm can become lost and movement in the upper arm painful.
There are a couple of varieties of a biceps tendon tear:
– A partial tear is a tear that does not completely sever the tendon
– A complete tear will fully split the tendon into two separate pieces
The tears can occur at the shoulder (proximal tears) or at the elbow (distal tears)
Most tears are the result of on-going, continuous strain and wear and tear on the biceps muscle and tendon. This is most commonly seen in weight and strength training and usually starts with just a simple fraying of the tendon. As the injured tendon progresses, it will eventually tear. These tears can occur in two distinct ways:
– At the shoulder joint: A proximal biceps tendon rupture is an injury to the biceps tendon as it enters the shoulder joint. The tendon is vlunerable to injury here because it makes a sharp right-turn to enter the shoulder joint and it moves in and out the shoulder up to 2 inches with shoulder motion. This is the most common area for the bicep tendon to tear and typically occurs in patients 60 years of age or older. This injury if frequently associated with rotator cuff tears. In some instances it creates minimal symptoms and can heal on its own; in other cases there is significant deformity (Popeye muscle) and cramping. In some cases surgery can be helpful to treat the symptoms of cramping, weakness, and deformity.
– At the elbow joint: A distal biceps tendon rupture is an injury that occurs at the elbow joint. It most commonly affects middle-aged men and is caused by heavy lifting or sports. There is usually a loud ‘pop’ when the tear occurs. Most people who suffer from this injury will need to have surgery in order to correct the problem.

Recurrent Shoulder Dislocation

First time Shoulder Dislocation

Symptoms :

Symptoms associated with a torn biceps tendon include sudden, sharp upper arm pain-sometimes with a noticeable snap or popping sound. Cramping, bruising, pain and tenderness of the shoulder, biceps and elbow are common. In addition, it will most likely be difficult to turn the palm up or down.

Treatment:

It is important to note that the biceps has two attachments at the shoulder: a long head and a short head. The long head is the tendon at the shoulder that is most frequently injured. Short head biceps injuries are exceedingly rare, while long head biceps injures are exceedingly common. Because of this second attachment at the shoulder, many people can still function and use their biceps even wihen the long head of the biceps is severely damaged or completely torn. With that said, many people can still function with a biceps tendon tear, and only need simple treatments to relieve symptoms.

– Non-Surgical

Treating a torn biceps tendon non-surgically will include resting the arm that is injured and avoiding any heavy lifting or the activity that may have caused the injury (i.e. weight training). Applying cold packs and ice will help with swelling and overall pain. You can also take anti-inflammatory medications and non-steroid drugs for pain relief. We will consult with you on various at-home physical therapy exercises you can do in order to help with flexibility and strength.

– Surgical

Several new torn biceps tendon procedures are available to repair the injured tendon with minimal incisions using arthroscopic surgery. The goal of the surgery is to re-anchor the torn tendon back to the bone. At the shoulder, the long head of the biceps is typically re-attached using a subpectoral (deep to the chest muscle) approach that anchors the long head biceps tendon into the upper part of the arm bone (proximal humerus) using a small screw and suture. Dr. Nasef has literally done over a lot of these procedures with excellent success. Once it is healed patients have normal strength and function, the scar becomes invisible in the armpit, and the muscle appearance returns to normal. When the biceps tendon is injured at the elbow, the repair is done with a small incision and reattachment of the torn tendon back to the forearm bone (radius) using sutures and a small fixation device. Dr. Nasef has also been invovled with the development and teaching behind this technique as well. Excellent results can be expected with full recovery in 3-4 months.