Wear your sling at all times except showering and getting dressed. Ice the shoulder for the first week, at least 2 times a day for 20 minutes to decrease swelling and inflammation. Squeeze a ball 3-5 times a day to keep strength in your hand and decrease swelling. You may still use your hand to type and write as tolerated.

How long will it take to heal?

Your age and health do affect your healing rate. It will take anywhere between 4 and 12 weeks to heal. Smoking or drinking alcohol in excess may increase your healing time. Make sure you are getting protein and calcium in your diet or you will need to supplement.

Shoulder Dislocation

Since the shoulder is one of the most mobile joints in the body, it is also the joint most commonly dislocated. Dislocations can either be complete (totally out of the socket) or partial which are referred to as a subluxation (partially out of socket).

Individuals under the age of 20 may have as high as a 90% re-dislocation rate because cartilage is usually torn when they dislocate. This cartilage is called the labrum and although it may heal on its own, it usually does not heal in the correct position.  Since it is one of the stabilizers of the shoulder, and is no longer in the correct position to help hold the shoulder in the socket, the shoulder can now move out of the socket if the arm gets in the wrong position.

The re-dislocation rate for those over 40 is as low as 20%. This is because when they dislocate, they usually do not tear the cartilage but stretch the capsule of the shoulder instead, which can heal without surgery.

 Compare the right shoulder (arrow) with the patients left shoulder. You will notice how the acromion and clavicle are more prominent due to the shoulder being dislocated.

Dislocated shoulder    /               Shoulder Reduced   /           Arthroscopic picture of torn labrum

Causes

These injuries normally occur from trauma, but can occur with relatively little force in individuals whose ligaments are loose. The most common dislocation is one that causes the humeral head (the ball of the joint) to dislocate anteriorly and inferiorly. This occurs with the arm out to the side and rotated back.

Symptoms

Initially, severe pain until joint is reduced

Loss of normal contour of shoulder

If anterior dislocation, may have large bump toward chest area

Unable to lift or rotate arm without pain

Numbness in hand and arm, usually resolves after reduction

After the reduction shoulder may feel loose or unstable

Weakness if rotator cuff is torn or stretched

Treatment

Initially the shoulder is reduced, usually in the emergency room. Medicine is given to relax muscle spasms and help with pain. Care after the relocation includes an examination and most likely x-rays or an MRI to determine the extent of the injury to your shoulder. You and your physician will then decide upon further care together, which may consist of a sling for several weeks and physical therapy vs. surgery to repair the cartilage.

Rotator Cuff Tendonitis, Bursitis, and Impingement Syndrome

These terms all refer to the same shoulder problem that is the most common cause of pain around the shoulder.

As the arm is raised, the rotator cuff tendons keep the ball (top of arm bone) tightly in the socket. The upper part of the scapula that makes up the roof of the shoulder is called the acromion.

A bursa is located between the acromion and the rotator cuff tendons. A bursa is a lubricated sac of tissue that cuts down on the friction between two moving parts. Bursae are located all over the body where tissues must rub against each other. In this case, the bursa protects the acromion and the rotator cuff from grinding against each other.

Usually, there is enough room between the acromion and the rotator cuff so that the tendons slide easily underneath the acromion as the arm is raised. But each time you raise your arm, there is a bit of rubbing or pinching on the tendons and the bursa. This rubbing or pinching action is called impingement

Causes

The most common cause of this shoulder problem is weakness of the rotator cuff muscles. The rotator cuff's primary function is to hold the ball of the shoulder in the socket when someone is active. If the muscles become weak or are injured, the humeral head (shoulder ball) will be allowed to migrate superiorly. The problem is perhaps the best-known overuse injury and individuals who work overhead (carpenters, plumbers) and overhead athletes are prone to this problem. Other problems which result in rotator cuff weakness (partial or full thickness tears and muscle atrophy secondary to disuse) often have a component of tendonitis.

Symptoms

Aching pain at side of shoulder

Trouble sleeping due to pain

Pain worsened by overhead activity

Weakness (secondary to pain)

Clicking or popping

Catching or rubbing sensation

Treatment

Fortunately, the majority of individuals with this problem get better with time and exercises. Avoiding activities which aggravate the shoulder, as well as beginning a rotator cuff strengthening program are the initial steps in recovering. Anti-inflammatories can help reduce the discomfort to allow these exercises to be done. Cortisone injections are occasionally needed to reduce pain and allow better ability to perform the exercises. Emphasis during the rehabilitation is on the shoulder blade muscles (peri-scapular) as these muscles, when strong, they form a strong foundation for the rotator cuff muscles to work with. Normally a period of at least 8 to 12 weeks is attempted before conservative therapy is felt to have failed.

In more severe cases, when rehabilitation is not successful, an MRI should be ordered to assess the condition of the rotator cuff tendon. Arthroscopic surgery may then be suggested. This occurs in roughly 10 to 15% of cases. The surgery is directed at removing inflamed tissue and bone spurs if they exist (subacromial decompression). Secondary problems such as partial thickness rotator cuff tears and A/C joint arthrosis are commonly encountered and can be dealt with at the same time.

Rotator Cuff Tendon Tears

Rotator cuff tears may be the most publicized of all shoulder problems. They are relatively common in those over the age of 40. There are many types and levels of tears from small partial thickness tears to full thickness tears involving one or more of the rotator cuff tendons. When caused traumatically, the pain, discomfort, and weakness is profound and leads to early evaluation and treatment. More insidious onset tears are often ‘dealt’ with for many weeks or months before treatment is sought. A full thickness tear will not heal on its own because the rotator cuff tendon does not have a good blood supply to help it heal. If the tendon is not repaired the tear will get bigger over time.

Note how the patient cannot actively  lift his arm.

MRI of tear in rotator cuff tendon. The white area is where the the tendon has torn from the bone.

 Arthroscopic picture of tear in rotator cuff tendon. You will notice the tendon-white tissue, has a hole in it, this is the tear. The arm bone (humerus) is the yellow area beneath the hole, the bone is not seen when the tendon is intact.

Causes

These tears can be from repetitive overuse or from a single traumatic event. The former is more common in older individuals and overhead athletes while the latter occurs with falls or contact athletic activities.

Symptoms

Pain with some or all motions

Aching pain at night and after use

Weakness with activities, especially overhead

Trouble sleeping due to pain

Limited motion secondary to pain or weakness

Clicking or popping

Unable to lift arm

Treatment

The diagnosis of a rotator cuff tear can often be made through physical examination. An MRI will help to determine the location and extent of the injury. In most cases, once the diagnosis is made, therapy is begun to regain better motion and function of the shoulder. It is not uncommon that partial or small tears be treated conservatively depending on work and athletic interests. Exercises begin simply to reduce pain, and then establish motion. Strengthening and a return to functional work or sport occur only after the first two steps – pain reduction and improved motion – are achieved. Anti-inflammatories and Tylenol are often helpful during the early stages. A tear that is full thickness will get larger overtime. At some point surgery will be needed to fix the tear.

Surgical care involves the reattachment of the torn tendon to the top of the arm bone, to their anatomic location. The repair can be performed often arthroscopically.  A larger tear may require a larger skin incision. Repairs are successful when both the tendon quality is good and the repair is done without significant tension. When the tendon has been torn for a long period of time or the tissue is of poor quality the success rate decreases.

Rotator cuff tendon surgery is common and techniques are improving. The success rates are high. However, any repair will fail if appropriate rehabilitation after the surgery is not performed. This includes immobilizing the shoulder until the surgeon tells you to remove it. Following instructions such as no pushing, pulling of lifting of the arm in the early postop period. Once the repair is healed then you will be allowed to return to your normal activities.

Frozen shoulder and adhesive capsulitis refer to the same condition. It begins with severe pain and then restriction of motion in the shoulder. The condition is more common in people with diabetes, thyroid disease and in woman over 40 years old. It has also occurred in people recovering from surgery such as heart surgery, or mastectomy. The exact cause cannot always be found but the disease process usually resolves, in some cases taking up to 2 years to regain the range of motion in the shoulder.

  Arthroscopic Surgery picture of frozen shoulder. Normally the joint is white not red as seen above. Here you see how inflammed the tissues of the shoulder can become when it is frozen.

The left shoulder has limited active abduction compared to the right shoulder.

Causes

The cause of a frozen shoulder is not completely understood. One theory is that it may be caused by an autoimmune reaction. The body's defense system, which normally protects it from infection, mistakenly begins to attack the tissues of the body. This causes an intense inflammatory reaction in the tissue that is under attack.

No one knows why this occurs so suddenly. For some reason, repetitive motion, trauma or immobilizing a joint in some people seems to trigger the autoimmune response

Other shoulder problems like bursitis, rotator cuff tears, or impingement syndrome can end up causing a frozen shoulder. Physicians theorize that the underlying condition may cause chronic inflammation and pain that make the individual use that shoulder less. This sets up a situation that can create frozen shoulder. Usually, the frozen shoulder must be treated first to regain its ability to move before the underlying problem can be addressed.

Symptoms

Severe Pain with all motions of shoulder

Aching pain at night and difficulty sleeping due to pain

Unable to lift arm even with the help of other arm

Severe stiffness in shoulder

Pain at entire shoulder increased with reaching

Sometimes pain radiating down arm or bicep region

Unable to reach behind back or hook bra

Treatment

X-rays should be taken to rule out arthritis as cause for stiffness. An MRI may be order if history of trauma to rule out a rotator cuff tendon tear or early arthritis. An MRI or X-rays will not show a frozen shoulder, they will only rule out other causes.

Treatment of this disorder focuses on restoring joint movement and reducing shoulder pain. Usually, treatment begins with nonsteroidal anti-inflammatory drugs and the application of heat, followed by gentle stretching exercises. These stretching exercises, which may be performed in the home with the help of a therapist, are the treatment of choice. The stretches should be done several times a day, everyday, to keep the shoulder from tightening up. In some cases, transcutaneous electrical nerve stimulation (TENS) with a small battery-operated unit may be used to reduce pain by blocking nerve impulses. If these measures are unsuccessful, the physician may recommend a cortisone injection in the joint to decrease the inflammation of the capsule of the shoulder. If conservative treatment fails, an arthroscopy with manipulation of the shoulder under general anesthesia may be recommended.  People with diabetes may have recurrence of a frozen shoulder even with a manipulation. Keeping sugars under control and starting therapy the day after the manipulation will decrease the chance of the recurrence.

Shoulder Arthritis

The most common arthritis in the shoulder is osteoarthritis. It is a degenerative joint disease in which the cartilage that covers the ends of bones in the joint deteriorates, causing pain and loss of movement as bone begins to rub against bone. It is the most prevalent form of arthritis.

Normal x-ray

                   X-ray of arthritic shoulder. Notice how there is no longer any space between the bones and the bones are rubbing together.

 Causes

The most common cause is recurrent dislocation of the shoulder, which causes damage to the smooth cartilage covering the arm bone and socket. This repetitive trauma over years can cause the cartilage to die and fall off.

Heavy weight lifting over many years, especially bench press can cause wear at the back portion of the shoulder joint.

Trauma due to a fall on the arm can knock cartilage off or interrupt the blood supply to the cartilage and cause arthritis later on in life.

A tear in the rotator cuff tendon will get larger in size if not fixed and allow the arm bone to move up and down in the socket rubbing the smooth cartilage off the bone.

Symptoms

Pain with all motions of shoulder

Aching pain at night and difficulty sleeping due to pain

Grinding in the shoulder

Progressive stiffness in shoulder, worse in the morning

Pain in the front or back of shoulder

Treatment

X-rays, symptoms and physical exam make the diagnosis. Early arthritis, which may not be seen on x-ray, can sometimes be seen on MRI, although in very early cases the MRI may be negative.

Conservative treatment consists of rest or change activities to avoid provoking pain; the individual may need to modify the way he or she moves the arm to do things. Anti-inflammatories, Glucosamine Chondroitin, icing shoulder 2-3 times a day to reduce swelling and pain, physical therapy to regain motion, or cortisone injections if pain is severe. In early arthritis lubricant injections can be helpful, but do not work well when the joint is bone on bone.

Surgical treatment consists of arthroscopy with removal of loose cartilage and possible stabilizing of the joint, if dislocation is the cause for the early arthritis. Other surgical treatment if the shoulder is stiff is arthroscopy and manipulation to regain range of motion. These treatments will not help if the arthritis is severe with bone rubbing on bone. The treatment of severe arthritis is to replace the joint.

An Alternative to Joint Replacement



Joint resurfacing is an alternative to total joint replacement surgery. It is a surgical procedure that allows patients to retain much of their natural tissue, by replacing only the diseased part of the joint instead of the entire joint. This gradual approach to surgery means the patient may still be able to have a total joint replacement later if necessary.

The Resurfacing Humeral Head Implant is for patients with arthritis, rheumatoid arthritis or humeral head fractures. It is an option for younger, more active patients who might otherwise postpone surgery.