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Shoulder, Common Shoulder Procedures
Operative Conditions of the Shoulder
Most surgery done today to treat these conditions is effectively performed employing “arthroscopic” methods. This means the surgery is performed by inserting a “scope” into the shoulder through a small puncture wound, visualizing the procedure with a special camera that puts the image on a “television” monitor and performing the repair work with small instruments inserted through one or more small additional puncture wounds. These techniques are commonly employed in the shoulder and the knee.
The surgery is almost always done in an outpatient setting. You come to the hospital or same-day surgery facility, are taken to the operating room, given an anesthetic (general or regional anesthesia or a combination of both) and then positioned on the operating table. Small puncture wounds are employed to insert the scope, fill the joint with fluid and examine all the important structures. Once the diagnosis is confirmed by direct visualization, the repair procedure is performed.
- What is Wrong? (Diagnosis)
Impingement occurs when the rotator cuff begins to rub, pinch or impinge against the acromion process. This may occur because the rotator cuff is damaged or weak thus allowing the humeral head to migrate upwards. It more commonly occurs because the acromion process (bone) has thickened or enlarged or developed bone spurs that then dig into the rotator cuff and “impinge” or pinch against the cuff.Long standing impingement of the bone against the rotator cuff causes pain, inflammation, stiffness, weakness and gradual loss of function. The inflammation caused by impingement is often called “bursitis” as the bursa between the bone and the rotator cuff is what becomes inflamed.If you ignore impingement long enough, it may ultimately cause a tear to develop in the rotator cuff. The repair and subsequent recovery from a rotator cuff repair is more extensive and much prolonged compared to the treatment of simple impingement. Early, aggressive treatment of shoulder impingement can avoid a much more serious problem (torn rotator cuff). - How do you make the diagnosis?
A careful description of the onset, nature and duration of symptoms combined with specific findings on physical exam usually confirms the diagnosis. Most patients experience a gradual onset of rather vague, non-descript shoulder pain. It is often worse at night and may be made worse by doing over head activities (playing tennis, reaching, lifting above shoulder level, weight lifting – military press)X-rays often show thickening of the acromion process or a spur on the corner or front of the acromion. The acromion is the bone above the shoulder against which the rotator cuff rubs or “impinges” causing inflammation, pain, swelling, loss of function, weakness and may lead to tearing of the rotator cuff. Long standing inflammation from impingement may also contribute to the development of calcium deposits in the tendons of the rotator cuff.MRI studies can demonstrate the rotator cuff, inflammation within the rotator cuff, tears in the rotator cuff and the bone spurs that are seen on plain x-rays. Since shoulder impingement is a dynamic condition (active rubbing of the rotator cuff tendons against the acromion bone) the MRI usually cannot make this diagnosis. The MRI can, in many cases, demonstrate the effects of the impingement. In most cases of shoulder impingement I do not order and MRI. If it important to know, prior to surgery, if the rotator cuff is torn, an MRI may be helpful in drawing that conclusion. - How do you treat Shoulder Impingement?
In most cases shoulder impingement comes on gradually and progresses slowly. Treatment is dictated by severity of symptoms and level of functional deficits.- Rest and shoulder specific exercises.
- Avoidance of overhead activities combined with rotator cuff strengthening exercise may be helpful in diminishing symptoms and improving function.
- Bracing
- Use of an arm sling may make the shoulder feel better but will not solve the underlying impingement.
- Physical therapy
- Therapy modalities such as heat, ultrasound and massage may temporarily reduce symptoms. When combined with rotator cuff strengthening exercises physical therapy can help reduce symptoms and may delay the progression of shoulder impingement.
- Anti-inflammatory medications
- Reduces irritation, inflammation and swelling and thus may reduce symptoms of impingement.
- Cortisone injection
- Usually dramatically reduces symptoms due to the irritations and inflammation of impingement. Response to injection may last several months. When combined with rotator cuff exercises, may be associated with even more prolonged relief of symptoms.
- Arthroscopic surgery to relieve the impingement (Decompression)
- This is the only treatment that actually eliminates the cause of the symptoms and protects the rotator cuff by removing the bone spurs that may be cutting in to the rotator cuff. In many cases, by the time the surgery is performed, the tendons that make up the rotator cuff are partially or completely torn. If a rotator cuff tear is identified at the time of surgery, in most cases it will be repaired through the arthroscope. Occasionally cuff tears are large and complex and are better repaired through an open incision rather than through the arthrosocope. Some cases of impingement occur because of instability within the shoulder rather than impingement from the acromion. In these cases correction of the instability through surgery combined with muscle strengthening may be necessary to correct the impingement. The actual surgical procedure is Arthroscopic Subacromial Decompression with possible Rotator Cuff Repair.
- Rest and shoulder specific exercises.
- What happens if I elect to have surgery to correct my shoulder impingement?
- First you must schedule the surgery with my office. The best way to do this is to call and ask for Kylie (my assistant), or Carrie (my surgical scheduler). Carrie will help put your schedule together with mine at a location consistent with the requirements of your insurance company.
- If you have any significant medical risk factors such as heart disease, a current infection, lung disease or a history of blood clots, such issues may need to be addressed with your internist or primary care doctor prior to proceeding with surgery.
- What happens on the day of surgery?
- Your surgery will be done at a “same-day-surgery” facility which means you will go home the same day, usually an hour or two after the procedure is done. I perform these procedures at the Central Utah Surgical Center, Utah Valley Regional Medical Center and Timpanogas Regional Hospital.
- You will be called the evening before surgery by the facility where your surgery is scheduled. They will ask you some questions and tell you what time to come to the facility the next day. They will want a phone number so they can notify you if the schedule changes.
- It will be necessary that you have nothing to eat or drink for 8 hours prior to the planned surgery. Failure to comply with this requirement dramatically increases the risks of anesthesia and will result in delay or cancellation of your surgery.
- When you come to the facility, initial blood and other tests may be done to verify the status of your medical condition prior to the planned surgery. If you are female, a pregnancy test is routinely performed.
- An intravenous line will be inserted into a vein in one of your arms. This will be used to administer medication intravenously.
- You will be placed on a bed and your shoulder will be shaved. You will be asked to mark a “YES” on the shoulder that is to receive the surgery.
- I will come and see you shortly before the surgery, answer any additional questions that you or your family members may have, and I will also put my mark on your leg. I want to take every precaution to make sure that I do the right procedure on the correct shoulder.
- The anesthesiologist will come and talk to you about the anticipated procedure and the roll he will play in taking care of you. He also will answer any questions you may have.
- At the appropriate time you will be moved to the operating room where you will be given an anesthetic and the procedure will be performed.
- What happens to my shoulder?
- The shoulder will be painted with antiseptic solution to reduce the risk of infection. You will also be administered antibiotic medication through your intravenous line for the same purpose.
- I will make small puncture wounds on the back and side of your shoulder.
- One is for the scope or camera which allows me to see the inside of your shoulder.
- One is for the instruments I use to relieve the impingement.
- Other portals may be used depending on the extent of damage encountered.
- I will carefully examine the interior of your shoulder, define the extent of damage and proceed with the appropriate repair.
- If there are other problems such as an area of arthritis, loose debris or ligament problems I will treat those at the same time UNLESS treating those unanticipated conditions would significantly alter your course of recovery.
- At the end of the procedure, I will remove the instruments, apply “steri-strips” to the tiny incisions, and apply gauze pads followed by an Ace bandage. At the end of the procedure but before you wake up I inject a local anesthetic into the shoulder to reduce pain or insert a Pain Pump Catheter into the surgical site to help relieve postoperative pain.
- You are then moved to the recovery room where you continue to awaken from the effects of the anesthesia. Once you have sufficiently awakened, you will get up, go to the bathroom, eat a snack and drink fluids prior to being released to go home. If you are over 65, are significantly over-weight or have pre-existing lung disease, I will require that you stay 24 hours for more careful observation. Although this may seem inconvenient, experience has taught me this careful approach.
- What happens when I get home?
- Many patients feel pretty good when they get home. This is because of the nerve block. Please take it easy. Put ice packs on your shoulder to help control swelling and limit your activity to light activities. Your arm will be in a sling for comfort and protection. As you start feeling better, it is OK to take your arm out of the sling and carefully move it about as allowed by pain. If it was necessary to repair your rotator cuff you must be more careful and avoid any forceful or active exercise with the affected arm except as described by my staff or me.
- My assistant will call you the day after your surgery to make sure you are doing O.K., to make sure your prescriptions are appropriate and to schedule a follow-up appointment in 7 – 10 days.
- Keep the shoulder dry. On the 3rd day, remove the bandages but leave the “steri-strips” in place. On the 3rd day it is OK to get the shoulder wet in the shower but do not soak it in the bath tub. If you wish to take a bath prior to the 3rd day, keep the shoulder out of the water.
- It is good to use the arm and shoulder and try to get back to normal but in a slow and gradual fashion. If all we had to do is relieve impingement, I expect you to be functioning without the sling within a few days to a week at the most, to have overcome pain within the first few weeks following surgery and to be “recovered” within six to 10 weeks. If there is rotator cuff involvement, the recovery will take even longer.
- Will I see Dr. Kimball after my surgery?
- It is my routine to visit briefly with you and/or your family following your surgery, before you go home. I explain what I found and what I did. You will probably not remember any of this but hopefully your family will remind you of what I said.
- Either my P.A. (Doug) or myself, will see you in the office about a week following your surgery. We will check your shoulder, review your surgery including providing you with copies of photos taken of the inside of your shoulder. I am not the greatest photographer but I try to at least obtain photos that demonstrate what was wrong and what I did (before and after photos.) I will also describe appropriate activities, exercises and rehabilitation efforts that should be performed.
- Will I need physical therapy following surgery?
- Most but not all shoulder impingement surgeries require formal physical therapy during the recovery phase. Physical therapy modalities such as heat, ultrasound, and massage may offer a temporary “feel good” reaction but usually have no significant impact on your overall recovery. Exercise however is very important. By the time you decide to do surgery for shoulder impingement, chances are you have been hurting for quite some time and as such, you muscles are weak and need specific work to regain strength. Physical therapists may teach you what to do but you must do the exercises. Doug, my PA is also a certified Athletic Trainer and educated in teaching you what you can do to facilitate your own recovery. In many cases, instruction in a self-directed home exercise program may be all you need. In others, a course of formal physical therapy my be what you need to maximize your recovery. Do not hesitate to ask for any additional help you may need.
Shoulder Bursitis
Calcific tendinitis is characterized by the presence of calcium deposits, actually hydroxyapatite (a crystalline calcium phosphate), in a tendon of the rotator cuff in the shoulder. It is often asymptomatic and occurs in 3-20% of shoulders in the general population.
When symptomatic it has a variable presentation of shoulder pain. It may be aggravated by elevation of the arm above shoulder level or lying on the shoulder. Patients may also complain of stiffness, snapping, catching, or weakness. It is most commonly found in adults between the ages of 30-50 years. Women, especially housewives and clerical workers, are more commonly affected than men.
Calcium deposits may respond to injections and sometimes require surgical removal.
An acromioclavicular joint separation, or AC separation, is a very frequent injury among physically active people. In this injury the clavicle (collar bone) separates from the scapula (shoulder blade). It is commonly caused by a fall directly on the “point” of the shoulder or a direct blow received in a contact sport. Football players and cyclists who fall over the handlebars are often subject to AC separations.
In general, most AC injuries don’t require surgery. There are certain situations, however, in which surgery may be necessary. Most patients recover with full function of the shoulder. The period of disability and discomfort ranges from a few days to 12 weeks depending on the severity of the separation. Disruption of the AC joint results in pain and instability in the entire shoulder and arm. The pain is most severe when the patient attempts overhead movements or tries to sleep on the affected side.
An AC joint separation, often called a shoulder separation, is a dislocation of the clavicle from the acromion. This injury is usually caused by a blow to the shoulder, or a fall in which the individual lands directly on the shoulder or an outstretched arm. AC joint separations are most common in contact sports, such as football and hockey.
The severity of an acromioclavicular joint injury depends on which supporting structures are damaged, and the extent of that damage. Tearing of the acromioclavicular ligament alone is not a serious injury, but when the coracoclavicular ligaments are ruptured, the whole shoulder unit is involved, thus complicating the dislocation.
Grade I – A slight displacement of the joint. The acromioclavicular ligament may be stretched or partially torn. This is the most common type of injury to the AC joint.
Grade II – A partial dislocation of the joint in which there may be some displacement that may not be obvious during a physical examination. The acromioclavicular ligament is completely torn, while the coracoclavicular ligaments remain intact.
Grade III – A complete separation of the joint. The acromioclavicular ligament, the coracoclavicular ligaments, and the capsule surrounding the joint are torn. Usually, the displacement is obvious on clinical exam. Without any ligament support, the shoulder falls under the weight of the arm and the clavicle is pushed up, causing a bump on the shoulder.
There are a total of six grades of severity of AC separations. Grades I-III are the most common. Grades IV-VI are very uncommon and are usually the result of a very high-energy injury such as one that might occur in a motor vehicle accident. Grades IV-VI are all treated surgically because of the severe disruption of all the ligamentous support for the arm and shoulder.
The term “rotator cuff” refers to a group of four tendons that attach four shoulder muscles to the upper arm. When you activate those muscles, your arm moves away from your body in a variety of directions. The shoulder is a very unique joint. It has a wider “range of motion,” which means it can move more freely, and in more directions, than any other joint. The shoulder’s versatility enables us to position our hand in space and hold it there while performing tasks. The shoulder’s flexibility is due to its unique structure. Like the hip, the shoulder is a “ball-and-socket” joint – a “ball” at the top of the upper arm bone (the humerus) fits neatly into a “socket” formed by the shoulder blade (Glenoid Fossa). This “socket” however, is more of a flat disc than a true socket surrounded by a rubber like rim called the “labrum”. The labrum effectively deepens the “socket” and adds stability to a potentially very unstable joint. Because of this unique anatomy the shoulder is extremely mobile and also prone to instability or dislocation.
Injury to the rotator cuff severely effects the function of the shoulder. It is almost always associated with pain and loss of strength. If a rotator cuff tendon becomes inflamed or is partially torn, it can cause pain and limit shoulder movement. Cuff tears can occur from an injury such as falling on your arm, from a sudden impact as might occur skiing, snowboarding, playing football or a similar collision sport, auto accidents and any number of other activities which might overload a tendon.
Cuff tears can also occur gradually as a result of years of “over-use” and from a condition within the shoulder referred to as “impingement”.
Impingement occurs when the rotator cuff rubs against the acromion (the bone adjacent to the cuff). As we get older, some of us grow bone spurs on the acromion which can rub (impinge) upon the cuff tendons leading to pain, swelling and ultimately cuff failure (rotator cuff tear).
A sick rotator cuff can cause pain, limitation of range of motion, clicking and popping sensations within the shoulder, weakness, sensations of instability and especially pain at night.
Treatment, to a large degree is dictated by the nature and extent of the damage. The first thing to do is try to make an accurate diagnosis by reviewing the history of onset of symptoms, a careful physical examination of the shoulder and x-ray examination of the shoulder. MRI of the shoulder may be useful but is often lacking in accuracy.
Questions I try to answer are:
Is it torn, partially torn or just inflamed and irritated?
Is there a bone spur, a calcium deposit or evidence of impingement of the cuff against the acromion?
Simple inflammation or bursitis can respond to rest, anti-inflammatory medication, injections and rehabilitative exercises. Partial tears can respond favorably to similar treatment as is used for simple inflammation. Full thickness or complete tears of the rotator cuff almost always require surgery for recovery. Bone spurs usually require surgical removal if they are contributing to impingement. Calcium deposits may respond to injections and sometimes require surgical removal.
Rotator cuff tears require that the tendon be sewn back to the bone. One must freshen up the surface of the bone, place anchors in the bone with sutures attached, weave the sutures through the torn end of the tendon and then tie knots to hold the tendon tightly to the bone. Recent advances allow us to use a “double row” repair to increase the strength of the repair.
The operation can last from as little as 20 minutes to correct impingement to greater than a hour to repair a large rotator cuff tear. Once the surgery is completed, the instruments are removed and “steri-strips” are applied to the small puncture wounds.
Various types of slings are applied at the end of the surgery to support or protect the surgery. A simple arm sling is used for the more minor procedures while a sling with a bolster to lift the arm slightly away from your body is used in cuff repairs and stabilization surgery.
Frozen shoulder is characterized by pain and loss of motion or stiffness in the shoulder. It affects about two percent of the general population. Frozen shoulder most commonly affects patients between the ages of 40 and 60 years, with no clear predisposition based on sex, arm dominance, or occupation.
A frozen shoulder is not usually surgically treated, but is treated with pain management and physical therapy. In patients who fail to recover with physical therapy, manipulation under anesthesia may be necessary to re-gain range of motion.