Shoulder joint separation at a glance
• Shoulder joint separation involves injury to the ligaments (fibrous tissue connecting bone to bone) in the AC joint (between the shoulder blade and the collarbone), ranging from partial tears to complete tears with dislocation.
• Shoulder separation is different from a dislocated shoulder, which is when the upper arm bone is dislocated from the shoulder blade.
• Shoulder joint separation is a common injury, especially in the athletic community.
• Shoulder separation symptoms can include shoulder pain, tenderness, weakness, swelling, bruising, and a visible bump at the site of the injury.
• Treatment includes rest, pain medication, strengthening exercises, and in some cases, surgery. Be sure to talk to your pharmacist before purchasing anti¬-inflammatories as these medications may be contraindicated as they may interact with other medications and medical conditions.
Causes of shoulder joint separation
Shoulder joint separation is caused by the ligaments supporting the AC (acromioclavicular) joint becoming stretched or torn. This can be a simple injury through a sprain to the ligaments (Grade 1 shoulder joint separation). If the ligaments in the AC joint are torn, the condition is more severe (Grade 2). Tearing to AC joint ligaments and other ligaments attached to the collarbone can result in a complete dislocation of the AC joint (Grade 3).
Shoulder separation most commonly is caused by a blow to the shoulder, such as a fall directly on the shoulder as seen during football or extreme sports.
Symptoms of shoulder joint separation
Symptoms can vary depending on the severity of the injury, ranging from tenderness near the joint, to a complete dislocation of the joint. In general, shoulder separation symptoms include :
• Shoulder pain, especially when reaching across the body.
• Tenderness over the AC joint (at the top of the shoulder).
• Shoulder and arm weakness.
• Limited shoulder movement due to pain.
Grade 2 and 3 separation may also include swelling, as well as bruising several days after the injury.
Grade 3 separation is usually accompanied by a popping sensation. If there is a complete shoulder dislocation, there will be a noticeable bump on the shoulder.
Treatment of shoulder joint separation
Treatment for Grade 1 or Grade 2 shoulder joint separation usually consists of rest, ice, a sling, and pain medication until the ligaments heal (usually within a few weeks). Activity should generally be continued as the separation heals, depending on the level of pain tolerance, to help maintain strength in the shoulder.
For Grade 3 separation, allowing a longer healing period (several weeks or months) or pursuing shoulder surgery are both treatment options. Surgery involves relocating the joint and repairing the torn ligaments.
It is controversial whether rest or surgery is the better option to treat Grade 3 shoulder joint separation, as both options produce similar results.
If you have a separated shoulder, contact us to request an appointment with one of our orthopedic shoulder specialists to learn about your treatment options.
Inflamed Shoulder Treatment
The shoulder is a very complex piece of machinery. Its elegant design gives us the ability to do many things. This design gives the shoulder joint great range of motion but not much stability. As long as the parts of this elegant machine are in good working order, the shoulder can move freely and painlessly. An injury to the shoulder or wear and tear in the parts of the shoulder, can lead to pain with movement or stiffness in the shoulder.
Many people are probably familiar with the term bursitis. Any pain in the shoulder is sometimes mistakenly referred to as bursitis. The term bursitis really only means that the part of the shoulder called the bursa is inflamed. In reality, there are many different problems that can lead to symptoms from inflammation of the bursa, or bursitis. Impingement is one of those things that can cause bursitis. Let’s see how this machine called the shoulder is put together and what might cause breakdown.
Causes of shoulder impingement
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 the arm is raised, there is a bit of rubbing on the tendons and the bursa between the tendons and the acromion. This rubbing, or pinching action, is called impingement. Impingement occurs to some degree in everyone’s shoulder, caused by day-to-day activities that we do using the arm above shoulder level.
But continuously working with the arms raised overhead, repeated throwing activities, or other repetitive actions of the arm can cause impingement to become a problem. Raising the arm tends to force the humerus against the edge of the acromion. With overuse this can cause irritation and swelling of the bursa.
If any condition decreases the amount of space between the acromion and the rotator cuff tendons, the impingement process may get worse. Bone spurs can further reduce the space available for the bursa and tendons to move under the acromion.
Wear and tear of the joint between the collarbone and the scapula, the acromioclavicular (AC) joint, is a fairly common cause of bone spurs around this joint. This joint sits right above the bursa and rotator cuff tendons and if bone spurs develop underneath the joint, this can make Impingement worse.
Symptoms of shoulder impingement syndrome
Early symptoms of Impingement Syndrome include :
• Generalized aching of the shoulder.
• Pain when raising the arm out from the side or in front of the body.
• Most patients complain of difficulty sleeping due to pain, especially when they roll over on the affected shoulder.
• A very reliable sign of impingement is a sharp pain when trying to reach into your back pocket.
As the process continues, discomfort increases and the joint may become stiffer. Sometimes a “catching” sensation is felt when the arm is lowered. Weakness and inability to raise the arm may indicate that the rotator cuff tendons are actually torn.
Should Impingement diagnosis
The diagnosis of impingement and bursitis is usually made on the basis of the history and physical examination. Your doctor will be interested in your activities and your job, because this condition is frequently related to continuous overhead activities.
Some people have an odd anatomy of the acromion, where the bone tilts too far down and reduces the space between the acromion and the rotator cuff.
The MRI scan, or arthrogram, may be performed if there is also a suspected tear of the rotator cuff tendons. An MRI scan is a special radiological test where magnetic waves are used to create pictures that look like slices of the shoulder. The MRI scan shows more than the bones of the shoulder. It can show the tendons as well, and whether there has been a tear in those tendons. The MRI scan is painless, and requires no needles or dye to be injected.
The arthrogram is an older test. This test is done by injecting dye into the shoulder joint and taking several x-rays. If the dye leaks out of the shoulder joint where it was placed, it suggests that there is a tear in the rotator cuff tendons where the dye leaked out. Both tests are still widely used.
Prevention, treatments & medications for shoulder impingement
Anti-inflammatory medications may be prescribed by your orthopedic physician. These include aspirin and ibuprofen. If these measures fail to improve your pain, an injection of cortisone into the bursa may reduce the inflammation and control the pain. Cortisone is a very strong anti- inflammatory medication and can reduce the inflammation in the bursa and tendons of the rotator cuff. Be sure to talk to your pharmacist before purchasing anti-inflammatories as these medications may be contraindicated as they may interact with other medications and medical conditions.
Rest
Your physician or therapist may prescribe a sling to provide adequate rest to the shoulder. It is crucial that the sling be removed several times daily while you perform your home exercises. This is paramount in order to prevent a stiff or “frozen’ shoulder.
Ice
Ice decreases the size of blood vessels in the sore area, halting inflammation and relieving pain. Choices of application include cold packs, ice bags, or ice massage. Ice massage is an easy and effective way to provide first aid. Simply freeze water in a paper cup. When needed, tear off the top inch, exposing the ice. Rub three to five minutes around the sore area until it feels numb.
Physical therapy
It is very important to maintain the strength in the muscles of the rotator cuff. These muscles help control the stability of the shoulder joint and strengthening these muscles can actually decrease the impingement of the acromion on the rotator cuff tendons and bursa. Long term management of this problem should also address worksite alterations to reduce the need for overhead activity
A posterior capsular stretching program and rotator cuff strengthening program may be started by your physical therapist. These programs are simply a set of exercises that will help keep the shoulder strong and flexible and help reduce the irritation from impingement.
Your therapist will make sure you understand the exercises and are doing them correctly before turning you loose on your own.
Shoulder surgery
Surgery to the shoulder to relieve the constant rubbing of impingement is not uncommon. When surgery becomes necessary, the major goal of the surgery is to increase the space between the acromion and the rotator cuff tendons. The first thing that must be done is to remove any bone spurs under the acromion that are rubbing on the rotator cuff tendons and the bursa. Usually a small part of the acromion may be removed as well to give the tendons even more space and allow them to move without rubbing on the underside of the acromion. In patients who have an abnormal tilt to the acromion, more of the bone may need to be removed.
Impingement may not be the only problem in a shoulder that has begun to show wear and tear due to aging and overuse. It is very common to see degenerative (wear and tear) arthritis in the acromioclavicular (AC) joint in addition to impingement. If there is reason to believe that the acromioclavicular (AC) joint is arthritic, the end of the clavicle may be removed as well. This procedure is called a resection arthroplasty. After removal of about one inch of the clavicle, scar tissue fills the space left between the clavicle and the acromion to form a false joint. This stops the arthritic pain in the acromioclavicular (AC) joint caused by bone rubbing against bone. The scar tissue that forms creates a stable, flexible connection between the clavicle and the scapula.
In some cases this can he accomplished using the arthroscope. The arthroscope is a small TV camera that can be inserted into joint through a small incision. Through other small incisions around the joint the surgeon can insert special instruments to cut and burr away bone while he watches what he is doing on a TV screen. If your surgery is done with the arthroscope you may be able to go home the same day.
In other cases, an open incision is made to allow removal of the bone. Usually an incision about three or four inches is made over the top of the shoulder. Any bone spurs are removed and a part of the acromion is removed and smoothed by the surgeon. If necessary, the end of the clavicle is removed to perform the resection arthroplasty of the acromioclavicular (AC) joint. If your surgery is done in this way, you may have to stay a night or two in the hospital.
If you are experience pain and symptoms of shoulder impingement, contact us to request an appointment with one of our orthopedic shoulder specialist to learn about treatment options available to you.
Reflex Sympathetic Dystrophy (RSD)
Reflex sympathetic dystrophy at a glance
• Reflex sympathetic dystrophy is a rare, complex pain disorder which usually develops after a trauma and is characterized by intense burning.
• As a result, it can also be referred to as Complex Regional Pain Syndrome.
• The exact cause of RSD.
• While there is no cure for RSD, treatment can diminish the symptoms and may improve function.
What is reflex sympathetic dystrophy (RSD)?
Reflex sympathetic dystrophy – or RSD, for short – is a term used to describe a complex pain disorder. It is also known as Complex Regional Pain Syndrome. The pain is characterized by its intense burning nature that is out of proportion to the inciting injury. The upper extremity is most commonly involved, but the lower extremities can also be effected.
What causes RSD?
The cause of Reflex sympathetic dystrophy is unknown. RSD develops as a consequence of a minor contusion or sprain. It can also occur with seemingly unrelated medical conditions such as myocardial infarction, stomach ulcers or minor surgery. In approximately 40 percent of cases, no precipitating cause can be identified.
RSD was first described in the medical literature during the Civil War. Soldiers who sustained nerve injury described severe burning pains which was termed “causalgia.” Initial investigation identified the sympathetic nervous system as being abnormal. Hence, the name reflex sympathetic dystrophy. The sympathetic nervous system is a portion of the nervous system which is not under voluntary control. Subsequent investigation has indicated that RSD does not necessarily involve sympathetic nerve damage. Therefore, the term complex regional pain syndrome (CRPS) is emerging to describe pain which is similar to RSD.
Symptoms of RSD
RSD is not a diagnosis. RSD is a descriptive term used to depict a painful extremity with the following characteristics. Patients may have a minor injury and then gradually develop severe burning pain on the skin which is out of proportion to the original injury. Although individual patients may vary considerably, RSD usually occurs in three overlapping phases :
• Phase I is called the acute stage and lasts up to 3 months. The pain surrounding the injured area and has a characteristic burning quality. Patients may also complain of hypersensitivity, cold intolerance, increased sweating and reddish skin discoloration.
• Phase II is called the dystrophic stage. Burning pain still predominates, but travels away from the injured area and may involve the entire extremity. Swelling of the extremity may occur and joints begin to stiffen and muscles begin to thin.
• Phase III is known as the atrophic stage. This stage occurs approximately one year following the acute stage and can persist for many years. The pain and discoloration may or may not diminish. There may be loss of skin creases and loss of normal sweating, giving the skin a cool, dry appearance. The stiffness of the joints can worsen and there is usually muscular dysfunction.
Diagnosis of RSD
The diagnosis of RSD can be difficult. Patients may complain of burning pain for several months before the diagnosis is confirmed. The diagnosis is based on the findings of pain which is out of proportion to the original injury, associated with swelling, discoloration and joint stiffness.
Diagnostic studies such as x-rays or bone scans are sometimes helpful. An anesthetic medication such as Lidocaine which is injected into the region of the sympathetic nerves as they exit the spinal column can result in temporary pain relief, confirming the diagnosis. This response is typically seen in the more acute phases of RSD and is often negative in chronic cases. Frequently, all studies are normal and the diagnosis is often based on the patient’s complaints and physical examination alone.
Treatment of RSD
There is no cure for Reflex Sympathetic Dystrophy which, fortunately, is a rare disease. Early intervention provides the best relief but has not been uniformly successful in all patients. Oral medications such as antihypertensives, neuroleptics and antidepressants may help. A series of sympathetic blocks is indicated in acute RSD patients who respond well to diagnostic injection.
Specialized hand therapy can greatly diminish the degree of stiffness and improve function. Be sure to talk to your pharmacist before purchasing anti-inflammatories as these medications may be contraindicated as they may interact with other medications and medical conditions.
Small electrical nerve stimulators which are placed on the skin surface may provide temporary pain relief. Surgical intervention is generally not beneficial.
Patients are encouraged to continue their daily activities such as much as possible in order to minimize or prevent further stiffness and dysfunction. RSD can progress through the various stages which become increasingly difficult to treat. Emotional support such as psychological counseling to help patients cope with the depression and anger, as well as ongoing physical therapy may be helpful. However, despite management, patients can occasionally experience persistent pain and dysfunction which is resistant to all forms of treatment.
Rotator Cuff Tear Treatment
Rotator cuff tear at a glance
• A tear of the rotator cuff (a set of muscles and tendons that connects the shoulder socket to the ball) occurs when the tendon(s) are torn through an injury or normal activity, such as raising objects above the head.
• Rotator cuff tears commonly occur because the tendons have been weakened through the aging process, degeneration or trauma.
• Symptoms may include intense pain and a popping sensation at the time of injury, followed by weakness and difficulty moving the shoulder and arm, and pain in the shoulder during sleep.
• Initial treatment should include rest, alternating ice and heat, pain medication and physical therapy.
• When initial treatments fail, rotator cuff tears may require shoulder surgery to repair the tendons and restore functionality.
• Injection based therapies such as platelet rich plasma and bone marrow concentrate (BMC) injections hold promise as nonsurgical alternatives in some cases.
Causes of a shoulder rotator cuff tear
Tendons and muscles connecting the upper arm bone to the shoulder blade comprise the rotator cuff and are located in low blood-supply areas, meaning they are more prone to wear and tear as the body ages. This makes a rotator cuff tear, when one or more of the tendons is ripped apart, a common injury later in life.
As the rotator cuff tendons become weaker, they are more susceptible to injury and tearing from everyday activities like lifting objects overhead. Rotator cuff tears can be categorized as either degenerative (happening over time) or acute (suddenly from trauma).
Rotator cuff tears are seen more often in middle-aged or older patients and often develop gradually, which would be a degenerative tear. Rotator cuff tears can also occur suddenly, in particular from trauma such as bracing the body during a fall or lifting extremely heavy objects with the arm extended. This would be categorized as an acute tear.
Rotator cuff tears can be a partial tear meaning the tendon is NOT completely severed but the tissue is damaged. A full-thickness tear (complete tear) splits the tissue in two. The tendon often tears off where it attaches to the humerus (upper arm bone).
Generally, large acute tears resulting in shoulder dysfunction are treated with expeditious repair in order to restore shoulder function. Partial or small degenerative tears are often successfully treated utilizing non-surgical strategies to manage symptoms and improve function.
Symptoms of a shoulder rotator cuff tear
Intense pain, weakness and a popping sensation can occur at the time of injury. However, it is possible to tear the rotator cuff and not experience acute symptoms.
The main symptoms of a rotator cuff tear come after the initial injury and include :
• Pain
• Tenderness
• Weakness
• Difficulty moving the shoulder and arm (especially moving the arm out and away from the side)
• A snapping or cracking sound may also accompany shoulder movement after the injury
• Pain at night in shoulder.
If the tear is only partial, dull pain with minor difficulty moving the arm is usually the result. A complete tear brings a higher level of pain and the inability to move the arm correctly. In the case of complete rotator cuff tears, intense pain is accompanied by the inability to raise the arm away from the side.
Treatment of a shoulder rotator cuff tear
In roughly half of patients, nonsurgical treatments can relieve pain and improve the function of the shoulder. This does not necessarily reattach a torn tendon, but can provide good pain and function improvement. Reattachment of the tendon generally requires surgery.
Nonsurgical treatment for rotator cuff tears
Initial treatment for shoulder rotator cuff tears includes rest, alternating ice and heat, and anti-inflammatory medication to control the pain. This can be followed if needed by physical therapy or exercises to regain motion after the pain has subsided. Patients should talk to their pharmacist before purchasing anti-inflammatories, as they may interact with other medications and medical conditions.
If the above treatments don’t relieve pain, a cortisone injection may help. Cortisone is a steroid hormone that works very well to reduce inflammation.
Orthopedists can treat partial or degenerative tears with injections such as cortisone or other new biological techniques such as platelet rich plasma (PRP), combined with physical therapy. PRP injections involve taking concentrated platelets from the patient’s blood and injecting them into the damaged tendon(s). This is believed to help rebuild the damaged soft tissue to aid in the healing process and reduce pain.
Surgery for torn rotator cuffs
Orthopedists generally recommend surgery when :
• Pain continues after nonsurgical treatments
• Symptoms remain after 6-12 months
• The tear is large (> 3cm)
• A recent injury caused the tear
• The person has considerable weakness and significant loss of function
• Pain is affecting quality of life or sleep.
Although symptoms of partial tears usually decrease over time with conservative treatment, most complete rotator cuff tears will require surgery to reattach the torn tendons to the upper arm bone. With complete rotator cuff tears, rotator cuff repair surgery within three months of the injury is advisable.
Surgery is performed in an outpatient setting. Orthopedic surgeons have several options in how they surgically repair the tendon and will discuss these with the patient beforehand. The surgery is usually followed by several months of diligent physical therapy to recover the full range of motion in the shoulder and arm.
Patients experiencing pain and discomfort in the shoulder, or other symptoms of a torn rotator cuff, should contact us to request an appointment. Our orthopedic surgeons will discuss the diagnsosis and treatment options that can optimize recovery from the injury.
Frozen Shoulder Treatment
Frozen shoulder at a glance
• Frozen shoulder (adhesive capsulitis) is a condition in which the capsule of connective tissue around the shoulder joint becomes thicker, restricting movement.
• Common symptoms include pain, stiffness, and restricted range of motion, which develop in several stages.
• Treatment options include over-the-counter pain medication, physical therapy, or injections of corticosteroids or sterile water into the affected joint. Be sure to talk to your pharmacist before purchasing anti-inflammatories as these medications may be contraindicated as they may interact with other medications and medical conditions.
• Most cases of frozen shoulder go away within 18 months, but for some patients, surgery may be necessary.
Causes of frozen shoulder
The exact cause of frozen shoulder is unknown. However, frozen shoulder often occurs after surgery or injury, when the shoulder joint has been immobilized for an extended period of time.
Frozen shoulder can also occur as a result of chronic conditions like arthritis or diabetes, and people over 40 are more likely to develop frozen shoulder.
Symptoms of frozen shoulder
Symptoms of frozen shoulder usually develop gradually over several months, and typically include :
• Shoulder pain
• Restricted range of motion in the joint
• Stiffness
Frozen shoulder symptoms can last for 12-18 months, and will usually go away over the course of several months.
Treatment for frozen shoulder
Initial treatment for frozen shoulder includes non-steroidal anti-inflammatory medicine like Advil or Aleve. Applying heat or ice to the joint and gently stretching it, as well as injections of corticosteroids or sterile water into the joint, can also help relieve the pain.
Physical therapy can help maintain the joints range of motion. However, if the symptoms are severe and treatment is not helping, surgery may be necessary.
If you are experiencing the symptoms of a frozen shoulder, contact us to schedule an appointment with one of our orthopedic shoulder specialists.
• Shoulder joint separation involves injury to the ligaments (fibrous tissue connecting bone to bone) in the AC joint (between the shoulder blade and the collarbone), ranging from partial tears to complete tears with dislocation.
• Shoulder separation is different from a dislocated shoulder, which is when the upper arm bone is dislocated from the shoulder blade.
• Shoulder joint separation is a common injury, especially in the athletic community.
• Shoulder separation symptoms can include shoulder pain, tenderness, weakness, swelling, bruising, and a visible bump at the site of the injury.
• Treatment includes rest, pain medication, strengthening exercises, and in some cases, surgery. Be sure to talk to your pharmacist before purchasing anti¬-inflammatories as these medications may be contraindicated as they may interact with other medications and medical conditions.
Causes of shoulder joint separation
Shoulder joint separation is caused by the ligaments supporting the AC (acromioclavicular) joint becoming stretched or torn. This can be a simple injury through a sprain to the ligaments (Grade 1 shoulder joint separation). If the ligaments in the AC joint are torn, the condition is more severe (Grade 2). Tearing to AC joint ligaments and other ligaments attached to the collarbone can result in a complete dislocation of the AC joint (Grade 3).
Shoulder separation most commonly is caused by a blow to the shoulder, such as a fall directly on the shoulder as seen during football or extreme sports.
Symptoms of shoulder joint separation
Symptoms can vary depending on the severity of the injury, ranging from tenderness near the joint, to a complete dislocation of the joint. In general, shoulder separation symptoms include :
• Shoulder pain, especially when reaching across the body.
• Tenderness over the AC joint (at the top of the shoulder).
• Shoulder and arm weakness.
• Limited shoulder movement due to pain.
Grade 2 and 3 separation may also include swelling, as well as bruising several days after the injury.
Grade 3 separation is usually accompanied by a popping sensation. If there is a complete shoulder dislocation, there will be a noticeable bump on the shoulder.
Treatment of shoulder joint separation
Treatment for Grade 1 or Grade 2 shoulder joint separation usually consists of rest, ice, a sling, and pain medication until the ligaments heal (usually within a few weeks). Activity should generally be continued as the separation heals, depending on the level of pain tolerance, to help maintain strength in the shoulder.
For Grade 3 separation, allowing a longer healing period (several weeks or months) or pursuing shoulder surgery are both treatment options. Surgery involves relocating the joint and repairing the torn ligaments.
It is controversial whether rest or surgery is the better option to treat Grade 3 shoulder joint separation, as both options produce similar results.
If you have a separated shoulder, contact us to request an appointment with one of our orthopedic shoulder specialists to learn about your treatment options.
Inflamed Shoulder Treatment
The shoulder is a very complex piece of machinery. Its elegant design gives us the ability to do many things. This design gives the shoulder joint great range of motion but not much stability. As long as the parts of this elegant machine are in good working order, the shoulder can move freely and painlessly. An injury to the shoulder or wear and tear in the parts of the shoulder, can lead to pain with movement or stiffness in the shoulder.
Many people are probably familiar with the term bursitis. Any pain in the shoulder is sometimes mistakenly referred to as bursitis. The term bursitis really only means that the part of the shoulder called the bursa is inflamed. In reality, there are many different problems that can lead to symptoms from inflammation of the bursa, or bursitis. Impingement is one of those things that can cause bursitis. Let’s see how this machine called the shoulder is put together and what might cause breakdown.
Causes of shoulder impingement
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 the arm is raised, there is a bit of rubbing on the tendons and the bursa between the tendons and the acromion. This rubbing, or pinching action, is called impingement. Impingement occurs to some degree in everyone’s shoulder, caused by day-to-day activities that we do using the arm above shoulder level.
But continuously working with the arms raised overhead, repeated throwing activities, or other repetitive actions of the arm can cause impingement to become a problem. Raising the arm tends to force the humerus against the edge of the acromion. With overuse this can cause irritation and swelling of the bursa.
If any condition decreases the amount of space between the acromion and the rotator cuff tendons, the impingement process may get worse. Bone spurs can further reduce the space available for the bursa and tendons to move under the acromion.
Wear and tear of the joint between the collarbone and the scapula, the acromioclavicular (AC) joint, is a fairly common cause of bone spurs around this joint. This joint sits right above the bursa and rotator cuff tendons and if bone spurs develop underneath the joint, this can make Impingement worse.
Symptoms of shoulder impingement syndrome
Early symptoms of Impingement Syndrome include :
• Generalized aching of the shoulder.
• Pain when raising the arm out from the side or in front of the body.
• Most patients complain of difficulty sleeping due to pain, especially when they roll over on the affected shoulder.
• A very reliable sign of impingement is a sharp pain when trying to reach into your back pocket.
As the process continues, discomfort increases and the joint may become stiffer. Sometimes a “catching” sensation is felt when the arm is lowered. Weakness and inability to raise the arm may indicate that the rotator cuff tendons are actually torn.
Should Impingement diagnosis
The diagnosis of impingement and bursitis is usually made on the basis of the history and physical examination. Your doctor will be interested in your activities and your job, because this condition is frequently related to continuous overhead activities.
Some people have an odd anatomy of the acromion, where the bone tilts too far down and reduces the space between the acromion and the rotator cuff.
The MRI scan, or arthrogram, may be performed if there is also a suspected tear of the rotator cuff tendons. An MRI scan is a special radiological test where magnetic waves are used to create pictures that look like slices of the shoulder. The MRI scan shows more than the bones of the shoulder. It can show the tendons as well, and whether there has been a tear in those tendons. The MRI scan is painless, and requires no needles or dye to be injected.
The arthrogram is an older test. This test is done by injecting dye into the shoulder joint and taking several x-rays. If the dye leaks out of the shoulder joint where it was placed, it suggests that there is a tear in the rotator cuff tendons where the dye leaked out. Both tests are still widely used.
Prevention, treatments & medications for shoulder impingement
Anti-inflammatory medications may be prescribed by your orthopedic physician. These include aspirin and ibuprofen. If these measures fail to improve your pain, an injection of cortisone into the bursa may reduce the inflammation and control the pain. Cortisone is a very strong anti- inflammatory medication and can reduce the inflammation in the bursa and tendons of the rotator cuff. Be sure to talk to your pharmacist before purchasing anti-inflammatories as these medications may be contraindicated as they may interact with other medications and medical conditions.
Rest
Your physician or therapist may prescribe a sling to provide adequate rest to the shoulder. It is crucial that the sling be removed several times daily while you perform your home exercises. This is paramount in order to prevent a stiff or “frozen’ shoulder.
Ice
Ice decreases the size of blood vessels in the sore area, halting inflammation and relieving pain. Choices of application include cold packs, ice bags, or ice massage. Ice massage is an easy and effective way to provide first aid. Simply freeze water in a paper cup. When needed, tear off the top inch, exposing the ice. Rub three to five minutes around the sore area until it feels numb.
Physical therapy
It is very important to maintain the strength in the muscles of the rotator cuff. These muscles help control the stability of the shoulder joint and strengthening these muscles can actually decrease the impingement of the acromion on the rotator cuff tendons and bursa. Long term management of this problem should also address worksite alterations to reduce the need for overhead activity
A posterior capsular stretching program and rotator cuff strengthening program may be started by your physical therapist. These programs are simply a set of exercises that will help keep the shoulder strong and flexible and help reduce the irritation from impingement.
Your therapist will make sure you understand the exercises and are doing them correctly before turning you loose on your own.
Shoulder surgery
Surgery to the shoulder to relieve the constant rubbing of impingement is not uncommon. When surgery becomes necessary, the major goal of the surgery is to increase the space between the acromion and the rotator cuff tendons. The first thing that must be done is to remove any bone spurs under the acromion that are rubbing on the rotator cuff tendons and the bursa. Usually a small part of the acromion may be removed as well to give the tendons even more space and allow them to move without rubbing on the underside of the acromion. In patients who have an abnormal tilt to the acromion, more of the bone may need to be removed.
Impingement may not be the only problem in a shoulder that has begun to show wear and tear due to aging and overuse. It is very common to see degenerative (wear and tear) arthritis in the acromioclavicular (AC) joint in addition to impingement. If there is reason to believe that the acromioclavicular (AC) joint is arthritic, the end of the clavicle may be removed as well. This procedure is called a resection arthroplasty. After removal of about one inch of the clavicle, scar tissue fills the space left between the clavicle and the acromion to form a false joint. This stops the arthritic pain in the acromioclavicular (AC) joint caused by bone rubbing against bone. The scar tissue that forms creates a stable, flexible connection between the clavicle and the scapula.
In some cases this can he accomplished using the arthroscope. The arthroscope is a small TV camera that can be inserted into joint through a small incision. Through other small incisions around the joint the surgeon can insert special instruments to cut and burr away bone while he watches what he is doing on a TV screen. If your surgery is done with the arthroscope you may be able to go home the same day.
In other cases, an open incision is made to allow removal of the bone. Usually an incision about three or four inches is made over the top of the shoulder. Any bone spurs are removed and a part of the acromion is removed and smoothed by the surgeon. If necessary, the end of the clavicle is removed to perform the resection arthroplasty of the acromioclavicular (AC) joint. If your surgery is done in this way, you may have to stay a night or two in the hospital.
If you are experience pain and symptoms of shoulder impingement, contact us to request an appointment with one of our orthopedic shoulder specialist to learn about treatment options available to you.
Reflex Sympathetic Dystrophy (RSD)
Reflex sympathetic dystrophy at a glance
• Reflex sympathetic dystrophy is a rare, complex pain disorder which usually develops after a trauma and is characterized by intense burning.
• As a result, it can also be referred to as Complex Regional Pain Syndrome.
• The exact cause of RSD.
• While there is no cure for RSD, treatment can diminish the symptoms and may improve function.
What is reflex sympathetic dystrophy (RSD)?
Reflex sympathetic dystrophy – or RSD, for short – is a term used to describe a complex pain disorder. It is also known as Complex Regional Pain Syndrome. The pain is characterized by its intense burning nature that is out of proportion to the inciting injury. The upper extremity is most commonly involved, but the lower extremities can also be effected.
What causes RSD?
The cause of Reflex sympathetic dystrophy is unknown. RSD develops as a consequence of a minor contusion or sprain. It can also occur with seemingly unrelated medical conditions such as myocardial infarction, stomach ulcers or minor surgery. In approximately 40 percent of cases, no precipitating cause can be identified.
RSD was first described in the medical literature during the Civil War. Soldiers who sustained nerve injury described severe burning pains which was termed “causalgia.” Initial investigation identified the sympathetic nervous system as being abnormal. Hence, the name reflex sympathetic dystrophy. The sympathetic nervous system is a portion of the nervous system which is not under voluntary control. Subsequent investigation has indicated that RSD does not necessarily involve sympathetic nerve damage. Therefore, the term complex regional pain syndrome (CRPS) is emerging to describe pain which is similar to RSD.
Symptoms of RSD
RSD is not a diagnosis. RSD is a descriptive term used to depict a painful extremity with the following characteristics. Patients may have a minor injury and then gradually develop severe burning pain on the skin which is out of proportion to the original injury. Although individual patients may vary considerably, RSD usually occurs in three overlapping phases :
• Phase I is called the acute stage and lasts up to 3 months. The pain surrounding the injured area and has a characteristic burning quality. Patients may also complain of hypersensitivity, cold intolerance, increased sweating and reddish skin discoloration.
• Phase II is called the dystrophic stage. Burning pain still predominates, but travels away from the injured area and may involve the entire extremity. Swelling of the extremity may occur and joints begin to stiffen and muscles begin to thin.
• Phase III is known as the atrophic stage. This stage occurs approximately one year following the acute stage and can persist for many years. The pain and discoloration may or may not diminish. There may be loss of skin creases and loss of normal sweating, giving the skin a cool, dry appearance. The stiffness of the joints can worsen and there is usually muscular dysfunction.
Diagnosis of RSD
The diagnosis of RSD can be difficult. Patients may complain of burning pain for several months before the diagnosis is confirmed. The diagnosis is based on the findings of pain which is out of proportion to the original injury, associated with swelling, discoloration and joint stiffness.
Diagnostic studies such as x-rays or bone scans are sometimes helpful. An anesthetic medication such as Lidocaine which is injected into the region of the sympathetic nerves as they exit the spinal column can result in temporary pain relief, confirming the diagnosis. This response is typically seen in the more acute phases of RSD and is often negative in chronic cases. Frequently, all studies are normal and the diagnosis is often based on the patient’s complaints and physical examination alone.
Treatment of RSD
There is no cure for Reflex Sympathetic Dystrophy which, fortunately, is a rare disease. Early intervention provides the best relief but has not been uniformly successful in all patients. Oral medications such as antihypertensives, neuroleptics and antidepressants may help. A series of sympathetic blocks is indicated in acute RSD patients who respond well to diagnostic injection.
Specialized hand therapy can greatly diminish the degree of stiffness and improve function. Be sure to talk to your pharmacist before purchasing anti-inflammatories as these medications may be contraindicated as they may interact with other medications and medical conditions.
Small electrical nerve stimulators which are placed on the skin surface may provide temporary pain relief. Surgical intervention is generally not beneficial.
Patients are encouraged to continue their daily activities such as much as possible in order to minimize or prevent further stiffness and dysfunction. RSD can progress through the various stages which become increasingly difficult to treat. Emotional support such as psychological counseling to help patients cope with the depression and anger, as well as ongoing physical therapy may be helpful. However, despite management, patients can occasionally experience persistent pain and dysfunction which is resistant to all forms of treatment.
Rotator Cuff Tear Treatment
Rotator cuff tear at a glance
• A tear of the rotator cuff (a set of muscles and tendons that connects the shoulder socket to the ball) occurs when the tendon(s) are torn through an injury or normal activity, such as raising objects above the head.
• Rotator cuff tears commonly occur because the tendons have been weakened through the aging process, degeneration or trauma.
• Symptoms may include intense pain and a popping sensation at the time of injury, followed by weakness and difficulty moving the shoulder and arm, and pain in the shoulder during sleep.
• Initial treatment should include rest, alternating ice and heat, pain medication and physical therapy.
• When initial treatments fail, rotator cuff tears may require shoulder surgery to repair the tendons and restore functionality.
• Injection based therapies such as platelet rich plasma and bone marrow concentrate (BMC) injections hold promise as nonsurgical alternatives in some cases.
Causes of a shoulder rotator cuff tear
Tendons and muscles connecting the upper arm bone to the shoulder blade comprise the rotator cuff and are located in low blood-supply areas, meaning they are more prone to wear and tear as the body ages. This makes a rotator cuff tear, when one or more of the tendons is ripped apart, a common injury later in life.
As the rotator cuff tendons become weaker, they are more susceptible to injury and tearing from everyday activities like lifting objects overhead. Rotator cuff tears can be categorized as either degenerative (happening over time) or acute (suddenly from trauma).
Rotator cuff tears are seen more often in middle-aged or older patients and often develop gradually, which would be a degenerative tear. Rotator cuff tears can also occur suddenly, in particular from trauma such as bracing the body during a fall or lifting extremely heavy objects with the arm extended. This would be categorized as an acute tear.
Rotator cuff tears can be a partial tear meaning the tendon is NOT completely severed but the tissue is damaged. A full-thickness tear (complete tear) splits the tissue in two. The tendon often tears off where it attaches to the humerus (upper arm bone).
Generally, large acute tears resulting in shoulder dysfunction are treated with expeditious repair in order to restore shoulder function. Partial or small degenerative tears are often successfully treated utilizing non-surgical strategies to manage symptoms and improve function.
Symptoms of a shoulder rotator cuff tear
Intense pain, weakness and a popping sensation can occur at the time of injury. However, it is possible to tear the rotator cuff and not experience acute symptoms.
The main symptoms of a rotator cuff tear come after the initial injury and include :
• Pain
• Tenderness
• Weakness
• Difficulty moving the shoulder and arm (especially moving the arm out and away from the side)
• A snapping or cracking sound may also accompany shoulder movement after the injury
• Pain at night in shoulder.
If the tear is only partial, dull pain with minor difficulty moving the arm is usually the result. A complete tear brings a higher level of pain and the inability to move the arm correctly. In the case of complete rotator cuff tears, intense pain is accompanied by the inability to raise the arm away from the side.
Treatment of a shoulder rotator cuff tear
In roughly half of patients, nonsurgical treatments can relieve pain and improve the function of the shoulder. This does not necessarily reattach a torn tendon, but can provide good pain and function improvement. Reattachment of the tendon generally requires surgery.
Nonsurgical treatment for rotator cuff tears
Initial treatment for shoulder rotator cuff tears includes rest, alternating ice and heat, and anti-inflammatory medication to control the pain. This can be followed if needed by physical therapy or exercises to regain motion after the pain has subsided. Patients should talk to their pharmacist before purchasing anti-inflammatories, as they may interact with other medications and medical conditions.
If the above treatments don’t relieve pain, a cortisone injection may help. Cortisone is a steroid hormone that works very well to reduce inflammation.
Orthopedists can treat partial or degenerative tears with injections such as cortisone or other new biological techniques such as platelet rich plasma (PRP), combined with physical therapy. PRP injections involve taking concentrated platelets from the patient’s blood and injecting them into the damaged tendon(s). This is believed to help rebuild the damaged soft tissue to aid in the healing process and reduce pain.
Surgery for torn rotator cuffs
Orthopedists generally recommend surgery when :
• Pain continues after nonsurgical treatments
• Symptoms remain after 6-12 months
• The tear is large (> 3cm)
• A recent injury caused the tear
• The person has considerable weakness and significant loss of function
• Pain is affecting quality of life or sleep.
Although symptoms of partial tears usually decrease over time with conservative treatment, most complete rotator cuff tears will require surgery to reattach the torn tendons to the upper arm bone. With complete rotator cuff tears, rotator cuff repair surgery within three months of the injury is advisable.
Surgery is performed in an outpatient setting. Orthopedic surgeons have several options in how they surgically repair the tendon and will discuss these with the patient beforehand. The surgery is usually followed by several months of diligent physical therapy to recover the full range of motion in the shoulder and arm.
Patients experiencing pain and discomfort in the shoulder, or other symptoms of a torn rotator cuff, should contact us to request an appointment. Our orthopedic surgeons will discuss the diagnsosis and treatment options that can optimize recovery from the injury.
Frozen Shoulder Treatment
Frozen shoulder at a glance
• Frozen shoulder (adhesive capsulitis) is a condition in which the capsule of connective tissue around the shoulder joint becomes thicker, restricting movement.
• Common symptoms include pain, stiffness, and restricted range of motion, which develop in several stages.
• Treatment options include over-the-counter pain medication, physical therapy, or injections of corticosteroids or sterile water into the affected joint. Be sure to talk to your pharmacist before purchasing anti-inflammatories as these medications may be contraindicated as they may interact with other medications and medical conditions.
• Most cases of frozen shoulder go away within 18 months, but for some patients, surgery may be necessary.
Causes of frozen shoulder
The exact cause of frozen shoulder is unknown. However, frozen shoulder often occurs after surgery or injury, when the shoulder joint has been immobilized for an extended period of time.
Frozen shoulder can also occur as a result of chronic conditions like arthritis or diabetes, and people over 40 are more likely to develop frozen shoulder.
Symptoms of frozen shoulder
Symptoms of frozen shoulder usually develop gradually over several months, and typically include :
• Shoulder pain
• Restricted range of motion in the joint
• Stiffness
Frozen shoulder symptoms can last for 12-18 months, and will usually go away over the course of several months.
Treatment for frozen shoulder
Initial treatment for frozen shoulder includes non-steroidal anti-inflammatory medicine like Advil or Aleve. Applying heat or ice to the joint and gently stretching it, as well as injections of corticosteroids or sterile water into the joint, can also help relieve the pain.
Physical therapy can help maintain the joints range of motion. However, if the symptoms are severe and treatment is not helping, surgery may be necessary.
If you are experiencing the symptoms of a frozen shoulder, contact us to schedule an appointment with one of our orthopedic shoulder specialists.
