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common injuries - shoulder

Impingement Syndrome/Rotator Cuff Tendonitis

Common Causes
Repetitive overhead use of the arm (tennis, hammering, gardening), frequent lifting, a fall on the shoulder or outstretched arm.
Symptoms
Pain in the shoulder or down the side of the arm. Usually fairly comfortable at rest. Pain with lifting the arm overhead, or sleeping on your side.
Physical Findings
Tenderness, positive 'impingement test'.
Workup
HX-Rays. and physical examination, MRI (rarely).
Non-Operative Treatment
Rest, anti-inflammatory medication, physical therapy. Possibly a trial of a corticosteroid injection.
Corticosteroids ("cortisone")(hide)

Key words: cortisone, corticosteroid, Medrol

Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.

Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.

This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.

Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.

Surgical Treatment
Shoulder arthroscopy, with arthroscopic decompression.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments
Generally curative with non-operative care when treated early. Arthroscopy is highly successful, with an early return to activities. Prolonged or worsening symptoms may be signs of a rotator cuff tear.

For more detailed information: Click here!

What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Rotator Cuff Tear

Description
A tear in the muscles that attach to the upper arm at the shoulder joint. These muscles are involved in shoulder and arm motion, and may tear off of the bone, or in the substance of the muscle itself.
Common Causes
Lifting heavy objects, overhead use of the arm, a fall on the outstretched arm or other trauma.
Symptoms
Pain in the shoulder, often radiating down the side of the arm or up to the neck. Pain is worsened with using the arm overhead, lifting objects, or sleeping on the injured side. Patients often report weakness in the arm and shoulder, with stiffness, or loss of motion.
Physical Findings
Tenderness over the rotator cuff, weakness, pain with 'impingement test'.
Workup
Physical examination, X-rays, possibly an MRI scan.
MR scans(hide)

MR scans (MRI, Magnetic Resonance Imaging) are a valuable way to visualize the soft tissues in the body, such as tendons, ligaments, muscles, and other organs. The MR scan uses a magnetic field, not radiation. Basically, you lie still on a flat table, with the MR tube over the body part, in a magnetic field. A computer is able to analyze the data (how fast hydrogen atoms change their spin direction!) and provide exquisitely detailed pictures of slices of your body. It is painless and safe, but people with significant claustrophobia may require some sedation. It is not cheap: about a thousand dollars per scan. It is also not perfect, and one must be careful not to rely too heavily on the MR scan. It does a poor job with bones and cartilage.

Non-Operative Treatment
Physical therapy and anti-inflammatory medication, avoidance of aggravating activities.
Surgical Treatment
Arthroscopy, with arthroscopic or open rotator cuff repair.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments
Rotator cuff tears generally do not heal on their own (the tendon retracts when torn, like a rubber band, and the torn edges are not adjacent to each other). Many rotator cuff tears can now be repaired arthroscopically, without a large incision. Following a rotator cuff repair, protection of the shoulder is usually required for several weeks, and full recovery may take many months.

For more detailed information: Click here!

What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Acromioclavicular (AC) Joint Sprain

Description
Injury to the joint on the top of the shoulder, with partial (grade 1 & 2) or complete (grade 3) tearing of the ligaments with dislocation of the AC joint.
Common Causes
Fall onto shoulder, occasionally by lifting heavy objects.
Symptoms
Pain on the top of the shoulder. May have bruising or swelling at time of injury. There are often complaints of 'popping'. May develop a 'bump' or deformity on top of the shoulder.
Physical Findings
Tenderness at the AC joint. Positive 'AC joint compression test'.
Workup
Physical examination and x-rays are usually diagnostic. Occasionally, stress x-rays are required.
Non-Operative Treatment
Rest, sling, and pain medication for grade 1 & 2 sprains, until symptoms subside. Most grade 3 sprains heal with time, although some advocate early repair in the competitive athlete.
Surgical Treatment
Repair is performed by 'relocating' the dislocated joint, and repairing the torn ligaments.
Comments

The majority of these injuries do heal with time, although a bony deformity is common. Surgical repair of the ligaments in grade 3 sprains may lead to faster recovery and better performance in certain athletes.

For more detailed information: Click here!

Acromioclavicular Joint Arthritis

Description
'Wear and tear' of the AC joint, the joint on the top of the shoulder that connects the scapula (shoulder blade) to the clavicle (collarbone). As the joint wears out, the ends of the bone rub, and become painful. Bone spurs may develop, causing pressure on the muscles underneath.
Common Causes
There may be an old history of an AC sprain, or other shoulder injury. Weightlifters are prone to this condition at a younger age. Often no cause is found, other than 'wear and tear'.
Symptoms
Pain, generally on the top of the shoulder, which may radiate up to the neck, the upper arm, or the back of the shoulder. Pain is usually worsened with sleeping on the side, lifting, and reaching across the body.
Physical Findings
Tenderness at the AC joint, positive physical exam tests.
Workup
Physical exam and x-rays are diagnostic.
X-rays(hide)

X-rays are the most common study used in Orthopaedic Surgery. Different tissues in the body, especially bone, will block the x-rays from passing through the body onto a sheet of film. Thus x-rays are an excellent way to visualize the bones in the body. This is useful for diagnosing fractures, dislocation, arthritis, tumors, growth injuries, and many other conditions. While X-rays are a form of radiation, they are generally extremely safe to the body in doses and quantities typically obtained by your doctor.

Non-Operative Treatment
Anti-inflammatory medications, and a trial of a corticosteroid injection. Physical therapy often aggravates symptoms.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
Shoulder arthroscopy, with removal of a small portion of the end of the collarbone, so that the two bones do not rub anymore.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments

Generally this condition slowly progresses, and non-operative treatment is of limited relief. Most of the time, the entire surgical procedure can be done arthroscopically, without a large incision, and with rapid return to full activities and pain relief.

For more detailed information: Click here!

Calcific Tendonitis

Description
A buildup of calcium develops in the muscles that move the shoulder. This causes pain and inflammation.
Common Causes
Repetitive overhead use of the arm, frequent lifting: tennis, hammering, gardening, weightlifting; occasionally there is a history of trauma to the shoulder.
Symptoms
Pain in the shoulder or down the side of the arm. Pain with lifting the arm overhead, or sleeping on the injured side.
Physical Findings
Tenderness, positive 'impingement test'.
Workup
X-Rays, physical examination, MRI (rarely).
X-rays(hide)

X-rays are the most common study used in Orthopaedic Surgery. Different tissues in the body, especially bone, will block the x-rays from passing through the body onto a sheet of film. Thus x-rays are an excellent way to visualize the bones in the body. This is useful for diagnosing fractures, dislocation, arthritis, tumors, growth injuries, and many other conditions. While X-rays are a form of radiation, they are generally extremely safe to the body in doses and quantities typically obtained by your doctor.

Non-Operative Treatment
Rest, anti-inflammatory medication, physical therapy. Possibly a trial of a corticosteroid injection.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
Shoulder arthroscopy, with removal of the calcific deposit.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments
Many cases will resolve with non-operative care. Arthroscopy is highly successful, with an early return to activities, and extremely low risk of recurrence. Prolonged or worsening symptoms may be signs of a rotator cuff tear.

Glenohumeral Joint Arthritis

Description
A wearing out of the 'ball and socket' joint of the shoulder. Progressive cartilage wear leads to bone rubbing on bone.
Common Causes
Most cases have no obvious cause. There is probably a genetic predisposition. Occasionally there is a history of an old injury.
Symptoms
Increasing aching pain in the shoulder, radiating down the arm. Aggravated with activity or motion of the shoulder, and relieved with rest. Sleeping on the involved side is usually very uncomfortable. Patients may report a grinding sensation.
Physical Findings
Tenderness along the glenohumeral joint of the shoulder. Decreased range of motion, with pain at the extremes of motion.
Workup
Physical examination and special x-rays are diagnostic.
Non-Operative Treatment
Anti-inflammatory medication may reduce symptoms. A well-placed corticosteroid injection can bring substantial relief to some patients, for a long time.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
Either a shoulder arthroscopy and debridement, or Total Shoulder Replacement.
Comments
Most patients can be managed non-operatively. A shoulder arthroscopy is a straight forward outpatient procedure that only washes out the joint; it doesn't replace the worn-out cartilage, and is of variable success. A shoulder replacement is a much more substantial procedure, but reliably improves pain relief and function.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Shoulder Dislocation / Shoulder Instability / Labral Tear / Bankart Lesion

Description
The shoulder joint is like a ball and a cup. The ball (humeral head) is held in the cup (glenoid) by both the shape of the bones, and the ligaments and capsule surrounding the joint. With a shoulder dislocation, the ball comes out of the socket. For this to occur, the ligaments and capsule stabilizing the shoulder must tear or stretch. The labrum is a thin rim of tissue surrounding the edge of the shoulder socket. When the labrum tears, this is called a 'Bankart lesion'.
Common Causes
Most shoulder dislocations are due to a traumatic injury, such as a fall. Occasionally an individual may develop a 'loose' or unstable shoulder with repetitive microtrauma (baseball pitchers, swimmers), or even without trauma.
Symptoms
A dislocation is obvious; the arm is held at the side, and cannot be voluntarily moved without severe pain. A loose, or unstable shoulder that is not dislocated may cause feelings of not being able to 'trust' the shoulder. This is especially true when the arm is overhead and out to the side. There may be a sense of 'catching' in the shoulder, followed by vague aching.
Physical Findings
A positive 'apprehension' test, or being able to recreate the feeling that the shoulder is about to 'come out of the socket'.
Workup
The diagnosis is primarily based on history and physical examination. X-rays are occasionally helpful. An MR scan may show a labral tear.
MR scans(hide)

MR scans (MRI, Magnetic Resonance Imaging) are a valuable way to visualize the soft tissues in the body, such as tendons, ligaments, muscles, and other organs. The MR scan uses a magnetic field, not radiation. Basically, you lie still on a flat table, with the MR tube over the body part, in a magnetic field. A computer is able to analyze the data (how fast hydrogen atoms change their spin direction!) and provide exquisitely detailed pictures of slices of your body. It is painless and safe, but people with significant claustrophobia may require some sedation. It is not cheap: about a thousand dollars per scan. It is also not perfect, and one must be careful not to rely too heavily on the MR scan. It does a poor job with bones and cartilage.

Non-Operative Treatment
Prolonged immobilization after a dislocation probably doesn't reduce the risk of redislocation. Aggressive physical therapy, working on strengthening the muscles around the shoulder, can reduce symptoms, but may not prevent recurrence.
Surgical Treatment
The ligaments holding the ball in the socket are repaired(if torn), or tightened (if loose). This may be done either arthroscopically with a fiberoptic camera, or with an open procedure.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments

Recurrent dislocation is the main complication with this type of injury. The risks of recurrence and chronic instability are much greater in the younger individual, and decrease with age.

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SLAP Lesion

Description
The labrum is a thin ring of tissue that surrounds the rim of the shoulder socket, deepening the socket and increasing the stability of the shoulder joint. At the top of the socket, or '12 o'clock' position, the biceps tendon also inserts into the labrum. A SLAP lesion stands for a tear of the superior labrum, from anterior to posterior.
Common Causes
A traction injury, such as catching oneself falling, is a common cause. A fall on the outstretched arm, or repetitive activities such as pitching may predispose to this injury.
Symptoms
Pain in the shoulder, occasionally radiating down the arm. A sense of catching may be felt, or deep aching that persists.
Physical Findings
Difficult to diagnose on physical examination. Must have a high degree of suspicion.
Workup
X-rays are rarely helpful. MR scans are frequently inaccurate. A well-placed injection of local anesthetic into the shoulder joint will temporarily relieve symptoms, suggesting the diagnosis.
Non-Operative Treatment
Anti-inflammatory medication and rest may reduce symptoms.
Surgical Treatment
Arthroscopic surgery, with either repair of the torn tissue, or removal of the torn piece, depending on the injury.
Comments
This injury is often seen with other shoulder injuries, such as shoulder instability, or a rotator cuff tear.