The shoulder is an extraordinary joint, allowing up to 180-degrees of motion in 3 different planes. But, the more that it can do, the more that can go wrong! Boston Orthopaedic & Spine physicians have the expertise and experience to provide comprehensive care of the shoulder including nonsurgical treatments, arthroscopic, and open surgeries.
COMMON SHOULDER CONDITIONS
Since your shoulder is such a complex joint, there are many conditions that can cause pain and limit function. Some of the most common conditions include:
- Rotator cuff tear
- Frozen shoulder
- Labral tear
- SLAP tear
Whether you have had pain for years, or the symptoms recently started to affect your life, we are here to help.
Most patients do not need surgery to manage their shoulder pain. At Boston Orthopaedic & Spine, we find that most shoulder pain is successfully managed with conservative measures such as rest, anti-inflammatory medications, ice/heat, stretching, injections, and physical therapy.
When nonsurgical options fail to relieve pain and restore function, our board-certified, fellowship-trained orthopedic surgeons are highly skilled with arthroscopic and open procedures.
- Shoulder arthroscopy – During arthroscopy, the surgeon with use small portals to insert a camera and instruments into your shoulder. This minimally invasive approach allows for faster healing and a more rapid recovery.
- Shoulder arthroplasty – Arthroplasty, or replacement, is reserved for advanced arthritis of the shoulder after failing conservative treatment. Our team of experts has performed hundreds of total and reverse total shoulder replacements to restore patients to activity.
Common Shoulder Conditions
The shoulder is a very complex part of the body, and when one component is not working properly, the result is pain and dysfunction. At Boston Orthopaedic & Spine, our team of board-certified, fellowship-trained experts understands this complex joint, and they have the training and expertise to return you to your active life.
The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone) and the clavicle (collarbone). Connecting these are ligaments and tendons.
- The part of the scapula that makes up the roof of the shoulder is called the acromion.
- The joint where the acromion and the clavicle join together is known as the acromioclavicular (AC) joint.
- The true shoulder joint is called the glenohumeral joint and consists humeral head and the glenoid. It is a ball and socket joint.
- The rotator cuff muscles and their tendons play an important role in the correct functioning of this joint. They are responsible for the motion, stability, and power of the humerus. 4 tendons join to make up the rotator cuff.
- The labrum surrounds the glenoid and deepens the socket. It aids in stability.
COMMON CAUSES OF SHOULDER PAIN AND INJURY TREATED AT BOSTON ORTHOPAEDIC & SPINE
Arthritis, or osteoarthritis, is loss of cartilage within a joint. While there are many other types of arthritis, including rheumatoid, psoriatic, septic, post-traumatic, and lupus, wear and tear osteoarthritis remains by far the most common. Arthritis symptoms can include swelling, tenderness, sharp pain, stiffness, and sometimes fever and chills.
Bursitis is painful inflammation of the bursae, the fluid-filled sacs that reduce friction between bones, tendons, and muscles. Bursitis in the shoulder is commonly caused by an injury, infection or other condition. Pain may be accompanied by swelling, tenderness or loss of movement. Treatment is rest, ice, activity modifications, injections, and in some cases, surgery.
A dislocated shoulder occurs when the upper arm bone (humerus) is forced out of its natural position inside the shoulder socket. Symptoms include severe pain, swelling, bruising, and a visible deformity of the shoulder.
A dislocation is a serious injury that requires medical attention. A physician will put the arm bone back into the socket either manually or surgically. The joint will be immobilized in a sling, and medication may be prescribed to help manage the pain. In the early stages after a dislocation, physical therapy is helpful to restore the shoulder stability. If instability persists, surgery is often indicated.
Rotator Cuff Tear
A rotator cuff tear is an injury to any of the four rotator cuff tendons in the shoulder. Tears are caused by repetitive motion or sudden injury.
Symptoms include pain, weakness in the shoulder, and difficulty raising the arm overhead. Treatment for a rotator cuff tear depends on the severity of the damage, and may include rest, ice, over-the-counter pain medication, physical therapy or surgery.
A fracture is a break in a bone. Broken bone symptoms include pain (intensified when the area is moved or pressure is applied), swelling, bruising, and loss of function. Fractures may also cause the area around the bone to appear distorted or deformed, especially in open fractures where the bone protrudes from the skin.
Frozen shoulder, also known as adhesive capsulitis, is a condition in which the capsule of tissue surrounding the shoulder joint becomes thicker or tighter, restricting movement. Symptoms typically develop in several stages, and resolve within one or two years.
Common symptoms include pain, stiffness, and restricted range of motion. Treatment options include over-the-counter pain medication, physical therapy, or injections. Most cases of frozen shoulder go away within 18 months, but for some patients, surgery may be necessary.
Impingement is caused by irritation of the tendons and bursa on the bones of the shoulder. It is often caused by repetitive overhead activities or throwing sports.
Symptoms include generalized aching of the shoulder and pain when raising the arm out from the side or in front of the body. Impingement may also cause a sharp pain when trying to reach into your back pocket, or difficulty sleeping due to pain. Treatment for shoulder impingement includes rest, ice, and physical therapy. In some cases, surgery may be necessary to restore functionality.
A shoulder separation is an injury to the ligament that connects the shoulder blade (scapula) and the collarbone (clavicle). This injury can vary in severity from a strain to a complete dislocation of the acromioclavicular (AC) joint. We often see athletes in sports like football, hockey, and skiing who may experience an AC joint injury as a result of falling or being hit on the shoulder.
Symptoms include pain, tenderness, swelling, and bruising. Signs of a severe separation are a popping sensation when the loose joint shifts, and a noticeable bump on the shoulder where the collarbone has moved out of place. Treatment for shoulder separation depends on the severity of the injury, but includes anti-inflammatory medications and immobilization of the shoulder with a sling. For more severe separations, surgery may be recommended.
A SLAP tear is an injury to the ring of cartilage that surrounds the shoulder socket, called the labrum. The acronym SLAP stands for superior labrum, anterior to posterior, and means that the top of the labrum is torn from back to front.
This injury is common among athletes, and often occurs when falling on the outstretched arm or the shoulder. SLAP tears can also happen as a result of repeated overhead motions or sudden heavy lifting. Symptoms include aching pain, weakness, and popping or clicking in the shoulder. Treatment for SLAP tears includes over-the-counter anti-inflammatory medicine, physical therapy, and in some cases, surgery.
Tendonitis is inflammation of the tendons, the tissue that connects muscle to bone. Tendonitis is caused by overuse (repetitive motion) or sudden injury. Tendonitis symptoms include pain in the tendon area, swelling, and loss of motion.
Biceps tendonitis is inflammation of the tendons that connect the biceps muscle to the top of the shoulder. It may be caused by overuse, wear and tear from aging, or injuries to the shoulder. Sports activities like golf, tennis, and swimming can cause biceps tendonitis, as well as work activities that require frequent overhead motions.
Symptoms of bicep tendonitis include aching pain that increases with use of the arm and shoulder It may also cause weakness when bending at the elbow or twisting the arm. Treatment includes rest, over-the-counter anti-inflammatory medicine, and physical therapy. In some cases, surgery may be necessary for patients who are not improving with non-surgical treatments.
Wear and Tear
A common cause of shoulder pain is arthritis. The most common type of arthritis is osteoarthritis (OA) — sometimes called degenerative arthritis because it is a “wearing out” condition involving the breakdown of cartilage in the joints. When cartilage wears away, the bones rub against each other, causing pain and stiffness. OA usually occurs in people aged 50 years and older, and frequently in individuals with a family history of osteoarthritis.
The most common cause of shoulder replacement, OA can occur without a shoulder injury. However, this seldom happens since the shoulder is not a weight-bearing joint like the knee or hip. Instead, shoulder OA commonly occurs many years following a shoulder injury, such as a dislocation, that has led to joint instability and repeated shoulder dislocations — damaging the shoulder joint so that OA develops.
Your Treatment Options for Shoulder Pain
Following an orthopaedic evaluation of your shoulder, your doctor will review and discuss the results with you. Based on his or her diagnosis, your treatment options may include:
- Physical therapy
- Shoulder joint fluid supplements (injections that provide temporary pain relief)
- Total shoulder joint replacement
When joint pain and stiffness become severe enough to affect your daily life and comfort, and when that pain is not relieved by other treatment options, shoulder replacement may be recommended.
Severe arthritis may lead to Shoulder Replacement Surgery.
Rotator Cuff Tear
Rotator cuff tears are common in the adult population of people over 40. The rotator cuff is made up of four muscles and their tendons, which act to hold the upper arm (humerus) to the socket of the shoulder (glenoid fossa). The rotator cuff also provides mobility and strength to the shoulder joint. Two sac-like structures, called bursae, allow smooth gliding between the bone, muscle, and tendon. They also cushion and protect the rotator-cuff structures from the upper part of the scapula (the acromion).
Pain occurring in the front of the shoulder that radiates down the side of your arm.
Gradual onset of pain is most common in the adult population. It is often caused by repetitive overhead activity or by wear and degeneration of the tendon. Activities involving reaching or lifting may bring about an onset of pain. At first the pain may be mild and relieved by over-the-counter medication such as aspirin or ibuprofen.
Over time the pain may become noticeable at rest or with no activity at all and be accompanied by stiffness and loss of motion. Simple tasks such as combing your hair or placing your arm behind your back may prove difficult and/or painful.
Trauma such as a lifting injury or fall can cause a tear in the rotator cuff that results in acute pain. When the tear occurs with an injury, there may be sudden acute pain, a snapping sensation and an immediate weakness of the arm.
Most people know right away if they broke their arm due to a snap or loud cracking sound, extreme pain at the site of the injury, pain increased by any movement, and / or loss of normal use of the arm. Arms often break due to a fall on an outstretched arm or major accident such as a car crash. Common fracture points include the wrist, radius (forearm), elbow, and humerous.
Trying to break a fall by putting your hand out in front of you seems almost instinctive, but the force of the fall could travel up your lower forearm bones and dislocate your elbow. It also could break the smaller bone (radius) in the forearm. The breaks can occur at the wrist (Colles fracture), or near the elbow at the radial “head.” Children are more likely to break the bones in their lower arm, which are called the radius and ulna. A direct blow to the elbow or fall on a bent elbow can cause it to break. About one in every 20 fractures involves the upper arm bone which is called the humerus.
If you have any of these signs or symptoms after a fall, see your doctor:
- Pain or swelling at the site of the injury (outside of the elbow, wrist, etc)
- Pain increased by any movement of the injured area
- Loss of normal use of the arm.
- Difficulty in bending or straightening the elbow accompanied by pain
- Inability or difficulty in turning the forearm (palm up to palm down or vice versa)
- Numbness in one or more fingers.
Because breaks often occur as a result of an accident first aid is usually required.
- Make sure the injured person is out of the way of further harm.
- Check to see if they are breathing normally.
- Check their pulse.
- Call 911 if their breathing and/or pulse are irregular, if there is serious bleeding, or if there is reason to suspect multiple broken bones or other injuries.
- Elevate the injured arm above the person’s heart. This slows bleeding and reduces swelling.
- If the bone is sticking out from the skin do not try to push it back in. Instead, cover it with a clean, dry cloth or bandage.
- Do not use the broken arm. Moving the arm could cause further injury. To immobilize a broken arm:
- Make a temporary splint. Find something long and stiff to attach to the site of the injury. Wood or rolled up magazines or newspapers attached to the arm with cloth, belts or tape can be used to immobilize the joint. Make sure both ends of the splint extend far above and below the injury. Tie the splint tight enough to hold it in place, but not so tight as to reduce blood flow.
- Make a sling. Place the injured arm across the chest with the hand resting near the shoulder. Use a loop of cloth supported from the neck and around the arm to stabilize the injury and support the splint.
Take the injured person to a doctor immediately.
Recovering From a Broken Arm
The Doctor’s Visit
Tell the doctor exactly what happened. He or she will physically examine the broken arm and check for other injuries, such as nerve damage. The doctor may want to see if the patient can flex and extend the wrist and fingers. Sometimes the doctor may use X-rays or other diagnostic imaging tools to see the bones of both the injured and uninjured arms.
What to Expect
The doctor may need to move pieces of bone back into their correct positions (a process called reduction). Depending upon the severity of injury, the patient may or may not need anesthesia. Those with more serious fractures may require surgery.
Once the broken bone is back in place the arm is immobilized by placing it in a cast or splint. You will be advised how long to wear the cast or splint, and given a follow-up appointment to check on the bone healing and cast removal.
Fracture Types and Treatments
Radial head fractures are classified according to the degree of displacement (movement from the normal position).
Type I fractures are generally small, like cracks, and the bone pieces remain fitted together.
The fracture may not be visible on initial X-rays, but can usually be seen if the X-ray is taken three weeks after the injury.
Nonsurgical treatment involves using a splint or sling for a few days, followed by early motion.
If too much motion is attempted too quickly, the bones may shift and become displaced.
Type II fractures are slightly displaced and involve a larger piece of bone.
If displacement is minimal, splinting for one to two weeks, followed by range of motion exercises, is usually successful.
Small fragments may be surgically removed.
If the fragment is large and can be fitted back to the bone, the orthopaedic surgeon will first attempt to fix it with pins or screws. If this is not possible, however, the surgeon will remove the broken pieces or the radial head.
The surgeon will also correct any other soft-tissue injury, such as a torn ligament.
Type III fractures have more than three broken pieces of bone, which cannot be fitted back together for healing.
Usually, there is also significant damage to the joint and ligaments.
Surgery is always required to remove the broken bits of bone and repair the soft-tissue damage.
Early movement is necessary to avoid stiffness.
Regardless of the type of fracture or the treatment used, physical therapy will be needed before resuming full activities.
It’s important that you take good care of your cast during your recovery period. View more information regarding the care of your cast.
For more information see the AAOS: Elbow Fractures, Radial Head Fractures, Broken Arm
RECOVERING FROM A BROKEN ARM
It may take from several weeks to several months for the broken arm to heal completely. Rehabilitation involves gradually increasing activities to restore muscle strength, joint motion and flexibility. The patient’s cooperation is essential to the rehabilitation process by completing range of motion, strengthening and other exercises prescribed by the doctor. Rehabilitation lasts until tissues perform their functions normally. After rehabilitation, the doctor may want to see the arm again to make sure healing is complete.
It’s important that you take good care of your cast during your recovery period. View more information regarding the care of your cast.
Shoulder Replacement Surgery
Are You Considering Shoulder Replacement Surgery?
Circumstances vary, but generally patients are considered for total joint replacement if:
- Functional limitations restrict not only work and recreation, but also the ordinary activities of daily living
- Pain is not relieved by more conservative methods of treatment — such as medications (including, for the shoulder, injections of cortisone, a powerful anti-inflammatory medication) and physical therapy — and/or by restricting activities
- Stiffness in the joint is marked and, in the shoulder, significantly limits range of motion of the arm
- X-rays show advanced arthritis or other problems
Restoration of movement is particularly important in the shoulder, the body mechanism that allows your arm to rotate in every direction. If you’re experiencing severe shoulder pain and reduced shoulder movement, there are probably many daily activities you can no longer do — or do as well or as comfortably — as before your shoulder problems began.
The Results: In a study of 24 patients who had undergone total shoulder replacement*
- Before surgery, 100% of patients had disabling pain
- After surgery, 92% of patients had no pain
Remember, even if your orthopaedic specialist determines that shoulder joint replacement is a good medical option for you, it is still up to you to make the final decision. The ultimate goal is for you to be as comfortable as possible, and that always means making the best decision for you based on your own individual needs.
If you’re reading this website, chances are you’re considering or preparing for shoulder surgery. That’s good news — because shoulder replacement has been proven to relieve severe shoulder pain and restore function in the vast majority of patients. Advancements in the design of shoulder prosthesis allow the potential for you to restore your range of motion. Developed with patient comfort in mind, the Solar® Shoulder is designed for a more natural feel throughout range of motion.
The Solar® Shoulder is designed to replicate the natural anatomy of the patient and help provide you with maximum range of motion so you can get back to the activities you enjoy.*
As you read, make a note of anything you don’t understand. Your orthopaedic surgeon will be happy to answer your questions so that you’ll feel comfortable and confident with your chosen treatment plan.
According to the American Academy of Orthopaedic Surgeons, approximately 23,000 people have shoulder replacement surgery each year. Shoulder problems may arise because of injury to the soft tissues of the shoulder, overuse or underuse of the shoulder, or even because of damage to the tissues. Shoulder problems result in pain, which may be localized to the joint or travel to areas around the shoulder or down the arm.
*Individual results vary and not every patient will experience the same post-operative range of motion and results.
About Shoulder Replacements
Replacement of an arthritic or injured shoulder is less common than knee or hip replacement. However, shoulder replacement typically offers all the same benefits as those procedures — including joint pain relief and the restoration of more normal joint movement.
Restoring your movement is particularly important in the shoulder, because it’s the mechanism that allows your arm to rotate in every direction. If you’re experiencing severe shoulder pain and reduced shoulder movement, there are probably many daily activities you can no longer do — or do as comfortably — as before your shoulder problems began. This may mean you’re ready to consider shoulder replacement surgery.
In shoulder replacement surgery, the artificial shoulder joint can have either two or three parts, depending on the type of surgery required.
- The humeral component (metal)
- The humeral head component (metal)
- The glenoid component (plastic) replaces the surface of the socket
There are two types of shoulder replacement procedures:
- Partial shoulder replacement is performed when the glenoid socket is intact and does not need to be replaced. In this procedure, the humeral component is implanted, and the humeral head is replaced.
- Total shoulder replacement is performed when the glenoid socket is damaged and needs to be replaced. All three shoulder joint components are used in this procedure.
What’s involved in shoulder surgery?
Certain parts of your shoulder joint are removed and replaced with a plastic or metal device called a prosthesis, or artificial joint. The artificial shoulder joint can have either two or three parts, depending on the type of surgery required.
- The humeral component (metal) is implanted in the humerus, or upper arm bone.
- The humeral head component (metal) replaces the humeral head at the top of the humerus.
- The glenoid component (plastic) replaces the surface of the glenoid socket, or shoulder socket.
There are two types of shoulder joint replacement procedures:
- A Partial Shoulder Joint Replacement is used when the glenoid socket is intact and does not need to be replaced. In this procedure, the humeral component is implanted, and the humeral head is replaced.
- A Total Shoulder Joint Replacement is used when the glenoid socket needs to be replaced. All three shoulder joint components are used in this procedure.
How Long Will an Artificial Shoulder Joint Last?
How long a joint replacement will last is impossible to predict. Individual results vary. As successful as most of these procedures are, over the years the artificial joints can become loose and unstable or wear out, requiring a revision (repeat) surgery. Many factors determine the outcome including:
- Activity level
- Bone strength
- Bone quality
- Disease progression
Loosening is a common cause of joint replacement surgery failure. A small amount of loosening and bone loss will occur. If it reaches a certain degree, a revision surgery may be indicated. Possible Complications of Surgery
As with any major surgical procedure, patients who undergo total joint replacement are at risk for certain complications; however, the vast majority can be successfully avoided and/or treated. In fact, the complication rate following joint replacement surgery is very low: serious complications, such as joint infection, occur in less than 2% of patients.1
Besides infection, possible complications include blood clots (the most common complication) and lung congestion, or pneumonia. Some shoulder-specific complications that may occur are nerve injury — since many major nerves and blood vessels travel through the armpit (axilla) — and dislocation, particularly just after the replacement surgery.
Complications may require medical intervention including additional surgery and, in rare instances, may lead to death. Your doctor should discuss these potential complications with you.
After the Surgery
During your hospital stay, your orthopaedic specialist works closely with nurses, physical therapists, and other healthcare professionals to ensure the success of your surgery and rehabilitation. Usually a case manager is assigned to work with you as you move through your rehabilitation routines. As the days progress, expect to become more independent in your movements.
If you need to work with a physical therapist after your joint replacement, the therapist will begin an exercise program to be performed in bed and in the therapy department. The physical therapist will work with you to help you regain muscle strength and increase range of motion.
When fully recovered, most patients with shoulder replacements can return to work and normal daily activities. However, individual results vary. If you are considering doing any of the following activities — which could potentially affect how long your artificial shoulder will last and how well it will perform — discuss it first with your doctor or orthopaedic specialist:
Any activity that places excessive stress on your shoulder joint such as:
- Lifting or pushing heavy objects
- Hammering and other forceful arm/shoulder movements
- Boxing and other arm/shoulder impact sports
The success of your joint replacement will strongly depend on how well you follow your orthopaedic specialist’s instructions. As time passes, you have the potential to experience a dramatic reduction in joint pain and a significant improvement in your ability to participate in daily activities.
- Hanssen, A.D., et al., “Evaluation and Treatment of Infection at the Site of Total Hip or Knee Arthroplasty,” JBJS, Volume 80-A, No. 6, June 1998, pp. 910-922.
Recovering from Shoulder Replacement Surgery
The vast majority of individuals who have joint replacement surgery experience a dramatic reduction in joint pain and a significant improvement in their ability to participate in the activities of daily living.
Keep in mind, however, that joint replacement surgery will not allow you to do more than you could before joint problems developed.
Please contact the office immediately if you develop any of the following symptoms after discharge from the hospital:
- a significant increase in pain
- new numbness, tingling or weakness the arm
- fever over 100°F
- severe swelling
- redness or discharge from the incision site
- excessive bleeding from the wound
POST OP VISITS
1st Post-Op visit
Your first post-operative visit will be scheduled by the surgical coordinator. You must be seen in the office between the 10th and 14th post-operative day for suture/staple removal and a wound check. If you are unable to come to the office for this visit, please contact our office as soon as possible.
2nd Post-Op visit
Your second post-op visit will be scheduled by the surgical coordinator. This will be approximately 6 weeks from the date of surgery. You will see your surgeon on this date and x-rays will be taken.
Immediately After Surgery Pain
Post-operative pain is normal and to be expected. Be sure to take your medications as prescribed. Contact the office with any significant increase in your pain.
Dressing: A dressing will be applied to your incision following surgery. This dressing should be left on until your first office visit unless otherwise specified by your physician or physician assistant. Your visiting nurse may receive instructions to remove or change this bandage before your first post-operative visit.
Do not be alarmed if the dressing becomes moist or bloodstained. However, if the area continues to bleed, you should call the office immediately.
Wound Care: Your wound should be kept clean and dry. You should not allow your incisions to get wet in a shower unless otherwise specified by your physician.
Incision Care: Initially the incision appears pink. Over time, with proper care, it will heal into afine white line. This may take up to one year. For best results, put vitamin E directly onto the incision once it has healed. Keep the incision out of the sun or cover with sunscreen.
Physical Therapy: Most total shoulder replacement patients receive home therapy for the first few weeks following their surgery. When appropriate, you will then be referred to an outpatient facility.
THE FIRST SIX WEEKS AFTER SURGERY
Exercise: You will be prohibited from exercising your surgical shoulder for the first 6 weeks after surgery.
Precautions & Limitations Avoid any lifting with the surgical limb for six weeks following surgery unless advised otherwise by your physician. You are restricted from household chores such as laundry, vacuuming, cleaning, raking, shoveling, etc. If you have a question regarding a certain activity, contact the office.
Work: Your ability to work will be largely dependent on your occupation. You are expected to be out of work for a minimum of 6 weeks. Return to work is dependent upon the rate of healing, symptoms, work demands, etc. If you need disability paperwork completed, please contact the office at the earliest possible date.
Driving: You should not drive for 6 weeks unless told otherwise by your surgeon.
LIVING WITH AN IMPLANT
Security Issues: Because your implant is made of metal, it may trigger security alarms in high security buildings or airports. Upon request, you will provided with an implant card for you to carry that states you have an implant.
Antibiotics: You will be required to take antibiotics before all dental procedures (including cleanings), colonoscopies, endoscopies and gynecologic procedures. This prevents bacteria from attacking and infecting you implant. This is recommended for the life of the implant.
Activity: If you are considering doing any of the following activities, which could affect how long your artificial shoulder will last and how well it will perform, discuss it first with your doctor or orthopaedic surgeon:
- Any activity involving lifting or pushing heavy objects
- Any activity that places excessive stress on your shoulder joint
- Hammering and other forceful arm/shoulder movements
- Boxing and other arm/shoulder impact sports