Shoulder Injury
Understanding Shoulder Injuries

Shoulder injuries are typically caused by athletic activities that involve excessive, repetitive, overhead motion, such as swimming, tennis, pitching, and weightlifting. Injuries can also occur during day-to-day activities such as: washing the car, hanging curtains, and gardening.

These are three common shoulder injuries caused by sports participation:

1. Superior Labral Tear - aka SLAP tear

A common diagnosis for shoulder injuries is a superior labral tear, aka SLAP tear. SLAP stands for Superior Labral tear Anterior to Posterior. There many different types of SLAP tears, with different variations of severity and treatments.

Q: What is a SLAP Tear?

A: A tear to the ring of cartilage around the shoulder socket. A SLAP tear occurs over time from repetitive, overhead motions, such as throwing a baseball, playing tennis or volleyball, or swimming.

Common symptoms:

  • Athletic performance reduction - You have less control in your shoulder, and you can feel/hear a “pop”.
  • Movements causing pain - You notice that pain occurs when moving in a certain way, when throwing or lifting an object overhead.
  • Range of motion decreased – can’t throw or lift an object overhead like you used to. You might notice reaching movements are difficult.
  • Shoulder pain you can’t identify - You have achy pain in your shoulder, but you can't pinpoint the specific location.

Q: Sounds you may notice if you have a SLAP tear?

A: Clicking, grinding, locking, and/or popping.

Labral tears are basically cartilage tears from the glenoid soffit of the glenohumeral joint and are involved in shoulder instability. Classically this is seen with the anterior labrum with a shoulder dislocation. These typically present with a first time dislocator, although 2% of the time the labrum is not involved and either can be a capsular stretch or a rupture of the capsule as well. But in most instances it involved the labrum. Once the shoulder is located we evaluate the patient, their demand level needs and their age, and discuss treatment options. The risks of recurrence of labral tears is higher amongst younger patients if they are conservatively treated, and most data suggests that operative intervention is the best way to treat initial dislocators, and definitely recurrent dislocators. When we look at labral tears we want to make sure that the patient does not have any other associated injuries because these are usually high level injuries, such as a nerve injury.

So a careful evaluation involving the neurovascular structures is performed. The patient will be checked for their range of motion. They will also be checked to see if they have an apprehension sign, which means at the 90/90 position the patient will show apprehension because the labrum is lost as a passive checkrein mechanism to locate the shoulder in that position. So that can be relieved with a relocation sign with the patient lying down, and the humeral head is pushed down to be relocated. With respect to shoulder instability, it can be graded. Usually labral tears in the anterior quadrant are unidirectional, but there can be a component of multidirectional instability. . So we look for other signs like a Sulcus sign, hypermobility, but ultimately when the decision has been made for surgery and examination under anesthesia is performed on that shoulder to see if there are other signs of instability besides unidirectional instability in the classic anterior labral tear. There can be SLAP tears, which is a superior labrum anterior posterior, which is not as dramatic as an anterior inferior labral tear.

They do not demonstrate the same instability issues because the anterior inferior glenohumeral ligament is attached to the anterior inferior labrum, and that is a key structure that is a checkrein against anterior translation of the humeral head in the 90/90 position. However, SLAP tears can be symptomatic. On physical exam they can be positive with an O'Brien's test. They can also have other physical findings such as a relocation and an apprehension sign as well if there is a significant anterior superior component. Posterior labral tears also exist and can be picked up on physical exam as well with a load and shift posteriorly. Labrums that are symptomatic are typically fixed arthroscopically with arthroscopic techniques. That procedure could take 15 to 20 minutes arthroscopically. Recovery although is longer. The patients are in a sling for six weeks, then they start physical therapy. They are usually in therapy for three to six months before full recovery. Also if there is associated stretch with the capsule, a capsulorrhaphy can be performed at the same time. That is basically sewing the capsule and tightening the capsule to provide more stability to the shoulder.

shoulder pain
2. Shoulder Instability

Athletes commonly experience Shoulder Instability. This injury often occurs when you’re partaking in contact sports (football, hockey, or ones that require repetitive movements, like baseball).

Q: How does Shoulder Instability happen?

A: Shoulder instability happens when your ligaments, muscles, and tendons no longer secure your shoulder joint. Shoulder instability results in, the humeral head (circular, top part of your upper arm bone) to be dislocated.

Q: What is a Dislocation?

A: A dislocation is characterized by severe, abrupt onset of pain; subluxation (partial dislocation) may be accompanied by short spurts of pain. Other symptoms may include: weakness in the arm, lack of motion. Swelling and bruising on your arm are visible changes you may also notice.

3. Rotator Cuff Injury

Rotator cuff injuries are very common. Each year, approximately 200,000 Americans require shoulder surgery to repair a torn rotator cuff.

Q: What is a Rotator Cuff Injury?

A: This is another injury commonly seen in players participating in repetitive, overhead sports. Some of these sports include: swimming, tennis, and baseball. Rotator cuff injuries are typically categorized by weakness in the shoulder, reduced range of motion, and stiffness.

Rotator cuff injuries are also painful. Here’s what you need to know:

  • Pain at night is common; you may not be able to sleep comfortably on the side of your injured shoulder.
  • Pain may be experienced with certain movements, especially overhead movements.
  • Pain in your shoulder or arm may also occur.

What are some common symptoms related to Rotator Cuff Tears injuries:

  • Pain at rest and at night, particularly if lying on the affected shoulder.
  • Pain when lifting and extending your arm or with specific movements.
  • Faintness when lifting and/or rotating your arm.
  • Crackling feeling when moving your shoulder in certain positions.

Like to a SLAP tear, people with rotator cuff injuries often experience achy shoulder pain.

Early treatment is the key to the best possible outcome regarding full recovery!

Rotator cuff tears are the most common entity that we treat in this office. We treat a lot of patients with work related injuries or accidents or athletes both amateur and professional with this problem. Rotator cuff tears are important because they basically effect the way the shoulder functions, and it is a very important structure because it smooths out the movement of the very large deltoid muscle, and it depresses the humeral head, and it dynamically stabilizes the should joint. So when it is injured patients really have a decrease in shoulder function and oftentimes complain of constant pain with and without movement. A lot of times patients with full thickness rotator cuff tears will not be able to lift their arm up against gravity or have profound weakness again gravity. Patients are typically in their 5th, 6th or 7th decade, but can be younger depending on the mechanism of injury.

Typically it is an eccentric load to the shoulder where a force overwhelms the shoulder joint and as a result the tendon gets overloaded and tears. Tears can either be partial or full thickness. Partial tears also present the same way with pain with pain and the inability to lift the arm. The physical examination with patients that have rotator cuff tears, one of the hallmarks is as, meaning the scapula kicks out. They get some winging and the smoothness of movement is lost in comparison to the non injured shoulder, and both shoulders should be examined. Oftentimes they have pain as the arm gets higher in the air. Sometimes they cannot get past a certain amount of what we call forward elevation. Another hallmark of physical exam is muscle testing, and we are able on physical exam to isolate the shoulder rotator cuff tendon and see if it can sustain itself against gravity or against external rotation. When we note weakness then we are suspicious of a rotator cuff tear. The next evaluation in terms of the rotator cuff tendon would be palpation of the structure, and this is done with patient seated. The arm is placed in extension and external rotation and the rotator cuff is palpated, and if tenderness is elicited by bringing it into extension and then abduction and external rotation, then that could be positive also in terms of physical finding for a rotator cuff tear.

We also test the Napoleon sign, or belly press sign, for the subscapularis tendon or the lift-off sign as well. We look for other pain generators in addition to the rotator cuff tendon, but that will be discussed in a later section. We obtain appropriate x-rays to make sure there is no other disease entities and to make sure that the humeral head is depressed on the Grashey view and there is no humeral head elevation. We also look for acromial morphology and glenohumeral arthritis as well. The next issue in terms of the workup would be the MRI. We usually get an MRI without contrast. The MRI is valuable because it can give us the information as to whether it is a full thickness rotator cuff tear or a partial thickness rotator cuff tear. It can tell us how far the tendon is retracted. It can also tell us whether there is fatty substitution in the muscle, an indication of a chronic tear. It can give us some prognostic indicators preoperatively as well depending on the quality of the MRI. It will also qualify the extent of the tear as well and other associated pathologies within the shoulder. So it is an important part of the workup. If there is a partial thickness tear, and the patient has good rotator cuff strength, then a physical therapy program would be the first line of treatment.

And if physical therapy failed, then injections would be performed. If the injections failed and a total of three months of therapy minimally has been done and the patient has not been improved then at that point arthroscopic surgery can be considered to go in and perhaps do an arthroscopic repair of that partial tear and a subacromial decompression and address other associated pain generators. With respect to full thickness tears, that would be addressed with an arthroscopic repair as well. Typically that is done as an outpatient procedure. The technique that we use, using the SpeedScrew, allows us to intraoperatively individually tension each anchor point so as to maximally load the tendon and compress it within the footprint, yet at the same time allow for medial movement and sliding of the tendons interdigitations which is a huge advantage over other current treatment methods that employ a medial row of an anchor that captures the tendon and prevents functioning of the rotator cuff. It is important to note that medial row repairs have a high rate of retear, 20% to 30%, and more than half of those are medial ruptures at the muscle tendon junction for which there is no treatment.

So our technique, in my opinion, is a huge advantage over that, and yet at the same time our technique allows us to restore the footprint and maintain footprint mechanics anatomically. This allows the ultrastructural sliding of the supraspinatus and infraspinatus interdigitation and does not compromise muscle tendon junction at all. We do our surgeries as an outpatient because it is arthroscopic. The portals are small. Procedure time is usually about 30 to 40

minutes, and the patients go home the same day. We start passive range of motion in physical therapy right away, and they get to do passive range of motion for six weeks. Then after six weeks they are doing active range of motion, which is strengthening. By about three to four months patients are done with their therapy program and are allowed to basically return to activities of daily living.

4. BICEPS PROBLEMS

The next problem is biceps problems. The long head of the biceps has been implicated in a lot of pain generation. Typically it is found in conjunction with other pathologies. The best way to determine on physical exam is basically palpating the structure, the long head of the biceps, and if it produces pain then there is bicipital tendinitis.

You may or may not see it on an MRI. Injections can help in terms of making the diagnosis. With respect to treatment, physical therapy rarely is helpful in the treatment of biceps problems. In the event that conservative management has failed, arthroscopy, a biceps tenotomy or cutting of the biceps tendon would be performed.

Then a small open incision where a tenodesis of the biceps would be done where the new length tension relationship of the biceps would be established with coning out a small hole in the humerus and using a BioScrew to fix the biceps into the humeral head. Biceps tenotomies are also acceptable in terms of treatment of biceps problems, not fixing the biceps, just cutting the long head of the tendon. The problem is there can be spasm of the muscle, and that can occur in about 20% of the patients. So, I prefer to do an open subpectoral tenodesis in these issues.

5. AC JOINT ARTHRITIS

Arthritis of the AC joint is also a problem. Typically patients have pain over the AC joint based on palpation over that structure. The AC joint can be injected oftentimes, and once injections fail then the treatment would then be arthroscopic.

We do an arthroscopic resection of the clavicle, anywhere from 5 mm to 10 mm, but we try to err toward 5-6 mm. Less is more. Once you get more than 10 mm you risk the problem of instability of the AC joint ligament by damaging them, and that can be worse than the original pain. So, we take great care to not take more than 6 mm of distal clavicle. We focus on the posterior inferior spur because that is the one that is the most symptomatic.

6. ARTHRITIS OF THE SHOULDER

The shoulder joint is a nonweightbearing joint. It basically can have arthritis, but arthritis is better tolerated in the shoulder than it is in the hip and the knee. So conservative management is paramount. You can do injections.

There are several off-label injections that we do in this practice including the Regenokine Program. However, if operative treatment is elected I like to use a stemless total shoulder, or a hemiarthroplasty where we only address the defect and the glenohumeral component. Rarely do we do an inlay glenoid. Compared to an anatomic total shoulder, the inlay hemiarthroplasty, the stemless procedure, has less blood loss. It takes about 40 minutes to do and is superior in range of motion and return to function.

7. SHOULDER IMPINGEMENT

Shoulder impingement, which is basically inflammation of the rotator cuff, is also treated. Typically those patients may have overused the shoulder. They present with rotator cuff symptoms because it is inflammation of the rotator cuff, but at an earlier stage.
This is most often treated with physical therapy and conservative management and injections. Then if conservative management does not work, then we can go ahead and do an arthroscopic subacromial decompression.

MENISCUS TEARS

Meniscus tears are some of the most commonly treated disorders in orthopedics, and it is a commonly treated item here at our practice. The most commonly involved comparted is the medial compartment, although the lateral compartment can also have meniscus tears as well. There are tears that resemble a hangnail tear where it is a very simple procedure, and you go in and you basically trim the hangnail. Then there are tears that may require an actual repair. Those are bigger repairs and more often times involved in association of an anterior cruciate ligament tear or a multiligament tear as well, but can exist in absence of a ligament tear. Treatment for meniscus tears is usually operative. It is very important to make sure that there is no concomitant arthritis in the knee joint, so appropriate x-rays are very necessary to obtain as a compliment to the MRI. Typically what the patient experiences is locking, catching or swelling. There are many causes to meniscus tears, any type of twisting of the knee in conjunction with an axial load. So this can occur with getting up from a seated position, such as a chair or in a car, which is a common mechanism. Other mechanisms are in sports, pivoting sports like basketball, soccer or football, can cause that was well. Or everyday activities can cause meniscus tears. Physical examination typically involves inspecting the joints. They may be present with swelling in the knee. Swelling is a secondary finding that usually indicates that there is some sort of pathology or derangement going on within the knee and can be associated with meniscus tears. The exam also will look at the range of motion of the knee and determine whether there is tenderness specifically with palpation along the joint lines. There are two joint lines. There is the inside or medial joint line, and the outside lateral joint line. With palpation of those structures if there is pain, then that is considered a positive finding for a meniscus tear. There are other maneuvers that are performed by the physician or clinician: The Steinman maneuver, and that is typically the knee in 90 degrees and twisting with concomitant palpation. The McMurray sign which basically takes the knee from range of motion and then eliciting either tenderness, clicking or a pop or pain. That can be performed on either joint line. Then pain with hyperextension of the knee is usually indicative of a medial meniscus tear. It is a physical finding that we see with a medial meniscus tear. Treatment, if conservative management has failed within a time period of six weeks, then what is recommended is an arthroscopy. We are the only ones that offer the single portal arthroscopy with the Stryker system. Most meniscus pathologies can be addressed with that system, and there are some advantages to that. Or there is a conventional dual portal system. The procedure for a partial medial meniscectomy takes about 10 to 15 minutes, and then the patient can go home that same day. Then after 4 to 6 weeks of physical therapy they are basically recovered from that injury as long as there are no injuries. For a meniscus repair where a suture would be used to repair the structure, the timeframe is longer. It is about three months of therapy. Those patients again would go home as an outpatient. They would then be in therapy as an outpatient for about three months and would be able to go home after therapy. That is it for meniscus tears.

CHONDRAL DAMAGE

Chondral damage or articular cartilage damage can be seen at the time of arthroscopy and can cause swelling. It is basically that glistening that you see at the end of a chicken bone, and that is damaged. Unfortunately, once it is damaged it is like a crack in a windowpane. The cartilage cells are basically unable to heal themselves, and so as a result the damage can get bigger with time. When it becomes the full thickness of the actual articular surface, or cartilage surface, then that is the definition of arthritis because exposed bone would then be present. In those situations patients have pain with weightbearing. They may have swelling. Their physical findings are nonspecific, but an MRI can show bone marrow edema and damage to the cartilage depending on the quality of the MRI. X-rays may or may not show anything but are very important to rule out advanced disease and should always be obtained in the evaluation. The treatment for chondral damage would be arthroscopy, and it can vary with stem cell techniques. The one that I use is a nanofracture device which is 1 mm in diameter and 9 mm deep, which allows full penetration into the marrow-rich elements to attract stem cells and allow stem cells to basically migrate in that area. I would do that in conjunction with an arthroscopic chondroplasty using radiofrequency energy. If that procedure is recommended as necessary and to be performed, it usually is done in lesions that are 10 x 10 mm and no greater than that. Again, that would be done as an outpatient. They would go home the same day. It would be about a 20 minute procedure. They would have about three months of physical therapy. They would be nonweightbearing for six months and have a postop MRI at three months. The results are usually fairly good with this type of repair of cartilage using marrow stem cells. The other option in lesions that are larger, in patients under the age of 40, would be an osteoarticular allograft transplant, or cartilage transplant. That would basically be a procedure that would be arthroscopic and then arthroscopic assisted with a small open incision where we can actually put in a *dowel of osteoarticular cartilage that matches the donor site where the damage is. We would prepare the area and then implant the cartilage to match the surface anatomically of that area that is involved. That can be done anywhere. That can be done on the medial femoral condyle. It can be done along the lateral femoral condyle. It can be done in the patellofemoral joint. Those procedures are outpatient. Patients are nonweightbearing for six weeks. MRIs are performed at six weeks and at three months, and then they need about three months of therapy and have good results.

PATELLOFEMORAL JOINT

The patellofemoral joint is very common joint that is involved in pain and most often requires conservative management or treatment. There are some indications for operative treatment in the event of patellofemoral instability or chronic patellofemoral dislocations. An arthroscopy can be performed, a lateral retinacular release and then an MPFL reconstruction using allograft, and a small incision can be performed. Again, those are outpatient procedures. The MPFL, or medial patellofemoral ligament, is a check rein to prevent recurrent dislocations. Usually the therapy for that is six weeks in a brace and then postop PT from six to three months. Then after three months they are discharged.

ACL OR ANTERIOR CRUCIATE LIGAMENT

The anterior cruciate ligament is the most common ligament torn in the human body. Oftentimes it is seen in patients that play pivoting sports like basketball, soccer or football. They oftentimes experience a pop and can experience the acute onset of swelling and then have instability as well. On physical examination typically there is swelling, but there may not be swelling, but most often in acute ACLs there is. The patients have difficulty moving the knee in some instances, and if the knee is locked that can be because of the torn stump of the ACL or a bucket handle tear of the meniscus, which can be associated with an ACL tear as well. So it is very important to look for secondary structure damage. Physical exam also would show that there would be a positive Lachman test which is noted, or a positive anterior drawer test, or a positive pivot shift test on exam. The typical treatment is once full range of motion is restored with physical therapy, then the ACL is reconstructed anatomically. For this reason I freehand my femur to make sure that I am at an anatomic point reconstructing the ACL, and I use allograft tendon because that is a fast recovery and does not sacrifice other anatomic structures that in my opinion is very necessary, like the hamstrings or the patellar tendon. Those are necessary structures that should not be sacrificed. From a technical standpoint, it is an outpatient procedure. It takes about 40 minutes to do an ACL reconstruction. The patients go home the same day. They are in therapy for about three months as an outpatient, and then they go to a home exercise program. They are discharged at six months. The PCL is less commonly involved. A lot of times isolated PCL injuries are rare, but can be seen. Their typical presentation is a hyperextension injury with a little bit of swelling and pain. Physical exam would be positive for a posterior drawer test. Again, it is important to get x-rays and MRI. Physical therapy is the initial hallmark treatment, but if patients fail physical therapy and continue to have issues mainly of patellofemoral pain, then a posterior cruciate ligament reconstruction would be performed. It is done as an outpatient with allograft, and they would be in therapy for about three to four months.

ARTGRITIS

Early arthritis of the knee in patients over the age of 40 is a very difficult area to treat. It is very important to know whether there is no joint space collapse, but exposed bone. A lot of times the workup that is needed in these situations would be x-rays, MRI and most likely a failed arthroscopy with associated lesions greater than 10 mm in circumference. Those lesions can be treated in the office with injections such as Supartz or any type of viscosupplementation. Cortisone is only a temporary treatment. There are stem cell treatments, both autologous stem cell treatments that can be done in the office or allograft stem stems, and the Regenokine program is also a very good treatment for early arthritis that is nonoperative. They all have their benefits in terms of their mechanism of action. Early arthritis can be treated surgically with an inlay resurfacing technique. Over the age of 40, biologic treatment of early arthritis does not work very well. The Arthrosurface inlay implant is a very good option in these situations, and I have published reports of this. Not only a second look report that was published in the Journal of Surgical Orthopedic Advances, looking at how the body reacts to the implants over time showing an overgrowth of cartilage on those implants and preservation of that actual joint space, but we also show a high level of return to function. That was presented at the ISAKOS Conference in Leon, France, where we looked at 33 consecutive knees for Worker’s Compensation claims that had failed knee arthroscopies because of the early arthritis that was present in the knee. All those patients had inlay resurfacing implants performed, and 91% returned to work, 65% returned without restrictions. So it is a very good alternative for early arthritis. If patients that have unicompartmental arthritis, then partial knee replacements would be the way to go. In both these instances they are outpatient procedures. In the case of the inlay procedure, they are nonweightbearing versus the partial knee replacement where they are weightbearing. The partial knee replacement gives you a more kinematic knee than a total knee replacement. Less is taken out. There is less bone loss. The literature is now showing that the return to function is good and complications are low.
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