Shoulder
There are numerous ligamentous injuries and joint conditions of the shoulder. Please select a condition below to learn more. If you do not see a specific condition listed, please feel free to discuss your concerns during your visit with Dr. Dedhia.
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Anatomy
A SLAP tear is an injury to the labrum of the shoulder, which is the ring of cartilage that surrounds the socket of the shoulder joint. The term SLAP stands for Superior Labrum Anterior and Posterior. In a SLAP injury, the top (superior) part of the labrum is injured. This top area is also where the biceps tendon attaches to the labrum. A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. The biceps tendon can be involved in the injury, as well.
The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. Surrounding the outside edge of the glenoid is a rim of strong, fibrous tissue called the labrum. The labrum helps to deepen the socket and stabilize the shoulder joint. It also serves as an attachment point for many of the ligaments of the shoulder, as well as one of the tendons from the biceps muscle in the arm.
Causes
The labrum can be damaged in several ways. Acutely, this can occur as a result of a traumatic injury such as a motor vehicle accident or fall on an outstretched arm. People who participate in repetitive overhead sports, such as throwing athletes or weightlifters, can experience labrum tears as a result of repeated shoulder motion.
Many SLAP tears, however, are the result of a wearing down of the labrum that occurs slowly over time. In patients over 40 years of age, tearing or fraying of the superior labrum can be seen as a normal process of aging.
Symptoms
- Pain with lifting overhead
- Sensation of locking, catching, grinding
- Feeling like the shoulder will “pop out”
- Pitchers may notice a decrease in their throw velocity, or the feeling of having a “dead arm” after pitching
Treatment
Treatment for a labral tear depends on many factors including age, activity level, and vocation. Dr. Dedhia will perform a detailed physical examination and may require advanced imaging to determine the extend of the injury.
In certain patients, conservative non-operative treatments including physical therapy and anti-inflammatory may be indicated. Larger tears and those affecting younger, more active patients may require surgical repair.
There are several different types of SLAP tears. Dr. Dedhia will determine how best to repair your labral injury during surgery. This may require simply removing the torn part of the labrum, or reattaching the torn part using stitches.
Dr. Dedhia utilizes an all-arthroscopic method. Arthroscopy is an outpatient surgical procedure used to visualize, diagnose, and treat problems within a joint.
.During an arthroscopic procedure, Dr. Dedhia makes very small incisions (about 5mm in diameter) in the skin surrounding the shoulder joint. A small camera, called an arthroscope, is then inserted in order to visualize the joint. The arthroscope enlarges and illuminates the structures inside the joint and sends those images to a monitor in the operating room.
During arthroscopic visualization of the shoulder, Dr. Dedhia will inspect the joint and determine which structures need to be surgically repaired. If the labrum is torn but not detached from the glenoid, Dr. Dedhia will smooth the frayed edges of the damaged labrum with a motorized shaver in a process called debridement.
If the labrum is completely detached from the glenoid, reattaching the labrum with sutures (stitches) and anchors may be necessary. To reattach the torn labrum to the glenoid rim, Dr. Dedhia will first weaves a suture through the labral tissue.
A drill is used to create a bone socket in the glenoid. The two ends of the suture are threaded through an anchor and advanced into the bone socket. When advanced, the anchor pulls the torn labrum back to its original anatomic location.
Depending on the size of the tear, multiple suture anchors may need to be placed to ensure stability of the repair. Once the labral repair is complete, the skin incisions are closed.
The decision to have a labral injury surgically repaired is based on numerous factors and can be discussed in detail during your office visit with Dr. Dedhia.
Content courtesy of AAOS
Anatomy
Biceps tendinitis is an inflammation or irritation of the upper biceps tendon. Also called the long head of the biceps tendon, this strong, cord-like structure connects the biceps muscle to the bones in the shoulder.
Biceps tendinitis is inflammation of the long head of the biceps tendon. In its early stages, the tendon becomes red and swollen. As tendinitis develops, the tendon sheath (covering) can thicken. The tendon itself often thickens or grows larger.
The tendon in these late stages is often dark red in color due to the inflammation. Occasionally, the damage to the tendon can result in a tendon tear, and then deformity of the arm (a “Popeye” bulge in the upper arm).
Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).
The biceps muscle is in the front of your upper arm. It has two tendons that attach it to bones in the shoulder. The long head attaches to the top of the shoulder socket (glenoid). The short head of the biceps tendon attaches to a bump on the shoulder blade called the coracoid process.
Causes
In most cases, damage to the biceps tendon occurs gradually as a result of normal activities. Many jobs and routine chores can cause overuse damage. Sports activities — particularly those that require repetitive overhead motion, such as swimming, tennis, and baseball — can also put people at risk for biceps tendinitis.
Repetitive overhead motion may play a part in other shoulder problems that occur with biceps tendinitis. Rotator cuff tears, osteoarthritis, and chronic shoulder instability are often caused by overuse.
Symptoms
- Pain with overhead movement
- Pain over the front of the shoulder
- Radiation into the upper arm that usually stops at the elbow
Treatment
- Biceps tendinitis is typically first treated conservatively:
- Rest
- Ice
- Nonsteroidal anti-inflammatory medicines
- Steroid injections
- Physical therapy
If conservative treatments fail, surgery can also be an option. Surgery for this condition involves removing the damaged section of the biceps and reattaching the tendon to the upper arm bone (humerus) with a screw. This is called a biceps tenodesis.
In severe cases, the long head of the biceps tendon may be so damaged that it is not possible to repair or tenodese it. Dr. Dedhia may simply elect to release the damaged biceps tendon from its attachment. This is called a biceps tenotomy. This option is the least invasive, but may result in a Popeye bulge in the arm.
Dr. Dedhia will discuss all options available to you and determine a solution suitable for your demands, goals, and lifestyle.
Biceps tenodesis may be performed as an isolated procedure, but often it is part of a larger shoulder surgery such as a rotator cuff repair. Essentially, a biceps tenodesis is performed by cutting the attachment of the biceps tendon from the shoulder socket (where it is damaged) and reattaching the tendon to the humerus (upper arm bone). The diseased segment of the tendon is excised, thus providing significant relief of pressure and pain on the shoulder joint. The reattached tendon must heal to the bone; therefore time in a sling is required.
A biceps tenotomy is indicated in certain patients where the biceps tendon is damaged and causing significant pain. In a biceps tenotomy, the biceps tendon is transected from its attachment in the shoulder, but it is not ultimately reattached to the humerus bone. Biceps tenotomy is generally reserved for lower demand patients interested in an expedient recovery. Since the tendon is not reattached to bone, an arm sling is not needed.
The decision to choose a biceps tenodesis versus a biceps tenotomy is based on numerous factors and can be discussed in detail during your office visit with Dr. Dedhia.
Content courtesy of AAOS
Anatomy
Your arm is kept in your shoulder socket by your rotator cuff. The rotator cuff is a group of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.
The rotator cuff tendons can tear as a result of direct trauma or as result of long-term wear and tear to the shoulder. Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be involved. In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.
There are different types of tears.
- Partial tear. This type of tear is also called an incomplete tear. It damages the tendon, but does not completely sever it.
- Full-thickness tear. This type of tear is also called a complete tear. It separates all of the tendon from the bone. With a full-thickness tear, there is basically a hole in the tendon.
When the rotator cuff is torn, patients may find it difficult to lift their arm above their shoulder, sleep on the affected side, or place their arm and hand behind their back.
Causes
There are two main causes of rotator cuff tears: injury and degeneration.
Acute Tear
If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.
Degenerative Tear
Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater likelihood of a rotator cuff tear in the opposite shoulder — even if you have no pain in that shoulder.
Several factors contribute to degenerative, or chronic, rotator cuff tears.
- Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.
- Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body’s natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
- Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.
Risk Factors
Because most rotator cuff tears are largely caused by the normal wear and tear that goes along with aging, people over 40 are at greater risk.
People who do repetitive lifting or overhead activities are also at risk for rotator cuff tears. Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers. Painters, carpenters, and others who do overhead work also have a greater chance for tears.
Although overuse tears caused by sports activity or overhead work also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall.
Symptoms
The most common symptoms of a rotator cuff tear include:
- Pain at rest and at night, particularly if lying on the affected shoulder
- Pain when lifting and lowering your arm or with specific movements
- Weakness when lifting or rotating your arm
- Crepitus or crackling sensation when moving your shoulder in certain positions
Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.
Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.
Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.
It should be noted that some rotator cuff tears are not painful. These tears, however, may still result in arm weakness and other symptoms.
Imaging Tests
Other tests which may help your doctor confirm your diagnosis include:
- X-rays. The first imaging tests performed are usually x-rays. Because x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur.
- Magnetic resonance imaging (MRI) or ultrasound. These studies can better show soft tissues like the rotator cuff tendons. They can show the rotator cuff tear, as well as where the tear is located within the tendon and the size of the tear. An MRI can also give your doctor a better idea of how “old” or “new” a tear is because it can show the quality of the rotator cuff muscles.
Treatment
If you have a rotator cuff tear and you keep using it despite increasing pain, you may cause further damage. A rotator cuff tear can get larger over time.
Chronic shoulder and arm pain are good reasons to see your doctor. Early treatment can prevent your symptoms from getting worse. It will also get you back to your normal routine that much quicker.
The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear you have.
There is no evidence of better results from surgery performed near the time of injury versus later on. For this reason, many doctors first recommend management of rotator cuff tears with physical therapy and other nonsurgical treatments
Nonsurgical Treatment
In about 80% of patients, nonsurgical treatment relieves pain and improves function in the shoulder.
Nonsurgical treatment options may include:
- Rest. Your doctor may suggest rest and limiting overhead activities. He or she may also prescribe a sling to help protect your shoulder and keep it still.
- Activity modification. Avoid activities that cause shoulder pain.
- Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.
- Strengthening exercises and physical therapy. Specific exercises will restore movement and strengthen your shoulder. Your exercise program will include stretches to improve flexibility and range of motion. Strengthening the muscles that support your shoulder can relieve pain and prevent further injury.
- Steroid injection. If rest, medications, and physical therapy do not relieve your pain, an injection of a local anesthetic and a cortisone preparation may be helpful. Cortisone is a very effective anti-inflammatory medicine; however, it is not effective for all patients.
Surgical Treatment
Your doctor may recommend surgery if your pain does not improve with nonsurgical methods. If you are very active and use your arms for overhead work or sports, your doctor may also suggest surgery.
Other signs that surgery may be a good option for you include:
- Your symptoms have lasted 6 to 12 months
- You have a large tear (more than 3 cm) and the quality of the surrounding tissue is good
- You have significant weakness and loss of function in your shoulder
- Your tear was caused by a recent, acute injury
Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). There are a few options for repairing rotator cuff tears.
A partial tear (tears in which portions of the rotator cuff still remain attached to bone) may only need to be trimmed or smoothed, a procedure called a debridement. A complete tear is one in which the rotator cuff tendon is completely detached from the bone most often requires surgery that involves re-attaching the tendon to the head of the humerus. The type of repair performed depends on several factors, including the size of your tear, your anatomy, and the quality of the tendon tissue and bone.
Dr. Dedhia utilizes an all-arthroscopic method, which is the least invasive method to repair a torn rotator cuff. Arthroscopy is an outpatient surgical procedure used to visualize, diagnose, and treat problems within a joint. During an arthroscopic procedure, Dr. Dedhia makes very small incisions (about 5mm in diameter) in the skin surrounding the shoulder joint. A small camera, called an arthroscope, is then inserted in order to visualize the joint. The arthroscope enlarges and illuminates the structures inside the joint and sends those images to a monitor in the operating room.
During arthroscopic visualization of the shoulder, Dr. Dedhia will inspect the joint and determine which structures need to be surgically repaired. In the case of a torn rotator cuff, Dr. Dedhia will first start by smoothing the edges of the torn rotator cuff and removing additional inflamed tissue within the joint. Next, he places a small suture anchor into the head of the humerus bone. This anchor has permanent sutures (stitches) attached, which are then weaved into the torn rotator cuff. When tightened, the sutures pull the torn rotator cuff back to its original anatomic location. Depending on the size of the tear, more suture anchors may need to be placed to ensure stability of the repair. Once the edges of the torn cuff are placed back together, the skin incisions are closed.
The decision to have a rotator cuff injury surgically repaired is based on numerous factors and can be discussed in detail during your office visit with Dr. Dedhia.
Content courtesy of AAOS
Overview
Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder is a ball-and-socket joint: The ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade, called the glenoid. The surfaces of these bones where they touch are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily.
Osteoarthritis of the shoulder is when this cartilage is worn away and is one of the leading reasons patients get a shoulder replacement. This natural “wear-and-tear” of the joint can ultimately lead to severe pain and disability.
The typical total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem, and a plastic socket. Dr. Dedhia begins by making an incision along the front of the shoulder. He then separates the deltoid and pectoral muscles, allowing visualization of the rotator cuff muscles. The subscapularis rotator cuff tendon is then released to allow better access to the bones of the shoulder joint. The arthritic portions of the shoulder joint are removed and the socket, ball, and stem components are implanted. The procedure is completed by repairing the previously released rotator cuff muscle and closing the incision.
Although the pre-surgical condition of the shoulder plays the biggest role in the patient’s outcome, commitment to rehabilitation immediately after the procedure can lead to a highly successful outcome. Overall, shoulder arthroplasty is very successful at providing significant pain relief and improvements in motion and function.
Reverse total shoulder replacement
A reverse total shoulder replacement is a different shoulder replacement procedure that is beneficial for patients with large rotator cuff tears who have developed a complex type of shoulder arthritis called “cuff tear arthropathy” and may be indicated in your situation. When the rotator cuff is deficient the ball may not be centered in the socket. In this case a traditional shoulder replacement is contraindicated and the preferred solution is a reverse shoulder replacement.
In this operation the metallic prosthesis in essence substitutes for the deficient rotator cuff allowing the patient to elevate the arm without pain. Dr. Dedhia will perform a complete examination and review your imaging studies to determine if this procedure is optimally suited for your condition.
Partial Shoulder Replacement
A partial shoulder replacement involves replacing only the humerus bone, or the ball of the shoulder joint, as compared with total shoulder replacement, which replaces both the ball and the socket. The procedure is less complex, requiring a smaller incision, less bone removal, and reduced surgery time. Patients suffering from arthritis or a traumatic shoulder injury may be candidates for partial shoulder replacement.
Anatomy
An AC Joint Separation is an injury to the acromioclavicular joint (also called the AC joint). It occurs where the collarbone (clavicle) meets the highest point of the shoulder blade (acromion).
Causes
This injury is usually caused by a blow to the shoulder, or a fall in which the individual lands directly on the shoulder or an outstretched arm. The fall injures the ligaments that surround and stabilize the AC joint.
If the force is severe enough, the ligaments attaching to the underside of the clavicle are torn. This causes the separation of the collarbone and the shoulder blade. The shoulder blade (scapula) actually moves downward from the weight of the arm. This creates a bump or bulge above the shoulder.
The injury can range from a mild sprain without a bump to a complete disruption of the stabilizing ligaments. There are a total of six grades of severity of AC separations. Grades I-III are the most common. Grades IV-VI are very uncommon and are usually the result of a very high-energy injury such as one that might occur in a motor vehicle accident. Grades IV-VI are all treated surgically because of the severe disruption of all the ligamentous support for the arm and shoulder.
Grade 1
A slight displacement of the joint. The acromioclavicular ligament may be stretched or partially torn. This is the most common type of injury to the AC joint.
Grade II
A partial dislocation of the joint in which there may be some displacement that may not be obvious during a physical examination. The acromioclavicular ligament is completely torn, while the coracoclavicular ligaments remain intact.
Grade III
A complete separation of the joint. The acromioclavicular ligament, the coracoclavicular ligaments, and the capsule surrounding the joint are torn. Usually, the displacement is obvious on clinical exam. Without any ligament support, the shoulder falls under the weight of the arm and the clavicle is pushed up.
Symptoms
- Swelling may be present.
- There is pain with arm movement.
- There may be a small bump on the top of the shoulder where the clavicle ends.
- The clavicle may move when pushed.
- The area of the coracoclavicular ligaments may be painful when touched.
Examination
The injury is easy to identify when it causes deformity. When there is less deformity, the location of pain and x-rays help make the diagnosis. Sometimes having the patient hold a weight in the hand can increase the deformity, which makes the injury more obvious on x-rays.
Treatment
Most AC joint injuries do not require surgery. This all depends on the grade of injury, pain level, and functionality.
Nonsurgical Treatment
Nonsurgical treatments, such as a sling, cold packs, and medications can often help manage the pain. Most people return to near full function with this injury, even if there is a persistent, significant deformity/bump. Once pain has subsided, physical therapy is often initiated to increase shoulder stability and functionality.
Surgical Treatment
Surgery may be necessary for AC separations that do not respond well to non-operative treatment. If, after 2 to 3 months, pain continues in the AC joint with overhead activity or in contact sports, surgery may be necessary. The decision to move forward with surgery may also be based upon such factors as age, activity level, and vocation.
A variety of surgical methods have been used to stabilize a separated AC joint. The surgical technique most often performed involves the reconstruction of the coracoclavicular ligaments.
Dr. Dedhia typically utilizes an arthroscopic approach to treat acute AC joint separations. During an arthroscopic procedure, Dr. Dedhia makes very small incisions (about 5mm in diameter) in the skin surrounding the shoulder joint. A small camera, called an arthroscope, is then inserted in order to visualize the joint. The arthroscope enlarges and illuminates the structures inside the joint and sends those images to a monitor in the operating room. With the scope, the coracoid process can be visualized. A guide is placed under the base of the coracoid process. A skin incision about 4cm in length is made just above the clavicle. Dissection is carried down to the clavicle. A drill is used to make a tunnel straight down through the clavicle and coracoid process. A heavy suture with a button attached is shuttled through the tunnel, affixing to the undersurface of the coracoid process. A second button is then attached to the suture coming out of the clavicle. The button on top of the clavicle is then tensioned so that the AC joint is properly reduced. The suture is then tied over the button to secure fixation.
Recovery
A sling is worn for 6 weeks following surgery. At six weeks, the sling is discontinued, and physical therapy is initiated to begin range of motion of the shoulder. Returning to sports typically occurs around 6 months after surgery.
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Locations
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