SHOULDER ANATOMY 101
First, let’s get into how the shoulder is constructed. It is a ball-and-socket joint. The humerus (upper arm bone) has a round end that fits into the curved structure on the outside of your shoulder blade, called the glenoid. Inside the joint is a layer of cartilage that provides cushioning so that the bones don’t rub against one another.
Osteoarthritis is a type of degenerative joint disease. It involves the breakdown of the cartilage the covers bones. Without articular cartilage to prevent friction between two adjoining bones, swelling and inflammation occur. In severe cases, bone spurs can form.
WHAT IS SHOULDER ARTHRITIS?
Shoulder arthritis often involves this process of cartilage breakdown. The shoulder is not one joint but two; the acromioclavicular (AC) joint and the glenohumeral joint. The AC joint connects the clavicle (collarbone), and the tip of the shoulder blade (acromion). The glenohumeral joint connects the top of the arm bone to the scapula (shoulder blade).
WHAT ARE THE SYMPTOMS OF SHOULDER ARTHRITIS?
Shoulder arthritis is often characterized by pain during or after the movement of this joint. The condition may also cause pain to occur when a person is sleeping and the muscles around the joint relax. Another common sign of shoulder arthritis is stiffness or pain that limits the range of motion. When the arm moves to such an extent that engages the shoulder joint, the joint may produce a clicking sound.
WHAT CAUSES SHOULDER ARTHRITIS?
Arthritis is the result of gradual wear and tear that breaks down the cartilage between two or more bones. The degeneration of this living tissue, which is normally about as thick as one or two layers of cardboard, occurs in stages. First, the cartilage softens. When soft, cartilage can develop cracks. The degraded cartilage then starts to flake and deteriorate. In a latter stage, the cartilage wears down enough to expose bone surfaces. This exposure inhibits the ability of cartilage to move in a mothing, gliding motion.
Cartilage does not wear away spontaneously nor consistently. Certain parts of the cartilage over a bone may wear down, creating a spot that sticks and rubs. The covering over bone becomes irregular and eventually leads to additional damage to surrounding cartilage tissue, bit by bit. It can take years for this process to result in bone-on-bone traction.
WHAT CONDITIONS CAN LEAD TO SHOULDER ARTHRITIS?
There are several circumstances or conditions that can lead to shoulder arthritis, including:
- Trauma – A shoulder that has been injured in some way, whether dislocation or fracture, may develop what is called post-traumatic arthritis.
- Rotator cuff tear – is a common shoulder injury. When not treated promptly or if severe, the tear in the rotator cuff can degrade one or more of the tendons that support the shoulder joint to such an extent that the bones in the shoulder bump up against the humeral head.
- Rheumatoid arthritis – is a systemic autoimmune disorder in which the healthy cells in the body are being attacked by the immune system. Different than other types of shoulder arthritis, rheumatoid arthritis can affect both shoulders simultaneously.
- Avascular necrosis – For tissue like cartilage to live, they rely on good blood supply. Without it, they die. Avascular necrosis describes tissue death resultant from disrupted blood supply. In the shoulder, it is the humeral head that may not receive the necessary circulation. This could be due to injury, disease, or other factors. As a result, the humeral head will degrade, lose shape, and cause uneven wear of the cartilage that covers it.
HOW IS SHOULDER ARTHRITIS DIAGNOSED?
After taking a thorough medical history, a doctor performs a physical examination that evaluates range of motion, tenderness, pain, and other symptoms. This examination may reveal signs of weakness and atrophy caused by lack of use. The structures within the shoulder also need to be observed. To do this, a doctor will order one or more tests, such as:
- Blood tests to exclude diseases like rheumatoid arthritis
- Testing of synovial fluid taken from the shoulder joint
NON-SURGICAL TREATMENT OPTIONS FOR SHOULDER ARTHRITIS
Shoulder arthritis is usually treated non-surgically before intervention is considered. The process may include:
- Rest – Minor injuries or pain in the shoulder may improve by limiting the movement of this joint.
- Non-steroidal anti-inflammatory medication – This over-the-counter medication may be recommended to reduce irritation in the inflamed joint.
- Physical therapy – A noninvasive program, physical therapy involves certain exercises to improve the strength, flexibility, and stability of the joint.
- Moist heat and ice may be recommended to reduce inflammation and pain.
- Prescription medication may be necessary in more severe cases.
SURGICAL TREATMENT OPTIONS FOR SHOULDER ARTHRITIS
Surgical intervention for shoulder arthritis may be necessary when more conservative modalities do not improve symptoms as desired. Shoulder surgery may involve:
- Resection arthroplasty. This procedure removes a small piece of the collarbone where it meets other bones at the AC joint.
- Hemiarthroplasty. This surgery remodels the head of the humerus, the bone of the upper arm, where it meets other structures at the glenohumeral joint.
- Total shoulder arthroplasty. More extensive shoulder arthritis may require the replacement of the entire shoulder joint with an artificial structure made of biocompatible materials.
HOW CAN SHOULDER ARTHRITIS BE PREVENTED?
The shoulder is one of the most used and most mobile joints of the body. Injury may not be completely avoidable, but steps can be taken to promote strength and integrity in the shoulder joint. Suggestions include:
Supporting joint cartilage by consuming foods rich in omega-3 fatty acids. These acids help control inflammation. Wild-caught sardines, mackerel, trout, and salmon are high in omega-3 fatty acids. Supplements with these acids are also available.
Exercise is good for all of our joints. Certain movements, such as plank pose or well-performed push-ups can strengthen the muscles that support the shoulder joint. The stabilization that stems from strong muscles can reduce wear and tear on the joint.
All movements and exercise, especially sports, must be engaged in with the proper form and equipment to reduce the risk of injury to the joint.
WHAT HAPPENS IF SHOULDER ARTHRITIS IS LEFT UNTREATED?
Shoulder arthritis must be treated. The earlier the better. Without adequate attention to the deterioration of the cartilage in the shoulder, patients run the risk of developing more extensive damage in the joint, such as:
- Bone spurs. Small growths may develop when the affected bone creates more surface area to support the weight and pressure within the joint.
- Tendon or ligament damage. When the joint is degraded by arthritis, tendon, and ligaments are forced to work harder and carry more weight and pressure than they are capable of. This causes stretching and can lead to injury.
- Septic arthritis, an infection in the joint, may occur in some cases. This condition can cause a deformity in the joint and exacerbate pain. Reconstructive surgery is needed to address this arthritic condition.
- Osteonecrosis. At a certain point, arthritis in a joint can impede blood flow to the bones and other structures. Without adequate blood circulating through, the bone will weaken, degrade, and die.
Arthroscopy is a minimally invasive surgical technique that involves making several small incisions and inserting a fiber-optic device (arthroscope) and tiny surgical instruments to diagnose or treat certain conditions. Connected to a camera that displays images of the internal structure of the shoulder on a computer screen, the arthroscope allows the surgeon to precisely identify and target joint abnormalities. Orthopedic surgeons may perform a shoulder arthroscopy to diagnose and treat several different conditions of the shoulder. With this type of procedure, patients benefit from less tissue damage, shorter recovery times, less scarring and less post-operative pain than traditional open procedures. The use of this technique also avoids cutting any muscles or tendons in order to gain access to the affected area. Arthroscopy is an ideal treatment option for many patients suffering from shoulder conditions.
CANDIDATES FOR SHOULDER ARTHROSCOPY
Shoulder arthroscopy, also known as shoulder scope, is often performed to confirm a diagnosis after a physical examination and other imaging tests have been performed. Some shoulder conditions may also be treated during the same procedure by inserting a few additional instruments into the joint area. Arthroscopy may be used to treat conditions that affect the shoulder joint which may include:
- Rotator cuff tears
- Labral tears
- Impingement syndrome
- Joint arthritis
Arthroscopy provides many benefits over traditional open shoulder surgery, including smaller incisions, less trauma and shorter recovery times.
THE SHOULDER ARTHROSCOPY PROCEDURE
The shoulder arthroscopy procedure is performed while the patient is sedated under general anesthesia, and is usually performed on an outpatient basis. During the procedure, the surgeon will insert the arthroscope into a tiny incision in order to thoroughly examine the cartilage, bones, tendons and ligaments within the joint. Any damaged areas may be repaired during the same procedure by making several other small incisions through which surgical instruments are inserted. The type of repair performed will depend on the patient’s individual condition, but may include removing inflamed tissue, reattaching torn tissue or replacing damaged cartilage. Once the repair is completed, the incisions will be closed with stitches and a dressing will be applied to the area.
RISKS OF SHOULDER ARTHROSCOPY
While arthroscopy is considered safer and less invasive than traditional surgery, there are risks associated with this procedure which may include:
- Blood clots
- Shoulder stiffness
- Shoulder weakness
Nerve damage and infection are also possible complications associated with the shoulder arthroscopy procedure.
RECOVERY FROM SHOULDER ARTHROSCOPY
After surgery, patients can usually return home the same day, although an overnight hospital stay may be required in some cases. Patients are encouraged to ice the shoulder and keep it immobilized in a sling for about a week. Some patients experience mild to moderate pain after this procedure, and medication is often prescribed to control pain. Most patients can return to work within a few days after their procedure, although physical activity may be limited for a longer period of time. Full recovery from the shoulder arthroscopy procedure may take anywhere from one to six months, depending on each patient’s individual condition. A physical rehabilitation program helps patients restore function to the joint and ensure that it heals properly.
Once the shoulder has fully healed, most patients experience restored function, pain relief, improved range of motion and improved stability of the shoulder.
WHAT IS A SHOULDER DISLOCATION?
A dislocation is an injury to a joint in which the ends of the bones are forced from their normal positions.
HOW DOES A SHOULDER DISLOCATION HAPPEN?
The shoulder is a “ball-and-socket” joint where the “ball” is the rounded top of the arm bone (humerus) and the “socket” is the cup (glenoid) of the shoulder blade. A layer of cartilage called the labrum cushions and deepens the socket. A shoulder dislocation occurs when the humerus pops out of its socket, either partially or completely.
CAUSES OF SHOULDER DISLOCATION
As the body’s most mobile joint, able to move in many directions, the shoulder is most vulnerable to dislocation. A shoulder dislocation may be caused by a sports injury, trauma from a motor vehicle accident or a fall.
SYMPTOMS OF SHOULDER DISLOCATION
Dislocation causes pain and unsteadiness in the shoulder. The shoulder may be visibly deformed or look out of normal placement. Other symptoms of a dislocated shoulder may include:
The muscles in the shoulder may spasm and cause tingling sensations in the neck and down the arm.
HOW IS SHOULDER DISLOCATION DIAGNOSED?
A shoulder dislocation is diagnosed through a physical examination and a review of symptoms. Additional diagnostic tests may include:
- MRI scan
The electromyography test is used to determine whether there is any nerve damage as a result of the shoulder dislocation.
TREATMENT OF SHOULDER DISLOCATION
In most cases, the dislocated shoulder can be manipulated back into place by a doctor in a process known as closed reduction. When the shoulder bone is back in place, severe pain normally subsides. The arm and shoulder are then immobilized in a special splint or sling for several weeks as the shoulder heals. Medication may also be prescribed for pain. A shoulder that is severely dislocated or in cases where surrounding ligaments or nerves have been damaged, surgery may be necessary to tighten stretched ligaments or reattach torn ones.
SHOULDER DISLOCATION RECOVERY
After treatment for a shoulder dislocation, when pain and swelling have subsided, physical therapy is recommended to restore the range of motion of the shoulder, strengthen the muscles, and prevent future dislocations.
AFTER SHOULDER DISLOCATION DOES THE SHOULDER GO BACK TO NORMAL?
After treatment and recovery, a previously dislocated shoulder may remain more susceptible to reinjury, potentially resulting in chronic shoulder instability and weakness.
WHAT HAPPENS IF A DISLOCATED SHOULDER GOES UNTREATED?
If a dislocated shoulder goes untreated it could cause muscle tears, tendon or ligament injuries, and blood vessel or nerve damage.
Shoulder impingement occurs when the front of the shoulder blade rubs against the rotator cuff causing irritation and pain. The rotator cuff is a group of muscles and tendons that stabilizes the shoulder and permits lifting and rotating movements. If the rotator cuff weakens or is injured, the bone of the upper arm (humerus) can lift up, pinching the rotator cuff against the shoulder blade. The muscles can then swell further, creating a cycle of pain and weakness that worsens over time. Shoulder impingement is one of the most common causes of shoulder pain and occurs more frequently in athletes who lift their arms overhead, such as swimmers, baseball players and tennis players.
CAUSES OF SHOULDER IMPINGEMENT
Shoulder impingement is often caused by the weakening of, or injury to, the shoulder tendons which may be due to:
- Rotator cuff injuries
Shoulder impingement may also be caused by overuse of the rotator cuff, and may be more common in people who do repetitive lifting or activities that include frequent raising of the arm, such as construction workers, painters or athletes. In some cases, impingement may occur without a discernible cause.
SYMPTOMS OF SHOULDER IMPINGEMENT
The symptoms of shoulder impingement often worsen over time. Initial symptoms may include mild pain in the shoulder, and may progress to
- Pain radiating from the front of the shoulder to the side of the arm
- Sudden pain when lifting and reaching the arm
- Swelling and tenderness in the shoulder
- Loss of strength and motion
As impingement progresses, pain and stiffness may worsen until it becomes difficult to lift or lower the arm. Left untreated, shoulder impingement may severely limit arm motion to the point that the shoulder becomes “frozen.”
DIAGNOSIS OF SHOULDER IMPINGEMENT
Shoulder impingement may be diagnosed after a review of symptoms and a physical examination of the shoulder. Additional tests may include X-rays or an MRI scan to rule out any other conditions that may be causing symptoms. A doctor may also test the individual’s range of motion and arm strength by asking the patient to perform different actions with the arm and shoulder.
TREATMENT OF SHOULDER IMPINGEMENT
Treatment for shoulder impingement focuses on managing pain and restoring function of the shoulder. Initial treatment may include rest and modifying physical activities as well as:
- Anti-inflammatory medication
- Steroid injections
- Physical therapy
Surgery is rarely recommended for shoulder impingement, however, in severe cases that do not respond to other treatment, arthroscopic surgery may be performed to remove the tissue that may be irritating the rotator cuff.
The human shoulder is a miracle of engineering, enabling an incredible range of motion. Unfortunately its durability is not unlimited, and some people can develop arthritis in this joint.
If the arthritis becomes severe, patients can experience pain and a limitation in function. If a patient has failed conservative management to eliminate pain and restore function, it may be time to consider shoulder replacement surgery. That’s where shoulder replacement with the team at Ortho Montana could be the answer.
The socket of the shoulder, or glenoid, is covered with a layer of cartilage called the labrum that cushions and deepens the socket to help stabilize the joint. Traumatic injuries and repetitive overhead shoulder movements may cause a tear in the labrum, leading to pain, limited motion, instability and weakness in the joint.
SYMPTOMS OF A LABRAL INJURY
Symptoms of a labral injury may include shoulder pain and a popping or clicking sensation when the shoulder is moved. Some people experience weakness and a restricted range of motion as well.
DIAGNOSING A LABRAL INJURY
A labral tear is typically diagnosed through imaging tests, a physical examination and a review of symptoms. While many labral tears can be treated by managing pain symptoms through medication and undergoing physical therapy, some cases require surgical treatment.
THE SHOULDER LABRAL REPAIR PROCEDURE
Labral repair surgery trims the damaged portion of the labrum in the shoulder and if necessary, secures it with staples, anchors or sutures. This outpatient procedure is usually performed through arthroscopy, which allows the doctor to view the tear through a small camera and insert the specialized tools through tiny incisions. Patients can benefit from less tissue damage, shorter recovery times and less scarring with arthroscopic techniques. However, larger tears may require an open procedure.
Once anesthesia has been administered, the surgeon will make the incisions in the shoulder area. Upon obtaining a visualization of the labrum, the injury can be better evaluated. The torn area will be removed and all necessary repairs are made. If a separation from the tendon has occurred as well, it may require the use of sutures and anchors to achieve fixation by drilling tiny holes in the glenoid bone in which the anchors are then embedded. Sutures are used to connect the labrum to the anchors, maintaining the correct positioning of the labrum and preventing the labrum from detaching again.
RISKS OF A LABRAL REPAIR PROCEDURE
Labral repair procedures are considered safe, but all forms of surgery carry some risk. The risks generally associated with a labral repair may include infection, bleeding, formation of a blood clot, shoulder stiffness, shoulder weakness and nerve damage.
RECOVERY FROM A LABRAL REPAIR PROCEDURE
It is important to properly support and protect the arm immediately following a labral repair surgery, so most patients typically wear a sling for three to four weeks after the procedure. Physical therapy begins soon after the surgery and can be very helpful in restoring the flexibility, strength, and full range of motion to the shoulder. Most patients can typically return to jobs and other activities that are mainly sedentary after a few weeks. As healing progresses, athletes will be able to gradually participate in sports again. Complete recovery time may vary and depends on a number of factors, including whether the procedure was performed using an arthroscopic or open approach, but usually takes several months.
Labral repair surgery is usually effective in treating labral tears, eradicating pain and regaining complete mobility in the arm.
WHAT IS SHOULDER REPLACEMENT?
In a shoulder replacement, your Ortho Montana surgeon will replace the natural bone in the ball and socket of your shoulder joint with what will likely be a combination of metal and plastic. Shoulder replacement isn’t all the same.
WHAT ARE THE SHOULDER REPLACEMENT OPTIONS?
There are three shoulder replacement options:
TOTAL SHOULDER REPLACEMENT
This is the most common of these procedures. The ball at the top of your humerus is replaced with a metal ball that is attached to the remaining natural bone. The socket is cleaned out and replaced with a new plastic socket.
PARTIAL SHOULDER REPLACEMENT
If your shoulder socket cartilage is still intact, a partial shoulder replacement only replaces the end of the humerus with a metal ball. This can be done with or without a stem.
REVERSE SHOULDER REPLACEMENT
This is often the procedure if the patient also has a torn rotator cuff, or if a previous replacement didn’t work. Here, the metal ball is attached to your shoulder blade, and the socket is placed atop your humerus. This allows other muscles to replace the function of the rotator cuff.
BENEFITS OF UNDERGOING SHOULDER REPLACEMENT SURGERY
What are the benefits of using your shoulder without pain? What are the benefits of being able to use your shoulder at all? Those are the big changes that will happen with shoulder replacement. Shoulder replacement will once again allow the patient to use his or her shoulder normally, raising your arm above your head and reaching into cabinets and bookshelves above your head. That’s a big deal considering that just about every movement of our upper body involves the shoulder to some degree. These procedures are very successful.
CANDIDATES FOR A SHOULDER REPLACEMENT
Of the major joint replacement procedures, shoulder replacement is the least common. Each year in the U.S. around 53,000 people have shoulder replacement. This compares with over 900,000 people having knee and hip replacement surgery.
This decision whether or not to have this surgery is usually a joint decision between you, your family members, your family doctor, and your orthopedic surgeon.
These are some characteristics of people who would be good candidates for shoulder replacement:
- Severe shoulder pain enters into everyday life, interfering with routine activities such as dressing, toileting, showering, even reaching into a cabinet.
- Loss of motion and weakness in the shoulder.
- Moderate to severe pain while sleeping, even preventing sleep.
- Failure for the injured shoulder to respond to other treatments such as corticosteroid injections, physical therapy, anti-inflammatory medications, and other conservative measures.
HOW SUCCESSFUL IS SHOULDER REPLACEMENT SURGERY?
Total shoulder replacement is a very successful procedure. The 10-year survival rate for these prostheses is over 90 percent. The vast majority of patients are able to return to normal activities and low-impact sports without pain.
HOW TO PREPARE FOR SHOULDER REPLACEMENT SURGERY
Preparation for these surgeries is no different than with any surgery. You’ll stop taking anti-inflammatory medications and arthritis therapies, as they can cause bleeding. You’ll stop taking blood thinners. If you smoke, you’ll need to stop for at least two weeks prior to and after your surgery, as smoking inhibits wound healing.
You’ll be staying in the hospital for 1-2 days after surgery. You won’t be able to drive until your shoulder regains adequate motion and strength, so plan on getting help with driving. Any items you’ll need in your cabinets should be brought down, as you won’t be able to reach up for several weeks. You’ll need some assistance around the house for about six weeks after your surgery.
THE SHOULDER REPLACEMENT PROCEDURE
TOTAL SHOULDER REPLACEMENT
The most common method replaces the arthritic joint surfaces with a highly polished metal ball attached to a stem, along with a plastic socket. Patients who have bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement. These components have various sizes, and they are matched to your natural humerus head and shoulder socket. The metal ball and stem can be cemented or “press fit” into the bone. If the bone is of good quality and able to fully accept the stem, we may opt for the press fit method. If your bone is soft, however, we will place the stem with bone cement. In the majority of cases, the plastic socket (glenoid) is placed with bone cement. Not all patients need a plastic socket if:
- The socket has good remaining cartilage
- The glenoid bone is severely deficient
- The rotator cuff tendons are irreparably torn
If the patient still has a normal socket, but the head of the humerus is severely fractured, we may opt to replace just the ball. This is usually replaced with a metal ball and stem, similar to the part of total shoulder replacement. This may be a good choice when a patient has any of these traits:
- Arthritis that only involves the head of the humerus, with a socket that is still intact
- Shoulders with severely weakened bone in the socket
- Some shoulders with severely torn rotator cuff tendons and arthritis
This is the same as above, but the metal head is only a cap-like prosthesis without the stem pushed down into the humerus. This preserves natural bone. For younger patients or for very active patients this option avoids the risks of component wear and loosening that may occur with conventional head and stem replacements.
REVERSE TOTAL SHOULDER REPLACEMENT
In reverse total shoulder replacement, the components are flipped. The metal ball is attached to the shoulder bone and a plastic socket is attached to the upper arm bone. This allows the patient to use the deltoid muscle instead of the torn rotator cuff to lift the arm. Reverse total shoulder replacement is used for people who have:
- Completely torn rotator cuffs with severe arm weakness
- The effects of severe arthritis and rotator cuff tearing
- A previous shoulder replacement that failed
For patients with these characteristics, conventional total shoulder replacement can still leave them with pain. They may also be unable to lift their arm up past a 90-degree angle with conventional methods.
RECOVERY FROM SHOULDER REPLACEMENT SURGERY
These are major surgical procedures, and they will involve some pain at times, especially early on. You’ll have prescription pain medication and possible a pain pump in the hospital. We’ll start you on rehabilitation right away, usually on the day of your surgery, which surprises most people. It’s good to have you up and moving as soon as possible. You’ll stay in the hospital for 1-2 days. You will be discharged with your arm in a sling that you will wear for anywhere from 2-4 weeks.
You will have limited arm function for 6 weeks after your surgery. You need to be careful and not push things. You cannot lift any objects that weigh more than one pound. You must not push or pull anything.
Most patients can return to gentle daily activities within two to six weeks. You cannot drive for up to six weeks.
It’s important to follow and perform the regimen of home exercises your physical therapist gives you. If you do so, in about six months you can get back to more vigorous activities, such as swimming or golf.
WILL I HAVE RESTORED RANGE OF MOTION AFTER REPLACEMENT SURGERY?
Patients can regain close to full range of motion and full strength in their repaired shoulder. This can take up to one full year to attain, however.
HOW LONG WILL MY SHOULDER COMPONENTS LAST?
The components being used today are of the highest quality. It is estimated that shoulder replacements today will last at least 15-20 years.
RISKS OF HAVING SHOULDER REPLACEMENT SURGERY
During your consultations and preparation for surgery, your Ortho Montana surgeon will explain all of the possible risks and complications of shoulder replacement surgery. These include both during the surgery and in the years after your procedure. Most of these can be successfully treated.
These are possible complications:
- Infection — Infection is a danger with any surgery. In shoulder joint replacement, infection may occur in the wound or deep around the prosthesis. It may happen immediately or years later. If the infection is major and deep, it may require more surgery to remove the prosthesis. Infections elsewhere in your body can spread to your new artificial joint.
- Prosthesis problems — Although materials used for today’s prostheses are state-of-the-art, they can still wear down and components may loosen. The new components of your shoulder replacement can even dislocate if the joint loosens enough or if there is trauma
- Nerve injury — It is possible to injure nerves in the vicinity of the joint replacement during surgery. This is very rare. If it does happen, these nerves will usually regenerate and heal.