Shoulder

A rotator cuff tear is a common cause of pain and disability among adults. Each year, almost 2 million people in the United States visit their doctors because of a rotator cuff problem.

A torn rotator cuff will weaken your shoulder. This means that many daily activities, like combing your hair or getting dressed, may become painful and difficult to do.

Anatomy

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.

Normal shoulder anatomy

This illustration of the shoulder highlights the major components of the joint.

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

The rotator cuff tendons cover the head of the humerus (upper arm bone), helping you to raise and rotate your arm.

There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.

Description

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus.

Illustration of a rotator cuff tendon torn away from bone

In most rotator cuff tears, the tendon is torn away from the bone.

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.

Rotator cuff tendons and a full-thickness tear in the supraspinatus tendon

(Left) Overhead view of the four tendons that form the rotator cuff.
(Right) A full-thickness tear in the supraspinatus tendon.

Front view of rotator cuff and full-thickness tear in supraspinatus tendon

(Left) The front view of a normal rotator cuff. (Right) A full-thickness tear in the supraspinatus tendon.

Cause

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.

Doctor Examination

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder. He or she will check to see whether it is tender in any area or whether there is a deformity. To measure the range of motion of your shoulder, your doctor will have you move your arm in several different directions. He or she will also test your arm strength.

Doctor testing patient's range of motion

Your doctor will test your range of motion by having you move your arm in different directions.

Your doctor will check for other problems with your shoulder joint. He or she may also examine your neck to make sure that the pain is not coming from a “pinched nerve,” and to rule out other conditions, such as arthritis.

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.

Cortisone injection in the shoulder

A cortisone injection may relieve painful symptoms.

The chief advantage of nonsurgical treatment is that it avoids the major risks of surgery, such as:

Infection
Permanent stiffness
Anesthesia complications
Sometimes lengthy recovery time

The disadvantages of nonsurgical treatment are:

Size of tear may increase over time
Activities may need to be limited

Surgical Treatment

Your doctor may recommend surgery if your pain does not improve with nonsurgical methods. Continued pain is the main indication for surgery. 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. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

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Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move.After a period of worsening symptoms, frozen shoulder tends to get better, although full recovery may take up to 3 years. Physical therapy, with a focus on shoulder flexibility, is the primary treatment recommendation for frozen shoulder.Frozen shoulder most commonly affects people between the ages of 40 and 60, and occurs in women more often than men. In addition, people with diabetes are at an increased risk for developing frozen shoulder.

Anatomy

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 head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.

To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

Shoulder anatomy

The shoulder capsule surrounds the shoulder joint and rotator cuff tendons.

Description

In frozen shoulder, the shoulder capsule thickens and becomes stiff and tight. Thick bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint.

The hallmark signs of this condition are severe pain and being unable to move your shoulder — either on your own or with the help of someone else. It develops in three stages:

Stage 1: Freezing

In the “freezing” stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

Stage 2: Frozen

Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the “frozen” stage, daily activities may be very difficult.

Stage 3: Thawing

Shoulder motion slowly improves during the “thawing” stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

Inflamed joint capsule

In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.

Cause

The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

Diabetes. Frozen shoulder occurs much more often in people with diabetes. The reason for this is not known. In addition, diabetic patients with frozen shoulder tend to have a greater degree of stiffness that continues for a longer time before “thawing.”

Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson’s disease, and cardiac disease.

Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

Symptoms

Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.

Doctor Examination

Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder.

Your doctor will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called “passive range of motion.” Your doctor will compare this to the range of motion you display when you move your shoulder on your own (“active range of motion”). People with frozen shoulder have limited range of motion both actively and passively.

Physical exam for frozen shoulder

Your doctor will test the range of motion in your shoulder.

Imaging Tests

Other tests that may help your doctor rule out other causes of stiffness and pain include:

X-rays. Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis.

Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of soft tissues. They are not required to diagnose frozen shoulder, however, they may help to identify other problems in your shoulder, such as a torn rotator cuff.

Treatment

Frozen shoulder generally gets better over time, although it may take up to 3 years. The focus of treatment is to control pain and restore motion and strength through physical therapy.

Nonsurgical Treatment

Most people with frozen shoulder improve with relatively simple treatments to control pain and restore motion.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.

Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint.

Hydrodilatation. If your symptoms are not relieved by other nonsurgical methods, your doctor may recommend hydrodilatation. This procedure involves gently injecting a large volume of sterile fluid into the shoulder joint to expand and stretch the shoulder joint capsule. Hydrodilatation is conducted by a radiologist who uses imaging to guide the placement of fluid.

Physical therapy. Specific exercises will help restore motion. These may be done under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before stretching. Below are examples of some of the exercises that might be recommended.

External rotation — passive stretch. Stand in a doorway and bend your affected arm’s elbow to 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.

External Rotation - Passive Stretch

External Rotation – Passive Stretch

Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.

Forward Flexion - Supine Position

Forward Flexion – Supine Position

Reproduced and modified from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.

Crossover Arm Stretch

Surgical Treatment

If your symptoms are not relieved by therapy and other conservative methods, you and your doctor may discuss surgery. It is important to talk with your doctor about your potential for recovery continuing with simple treatments, and the risks involved with surgery.Surgery for frozen shoulder is typically offered during “Stage 2: Frozen.” The goal of surgery is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.Manipulation under anesthesia. During this procedure, you are put to sleep. Your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of motion.Shoulder arthroscopy. In this procedure, your doctor will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have good outcomes with these procedures.

Arthroscopic photos of shoulder joint

These photos taken through an arthroscope show a normal shoulder joint lining (left) and an inflamed joint lining affected by frozen shoulder.

Recovery. After surgery, physical therapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 6 weeks to 3 months. Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.

Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and improved range of motion. In some cases, however, even after several years, the motion does not return completely and some degree of stiffness remains. Diabetic patients often have some degree of continued shoulder stiffness after surgery.

Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.

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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.Pain in the front of the shoulder and weakness are common symptoms of biceps tendinitis. They can often be relieved with rest and medication. In severe cases, surgery may be needed to repair the tendon.

Anatomy

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).

Biceps tendons

The biceps tendons attach the biceps muscle to the shoulder bone.

Glenoid. The head of your upper arm bone fits into the rounded socket in your shoulder blade. This socket is called the glenoid. The glenoid is lined with soft cartilage called the labrum. This tissue helps the head of the upper arm fit into the shoulder socket.

Rotator cuff. A combination of muscles and tendons keeps your arm centered in your shoulder socket. These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.

Biceps tendons. 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.

Description

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).

Normal shoulder anatomy.

Biceps tendinitis

Biceps tendinitis causes the tendon to become red and swollen.

Biceps tendinitis usually occurs along with other shoulder problems. In most cases, there is also damage to the rotator cuff tendon. Other problems that often accompany biceps tendinitis include:

Arthritis of the shoulder joint
Tears in the glenoid labrum
Chronic shoulder instability (dislocation)
Shoulder impingement
Other diseases that cause inflammation of the shoulder joint lining

Cause

In most cases, damage to the biceps tendon is due to a lifetime of normal activities. As we age, our tendons slowly weaken with everyday wear and tear. This degeneration can be worsened by overuse — repeating the same shoulder motions again and again.

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 or tenderness in the front of the shoulder, which worsens with overhead lifting or activity
Pain or achiness that moves down the upper arm bone
An occasional snapping sound or sensation in the shoulder

Doctor Examination

Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder.

During the examination, your doctor will assess your shoulder for range of motion, strength, and signs of shoulder instability. In addition, he or she will perform specific physical examination tests to check the function of your biceps.

Physical examination for biceps tendinitis

Your doctor may press over the area where the biceps tendon attaches to the shoulder. Patients with tendinitis will have tenderness and swelling in this area.

Imaging Tests

Other tests that may help your doctor confirm your diagnosis include:

X-rays. Although they only visualize bones, x-rays may show other problems in your shoulder joint.

Magnetic resonance imaging (MRI) and ultrasound. These images can show soft tissues like the biceps tendon in greater detail.

Treatment

Your orthopedic surgeon will work carefully to identify any other problems in your shoulder and treat them along with your tendinitis.

Nonsurgical Treatment

Biceps tendinitis is typically first treated with simple methods.

Rest. The first step toward recovery is to avoid activities that cause pain.

Ice. Apply cold packs for 20 minutes at a time, several times a day, to keep swelling down. Do not apply ice directly to the skin.

Nonsteroidal anti-inflammatory medicines. Drugs like ibuprofen and naproxen reduce pain and swelling.

Steroid injections. Steroids such as cortisone are very effective anti-inflammatory medicines. Injecting steroids into the tendon can relieve pain. Your doctor will use these cautiously. In rare circumstances, steroid injections can further weaken the already injured tendon, causing it to tear.

Physical therapy. Specific stretching and strengthening exercises can help restore range of motion and strengthen your shoulder.

Surgical Treatment

If your condition does not improve with nonsurgical treatment, your doctor may offer surgery. Surgery may also be an option if you have other shoulder problems.

Arthroscopic surgery

During arthroscopy, your surgeon inserts the arthroscope and small instruments into your shoulder joint.

Surgery for biceps tendinitis is usually performed arthroscopically. This allows your doctor to assess the condition of the biceps tendon as well as other structures in the shoulder.

During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments.

Repair. Rarely, the biceps tendon can be repaired where it attaches to the shoulder socket (glenoid).

Biceps tenodesis. In some cases, the damaged section of the biceps is removed, and the remaining tendon is reattached to the upper arm bone (humerus). This procedure is called a biceps tenodesis. Removing the painful part of the biceps usually resolves symptoms and restores normal function.

Incision for biceps tenodesis.

A photograph and illustration showing the incision site for a biceps tenodesis.

Chalmers P, Sherman SL, Ghodadra N, Mather RC, Romeo AA: Biceps Tenotomy and Tenodesis, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 25-29.

Depending on your situation, your surgeon may choose to do this procedure arthroscopically or through an open incision.

Biceps tenodesis

In a tenodesis, the remaining tendon is attached to the humerus with a type of screw.

Tenotomy. In severe cases, the long head of the biceps tendon may be so damaged that it is not possible to repair or tenodese it. Your surgeon 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.

Surgical complications. Overall, complication rates are low, and your surgeon can correct them without difficulty.

Infection, bleeding, stiffness, and other problems are possible complications. These are more likely to occur in open surgical procedures than in arthroscopic surgeries.

Rehabilitation. After surgery, your doctor will prescribe a rehabilitation plan based on the procedures performed. You may wear a sling for a few weeks to protect the tendon repair.

You should have immediate use of your hand for daily activities — writing, using a computer, eating, or washing. Your doctor may restrict certain activities to allow the repaired tendon to heal. It is important to follow your doctor’s directions after surgery to avoid damage to your repaired biceps.

Your doctor will soon start you on therapeutic exercises. Flexibility exercises will improve range of motion in your shoulder. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.

Surgical outcome. Most patients have good results. They typically regain full range of motion and are able to move their arms without pain. People who play very high-demand overhead sports occasionally need to limit these activities after surgery.

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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.

Anatomy

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 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.

shoulder labrum anatomy

The labrum deepens the socket of the shoulder joint, making it a stronger fit for the head of the humerus.

Description

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.

SLAP tear

This cross-section view of the shoulder socket shows a typical SLAP tear.

Cause

Injuries to the superior labrum can be caused by acute trauma or by repetitive shoulder motion. An acute SLAP injury may result from:

A motor vehicle accident
A fall onto an outstretched arm
Forceful pulling on the arm, such as when trying to catch a heavy object
Rapid or forceful movement of the arm when it is above the level of the shoulder
Shoulder dislocation

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 30 to 40 years of age, tearing or fraying of the superior labrum can be seen as a normal process of aging. This differs from an acute injury in a younger person.

Symptoms

The common symptoms of a SLAP tear are similar to many other shoulder problems. They include:

A sensation of locking, popping, catching, or grinding
Pain with movement of the shoulder or with holding the shoulder in specific positions
Pain with lifting objects, especially overhead
Decrease in shoulder strength
A feeling that the shoulder is going to “pop out of joint”
Decreased range of motion
Pitchers may notice a decrease in their throw velocity, or the feeling of having a “dead arm” after pitching

Doctor Examination

Medical History

Your doctor will talk with you about your symptoms and when they first began. If you can remember a specific injury or activity that caused your shoulder pain, it can help your doctor diagnose your shoulder problem — although many patients may not remember a specific event. Any work activities or sports that aggravate your shoulder are also important to mention, as well as the location of the pain, and what treatment, if any, you have had.

Physical Examination

During the physical examination, your doctor will check the range of motion, strength, and stability of your shoulder.

He or she may perform specific tests by placing your arm in different positions to reproduce your symptoms. Your doctor may also examine your neck and head to make sure that your pain is not coming from a “pinched nerve.”

The results of these tests will help your doctor decide if additional testing or imaging of your shoulder is necessary.

testing shoulder range of motion

Your doctor will test your range of motion by having you move your arm in different directions.

Imaging Tests

X-rays. This imaging test provides clear pictures of dense structures, like bone. The labrum of the shoulder is made of soft tissue so it will not show up on an x-ray. However, your doctor may order x-rays to make sure there are no other problems in your shoulder, such as arthritis or fractures.

Magnetic resonance imaging (MRI) scans. This test can better show soft tissues like the labrum. To make a tear in the labrum show up more clearly on the MRI, a dye may be injected into your shoulder before the scan is taken.

MRI of SLAP tear

(Left) An MRI image of a healthy shoulder. (Right) This MRI image shows a tear in the labrum.

Treatment

Nonsurgical Treatment

In most cases, the initial treatment for a SLAP injury is nonsurgical.

Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.

Physical therapy. Specific exercises will restore movement and strengthen your shoulder. Flexibility and range-of-motion exercises will include stretching the shoulder capsule, which is the strong connective tissue that surrounds the joint. Exercises to strengthen the muscles that support your shoulder can relieve pain and prevent further injury. This exercise program can be continued anywhere from 3 to 6 months, and usually involves working with a qualified physical therapist.

Surgical Treatment

Your doctor may recommend surgery if your pain does not improve with nonsurgical methods.

Arthroscopy. The surgical technique most commonly used for treating a SLAP injury is arthroscopy. During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays pictures on a video monitor, and your surgeon uses these images to guide miniature surgical instruments.

shoulder arthroscopy

During arthroscopy, your surgeon inserts the arthroscope and small instruments into your shoulder joint.

Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.

arthroscopic images of SLAP tear and repair

(Left) An arthroscopic view of a healthy labrum. (Center) In this image, the surgeon uses a small instrument to evaluate a large SLAP tear. (Right) The labrum has been reattached with sutures.

Treatment options.There are several different types of SLAP tears. Your surgeon will determine how best to treat your SLAP injury once he or she sees it fully during arthroscopic surgery. This may require simply removing the torn part of the labrum, or reattaching the torn part using sutures. Some SLAP injuries do not require repair with sutures; instead, the biceps tendon attachment is released to relieve painful symptoms.

Your surgeon will decide the best treatment option based upon the type of tear you have, as well as your age, activity level, and the presence of any other injuries seen during the surgery.

Complications. Most patients do not experience complications from shoulder arthroscopy. As with any surgery, however, there are some risks. These are usually minor and treatable. Potential problems with arthroscopy include infection, excessive bleeding, blood clots, shoulder stiffness, and damage to blood vessels or nerves.

Your surgeon will discuss the possible complications with you before your operation.

Rehabilitation. At first, your shoulder needs to be protected while the repaired structures heal. To keep your arm from moving, you will most likely use a sling for 2 to 6 weeks after surgery. How long you require a sling depends upon the severity of your injury and the complexity of your surgery.

protective sling

Wearing a sling will protect your shoulder after surgery.

Once the initial pain and swelling has settled down, your doctor will start you on a physical therapy program that is tailored specifically to you and your injury.

In general, a therapy program focuses first on flexibility. Gentle stretches will improve your range of motion and prevent stiffness in your shoulder. As healing progresses, exercises to strengthen the shoulder muscles and the rotator cuff will gradually be added to your program. This typically occurs 6 to 10 weeks after surgery.

Your doctor will discuss with you when it is safe to return to sports activity. In general, throwing athletes can return to early interval throwing 3 to 4 months after surgery.

Outcomes

The majority of patients report improved shoulder strength and less pain after surgery for a SLAP tear.

Because patients have varied health conditions, complete recovery time is different for everyone.

In cases of complicated injuries and repairs, full recovery may take several months. Although it can be a slow process, following your surgeon’s guidelines and rehabilitation plan is vital to a successful outcome.

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The shoulder is the most moveable joint in your body. It helps you to lift your arm, to rotate it, and to reach up over your head. It is able to turn in many directions. This greater range of motion, however, can cause instability.Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse.Once a shoulder has dislocated, it is vulnerable to repeat episodes. When the shoulder is loose and slips out of place repeatedly, it is called chronic shoulder instability.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

Normal shoulder anatomy

Normal shoulder anatomy.

The head, or ball, of your upper arm bone fits into a shallow socket in your shoulder blade. This socket is called the glenoid. Strong connective tissue, called the shoulder capsule, is the ligament system of the shoulder and keeps the head of the upper arm bone centered in the glenoid socket. This tissue covers the shoulder joint and attaches the upper end of the arm bone to the shoulder blade.

Your shoulder also relies on strong tendons and muscles to keep your shoulder stable.

Description

Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.

Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Chronic shoulder instability is the persistent inability of these tissues to keep the arm centered in the shoulder socket.

Illustration of normal shoulder stability and shoulder dislocation

(Left) Normal shoulder stability. (Right) Head of the humerus dislocated to the front of the shoulder.

Cause

There are three common ways that a shoulder can become unstable:

Shoulder Dislocation

Severe injury, or trauma, is often the cause of an initial shoulder dislocation. When the head of the humerus dislocates, the socket bone (glenoid) and the ligaments in the front of the shoulder are often injured. The labrum — the cartilage rim around the edge of the glenoid — may also tear. This is commonly called a Bankart lesion. A severe first dislocation can lead to continued dislocations, giving out, or a feeling of instability.

Illustration of a Bankart lesion in the labrum

A Bankart lesion is a tear in the labrum—the cartilage rim around the edge of the shoulder socket.

Repetitive Strain

Some people with shoulder instability have never had a dislocation. Most of these patients have looser ligaments in their shoulders. This increased looseness is sometimes just their normal anatomy. Sometimes, it is the result of repetitive overhead motion.

Swimming, tennis, and volleyball are among the sports requiring repetitive overhead motion that can stretch out the shoulder ligaments. Many jobs also require repetitive overhead work.

Looser ligaments can make it hard to maintain shoulder stability. Repetitive or stressful activities can challenge a weakened shoulder. This can result in a painful, unstable shoulder.

Multidirectional Instability

In a small minority of patients, the shoulder can become unstable without a history of injury or repetitive strain. In such patients, the shoulder may feel loose or dislocate in multiple directions, meaning the ball may dislocate out the front, out the back, or out the bottom of the shoulder. This is called multidirectional instability. These patients have naturally loose ligaments throughout the body and may be “double-jointed.”

Symptoms

Common symptoms of chronic shoulder instability include:

Pain caused by shoulder injury
Repeated shoulder dislocations
Repeated instances of the shoulder giving out
A persistent sensation of the shoulder feeling loose, slipping in and out of the joint, or just “hanging there”

Doctor Examination

Physical Examination and Patient History

After discussing your symptoms and medical history, your doctor will examine your shoulder. Specific tests help your doctor assess instability in your shoulder. Your doctor may also test for general looseness in your ligaments. For example, you may be asked to try to touch your thumb to the underside of your forearm.

Imaging Tests

Your doctor may order imaging tests to help confirm your diagnosis and identify any other problems.

X-rays. These pictures will show any injuries to the bones that make up your shoulder joint.

Magnetic resonance imaging (MRI). This provides detailed images of soft tissues. It may help your doctor identify injuries to the ligaments and tendons surrounding your shoulder joint.

Treatment

Chronic shoulder instability is often first treated with nonsurgical options. If these options do not relieve the pain and instability, surgery may be needed.

Nonsurgical Treatment

Your doctor will develop a treatment plan to relieve your symptoms. It often takes several months of nonsurgical treatment before you can tell how well it is working. Nonsurgical treatment typically includes:

Activity modification. You must make some changes in your lifestyle and avoid activities that aggravate your symptoms.

Non-steroidal anti-inflammatory medication. Drugs like aspirin and ibuprofen reduce pain and swelling.

Physical therapy. Strengthening shoulder muscles and working on shoulder control can increase stability. Your therapist will design a home exercise program for your shoulder.

Surgical Treatment

Surgery is often necessary to repair torn or stretched ligaments so that they are better able to hold the shoulder joint in place.

Surgical repair of a Bankart lesion

Bankart lesions can be surgically repaired. Sutures and anchors are used to reattach the ligament to the bone.

Arthroscopy. Soft tissues in the shoulder can be repaired using tiny instruments and small incisions. This is a same-day or outpatient procedure. Arthroscopy is a minimally invasive surgery. Your surgeon will look inside the shoulder with a tiny camera and perform the surgery with special pencil-thin instruments.

Open Surgery. Some patients may need an open surgical procedure. This involves making a larger incision over the shoulder and performing the repair under direct visualization.

Rehabilitation. After surgery, your shoulder may be immobilized temporarily with a sling.

When the sling is removed, exercises to rehabilitate the ligaments will be started. These will improve the range of motion in your shoulder and prevent scarring as the ligaments heal. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.

Be sure to follow your doctor’s treatment plan. Although it is a slow process, your commitment to physical therapy is the most important factor in returning to all the activities you enjoy.

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In 2011, more than 50 million people in the United States reported that they had been diagnosed with some form of arthritis, according to the National Health Interview Survey. Simply defined, arthritis is inflammation of one or more of your joints. In a diseased shoulder, inflammation causes pain and stiffness. Although there is no cure for arthritis of the shoulder, there are many treatment options available. Using these, most people with arthritis can manage pain and stay active.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff.

Illustration of normal shoulder anatomy

The bones and joints of the shoulder.

There are two joints in the shoulder, and both may be affected by arthritis. One joint is located where the clavicle meets the tip of the shoulder blade (acromion). This is called the acromioclavicular (AC) joint.

Where the head of the humerus fits into the scapula is called the glenohumeral joint.

To provide you with effective treatment, your physician will need to determine which joint is affected and what type of arthritis you have.

Description

Five major types of arthritis typically affect the shoulder.

Osteoarthritis

Also known as “wear-and-tear” arthritis, osteoarthritis is a condition that destroys the smooth outer covering (articular cartilage) of bone. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. During movement, the bones of the joint rub against each other, causing pain.

Osteoarthritis usually affects people over 50 years of age and is more common in the acromioclavicular joint than in the glenohumeral shoulder joint.

Illustration and x-ray showing osteoarthritis of the shoulder

(Left) An illustration of damaged cartilage in the glenohumeral joint. (Right) This x-ray of the shoulder shows osteoarthritis and decreased joint space (arrow).

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic disease that attacks multiple joints throughout the body. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.

The joints of your body are covered with a lining — called synovium — that lubricates the joint and makes it easier to move. Rheumatoid arthritis causes the lining to swell, which causes pain and stiffness in the joint.

Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In RA, the defenses that protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and soften bone.

Rheumatoid arthritis is equally common in both joints of the shoulder.

Posttraumatic Arthritis

Posttraumatic arthritis is a form of osteoarthritis that develops after an injury, such as a fracture or dislocation of the shoulder.

Rotator Cuff Tear Arthropathy

Arthritis can also develop after a large, long-standing rotator cuff tendon tear. The torn rotator cuff can no longer hold the head of the humerus in the glenoid socket, and the humerus can move upward and rub against the acromion. This can damage the surfaces of the bones, causing arthritis to develop.

The combination of a large rotator cuff tear and advanced arthritis can lead to severe pain and weakness, and the patient may not be able to lift the arm away from the side.

Illustration of rotator cuff arthropathy

Rotator cuff arthropathy.

Avascular Necrosis

Avascular necrosis (AVN) of the shoulder is a painful condition that occurs when the blood supply to the head of the humerus is disrupted. Because bone cells die without a blood supply, AVN can ultimately lead to the destruction of the shoulder joint and arthritis.

Avascular necrosis develops in stages. As it progresses, the dead bone gradually collapses, which damages the articular cartilage covering the bone and leads to arthritis. At first, AVN affects only the head of the humerus, but as AVN progresses, the collapsed head of the humerus can damage the glenoid socket.

Causes of AVN include high dose steroid use, heavy alcohol consumption, sickle cell disease, and traumatic injury, such as fractures of the shoulder. In some cases, no cause can be identified; this is referred to as idiopathic AVN.

Symptoms

Pain. The most common symptom of arthritis of the shoulder is pain, which is aggravated by activity and progressively worsens.

If the glenohumeral shoulder joint is affected, the pain is centered in the back of the shoulder and may intensify with changes in the weather. Patients complain of an ache deep in the joint.
The pain of arthritis in the acromioclavicular (AC) joint is focused on the top of the shoulder. This pain can sometimes radiate or travel to the side of the neck.
Someone with rheumatoid arthritis may have pain throughout the shoulder if both the glenohumeral and AC joints are affected.

Limited range of motion. Limited motion is another common symptom. It may become more difficult to lift your arm to comb your hair or reach up to a shelf. You may hear a grinding, clicking, or snapping sound (crepitus) as you move your shoulder.

As the disease progresses, any movement of the shoulder causes pain. Night pain is common and sleeping may be difficult.

Doctor Examination

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder.

During the physical examination, your doctor will look for:

Weakness (atrophy) in the muscles
Tenderness to touch
The extent of passive (assisted) and active (self-directed) range of motion
Any signs of injury to the muscles, tendons, and ligaments surrounding the joint
Signs of previous injuries
Involvement of other joints (an indication of rheumatoid arthritis)
Crepitus (a grating sensation inside the joint) with movement
Pain when pressure is placed on the joint

X-Rays

X-rays are imaging tests that create detailed pictures of dense structures, like bone. They can help distinguish among various forms of arthritis.

X-rays of an arthritic shoulder will show a narrowing of the joint space, changes in the bone, and the formation of bone spurs (osteophytes).

X-ray of severe osteoarthritis of the glenohumeral joint

This x-ray shows severe osteoarthritis of the glenohumeral joint.

To confirm the diagnosis, your doctor may inject a local anesthetic into the joint. If it temporarily relieves the pain, the diagnosis of arthritis is supported.

Treatment

Nonsurgical Treatment

As with other arthritic conditions, initial treatment of arthritis of the shoulder is nonsurgical. Your doctor may recommend the following treatment options:

Rest or change in activities to avoid provoking pain. You may need to change the way you move your arm to do things.
Physical therapy exercises may improve the range of motion in your shoulder.
Nonsteroidal anti-inflammatory medications (NSAIDs), such as aspirin or ibuprofen, may reduce inflammation and pain. These medications can irritate the stomach lining and cause internal bleeding. They should be taken with food. Consult with your doctor before taking over-the-counter NSAIDs if you have a history of ulcers or are taking blood-thinning medication.
Corticosteroid injections in the shoulder can dramatically reduce inflammation and pain. However, the effect is often temporary.
Moist heat
Ice your shoulder for 20 to 30 minutes two or three times a day to reduce inflammation and ease the pain.
If you have rheumatoid arthritis, your doctor may prescribe a disease-modifying drug, such as methotrexate.
Dietary supplements, such as glucosamine and chondroitin sulfate may help relieve pain. (Note: There is little scientific evidence to support the use of glucosamine and chondroitin sulfate to treat arthritis. In addition, the U.S. Food and Drug Administration does not test dietary supplements. These compounds may cause negative interactions with other medications. Always consult your doctor before taking dietary supplements.)

Surgical Treatment

Your doctor may consider surgery if your pain causes disability and is not relieved with nonsurgical options.

Arthroscopy. Cases of mild glenohumeral arthritis may be treated with arthroscopy, During arthroscopy, the surgeon inserts a small camera, called an arthroscope, into the shoulder joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.

During the procedure, your surgeon can debride (clean out) the inside of the joint. Although the procedure provides pain relief, it will not eliminate arthritis from the joint. If arthritis progresses, further surgery may be needed in the future.

Shoulder joint replacement (arthroplasty). Advanced arthritis of the glenohumeral joint can be treated with shoulder replacement surgery, in which the damaged parts of the shoulder are removed and replaced with artificial components, called a prosthesis.

Replacement surgery options include:

Hemiarthroplasty. Just the head of the humerus is replaced by an artificial component.
Total shoulder arthroplasty. Both the head of the humerus and the glenoid are replaced. A plastic “cup” is fitted into the glenoid, and a metal “ball” is attached to the top of the humerus.
Reverse total shoulder arthroplasty. In a reverse total shoulder replacement, the socket and metal ball are opposite a conventional total shoulder arthroplasty. The metal ball is fixed to the glenoid and the plastic cup is fixed to the upper end of the humerus. A reverse total shoulder replacement works better for people with cuff tear arthropathy because it relies on different muscles — not the rotator cuff — to move the arm.

Illustrations of total shoulder replacement and reverse total shoulder replacement

(Left) A conventional total shoulder replacement (arthroplasty) mimics the normal anatomy of the shoulder. (Right) In a reverse total shoulder replacement, the plastic cup inserts on the humerus, and the metal ball screws into the shoulder socket.

Resection arthroplasty. The most common surgical procedure used to treat arthritis of the acromioclavicular joint is a resection arthroplasty. Your surgeon may choose to do this arthroscopically.

In this procedure, a small amount of bone from the end of the collarbone is removed, leaving a space that gradually fills in with scar tissue. Recovery. Surgical treatment of arthritis of the shoulder is generally very effective in reducing pain and restoring motion. Recovery time and rehabilitation plans depend upon the type of surgery performed. Pain management. After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster. Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.Be aware that although opioids help relieve pain after surgery, they are narcotic and can be addictive. Opioid dependency and overdose have become critical public health issues in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.Complications. As with all surgeries, there are some risks and possible complications. Potential problems after shoulder surgery include infection, excessive bleeding, blood clots, and damage to blood vessels or nerves.

Your surgeon will discuss the possible complications with you before your operation.

Future Developments

Research is being conducted on shoulder arthritis and its treatment.

In many cases, it is not known why some people develop arthritis and others do not. Research is being done to uncover some of the causes of arthritis of the shoulder.
Joint lubricants, which are currently being used for the treatment of knee arthritis, are being studied in the shoulder.
New medications to treat rheumatoid arthritis are being investigated.
Much research is being done on shoulder joint replacement surgery, including the development of different joint prosthesis designs.
The use of biological materials to resurface an arthritic shoulder is also being studied. Biologic materials are tissue grafts that promote the growth of new tissue in the body and foster healing.

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What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion in the arm — from scratching your back to throwing the perfect pitch.Mobility has its price, however. It may lead to increasing problems with instability or impingement of the soft tissue or bony structures in your shoulder, resulting in pain. You may feel pain only when you move your shoulder, or all of the time. The pain may be temporary or it may continue and require medical diagnosis and treatment.This article explains some of the common causes of shoulder pain, as well as some general treatment options. Your doctor can give you more detailed information about your shoulder pain.

normal shoulder anatomy

This illustration of the shoulder highlights the major components of the joint.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.

Cause

Most shoulder problems fall into four major categories:

Tendon inflammation (bursitis or tendinitis) or tendon tear
Instability
Arthritis
Fracture (broken bone)

Other much less common causes of shoulder pain are tumors, infection, and nerve-related problems.

Bursitis

Bursae are small, fluid-filled sacs that are located in joints throughout the body, including the shoulder. They act as cushions between bones and the overlying soft tissues, and help reduce friction between the gliding muscles and the bone.

Sometimes, excessive use of the shoulder leads to inflammation and swelling of the bursa between the rotator cuff and part of the shoulder blade known as the acromion. The result is a condition known as subacromial bursitis.

Bursitis often occurs in association with rotator cuff tendinitis. The many tissues in the shoulder can become inflamed and painful. Many daily activities, such as combing your hair or getting dressed, may become difficult.

Tendinitis

A tendon is a cord that connects muscle to bone. Most tendinitis is a result of inflammation in the tendon.

Generally, tendinitis is one of two types:

Acute. Excessive ball throwing or other overhead activities during work or sport can lead to acute tendinitis.
Chronic. Degenerative diseases like arthritis or repetitive wear and tear due to age, can lead to chronic tendinitis.

The most commonly affected tendons in the shoulder are the four rotator cuff tendons and one of the biceps tendons. The rotator cuff is made up of four small muscles and their tendons that cover the head of your upper arm bone and keep it in the shoulder socket. Your rotator cuff helps provide shoulder motion and stability.

Tendon Tears

Splitting and tearing of tendons may result from acute injury or degenerative changes in the tendons due to advancing age, long-term overuse and wear and tear, or a sudden injury. These tears may be partial or may completely separate the tendon from its attachment to bone. In most cases of complete tears, the tendon is pulled away from its attachment to the bone. Rotator cuff and biceps tendon injuries are among the most common of these injuries.

Impingement

Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the underlying soft tissues when the arm is lifted away from the body. As the arm is lifted, the acromion rubs, or “impinges” on, the rotator cuff tendons and bursa. This can lead to bursitis and tendinitis, causing pain and limiting movement.

Instability

Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse.

Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.

Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Recurring dislocations, which may be partial or complete, cause pain and unsteadiness when you raise your arm or move it away from your body. Repeated episodes of subluxations or dislocations lead to an increased risk of developing arthritis in the joint.

Arthritis

Shoulder pain can also result from arthritis. There are many types of arthritis. The most common type of arthritis in the shoulder is osteoarthritis, also known as “wear and tear” arthritis. Symptoms such as swelling, pain, and stiffness, typically begin during middle age. Osteoarthritis develops slowly and the pain it causes worsens over time.

Osteoarthritis, may be related to sports or work injuries or chronic wear and tear. Other types of arthritis can be related to rotator cuff tears, infection, or an inflammation of the joint lining.

Often people will avoid shoulder movements in an attempt to lessen arthritis pain. This sometimes leads to a tightening or stiffening of the soft tissue parts of the joint, resulting in a painful restriction of motion.

Fracture

Fractures are broken bones. Shoulder fractures commonly involve the clavicle (collarbone), humerus (upper arm bone), and scapula (shoulder blade).

Shoulder fractures in older patients are often the result of a fall from standing height. In younger patients, shoulder fractures are often caused by a high energy injury, such as a motor vehicle accident or contact sports injury.

Fractures often cause severe pain, swelling, and bruising about the shoulder.

Doctor’s Examination

In the case of an acute injury causing intense pain, seek medical care as soon as possible. If the pain is less severe, it may be safe to rest a few days to see if time will resolve the problem. If symptoms persist, see a doctor.

Your doctor will conduct a thorough evaluation in order to determine the cause of your shoulder pain and provide you with treatment options.

Medical History

The first step in the evaluation is a thorough medical history. Your doctor may ask how and when the pain started, whether it has occurred before and how it was treated, and other questions to help determine both your general health and the possible causes of your shoulder problem. Because most shoulder conditions are aggravated by specific activities, and relieved by specific activities, a medical history can be a valuable tool in finding the source of your pain.

Physical Examination

A comprehensive examination will be required to find the causes of your shoulder pain. Your doctor will look for physical abnormalities, swelling, deformity or muscle weakness, and check for tender areas. He or she will observe your shoulder range of motion and strength.

Tests

Your doctor may order specific tests to help identify the cause of your pain and any other problems.

X-rays. These pictures will show any injuries to the bones that make up your shoulder joint.
Magnetic resonance imaging (MRI) and ultrasound. These imaging studies create better pictures of soft tissues. MRI may help your doctor identify injuries to the ligaments and tendons surrounding your shoulder joint.
Computed tomography (CT) scan. This tool combines x-rays with computer technology to produce a very detailed view of the bones in the shoulder area.
Electrical studies. Your doctor may order a test, such as an EMG (electromyogram), to evaluate nerve function.
Arthrogram. During this x-ray study, dye is injected into the shoulder to better show the joint and its surrounding muscles and tendons. It may be combined with an MRI.
Arthroscopy. In this surgical procedure, your doctor looks inside the joint with a fiber-optic camera. Arthroscopy may show soft tissue injuries that are not apparent from the physical examination, x-rays, and other tests. In addition to helping find the cause of pain, arthroscopy may be used to correct the problem.

Treatment

Activity Changes

Treatment generally involves rest, altering your activities, and physical therapy to help you improve shoulder strength and flexibility. Common sense solutions such as avoiding overexertion or overdoing activities in which you normally do not participate can help to prevent shoulder pain.

Medications

Your doctor may prescribe medication to reduce inflammation and pain. If medication is prescribed to relieve pain, it should be taken only as directed. Your doctor may also recommend injections of numbing medicines or steroids to relieve pain.

Surgery

Surgery may be required to resolve some shoulder problems. However, the large majority of patients with shoulder pain will respond to simple treatment methods such as altering activities, rest, exercise, and medication.

Certain types of shoulder problems, such as recurring dislocations and some rotator cuff tears, may not benefit from exercise. In these cases, surgery may be recommended fairly early.

Surgery can involve arthroscopy to remove scar tissue or repair torn tissues, or traditional open procedures for larger reconstructions or shoulder replacement.

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Thoracic outlet syndrome is a term used for several different conditions that can occur when nerves and/or blood vessels in the thoracic outlet are compressed or irritated.The thoracic outlet is the space between your collarbone (clavicle) and your first rib. This narrow passageway is crowded with blood vessels, muscles, and nerves. If the shoulder muscles in your chest are not strong enough to hold the collarbone in place, it can slip down and forward, putting pressure on the nerves and blood vessels that lie under it. This causes a variety of symptoms which together are known as thoracic outlet syndrome.

Anatomy illustration, including the location of the thoracic outlet

The thoracic outlet is the space between your collarbone and first rib.

Cause

Thoracic outlet syndrome can result from injury, disease, or a congenital problem, such as an abnormal first rib. It is more common in women than in men, and poor posture and obesity can aggravate the condition.

Psychological changes are often seen in patients with thoracic outlet syndrome. It is not clear whether these changes are a cause or result of the syndrome.

Symptoms

Symptoms may vary, depending on which nerves or blood vessels are compressed. Symptoms from nerve compression are much more common than symptoms from blood vessel compression.

Pressure on the nerves (brachial plexus) may cause a vague, aching pain in the neck, shoulder, arm, or hand. It may also cause pain, numbness, or tingling on the inside of the forearm and the fourth and fifth fingers of the hand. Weakness may make your hand clumsy.
Pressure on the blood vessels can reduce the flow of blood out of your arm, resulting in swelling and redness of your arm. Less commonly, pressure can reduce the blood flow into your arm and hand, making them feel cool and easily fatigued.
Overhead activities are particularly difficult because they worsen both types of compression.
There may be a depression in your shoulder, or swelling or discoloration in your arm.
Your range of motion may be limited.

Doctor’s Examination

Diagnosis of this condition can be more complicated than diagnosis of other more common shoulder conditions because there may be many symptoms to explain. Your doctor’s evaluation will include an extensive medical history, physical examination, and diagnostic testing.

Medical History and Physical Examination

Your doctor will ask you about the history of your symptoms, perform a thorough physical examination, and try to reproduce your symptoms by examining your arm and hand in several positions.

Tests

Elevated arm stress test. A test doctors often use to help them identify thoracic outlet syndrome is the elevated arm stress test. Your doctor will have you raise your arms over your head, then open and close your fists for approximately 3 minutes. If this reproduces your symptoms, it is possible that you have thoracic outlet syndrome. However, people who do not have thoracic outlet syndrome may sometimes have a positive test.

Illustration of elevated arm stress test

Elevated arm stress test.

Imaging tests. To better see and evaluate the bones, muscles, tendons, and blood vessels, your doctor may order imaging tests. These may include x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and/or ultrasound.

Additional tests. Your doctor may order special blood circulation tests and nerve conduction tests to help make the diagnosis.

Treatment

Treatment for thoracic outlet syndrome usually does not include surgery.

Nonsurgical Treatment

Physical therapy. Exercises can help strengthen the muscles surrounding the shoulder so that they are better able to support the collarbone. Postural exercises can help you stand and sit straighter, which lessens the pressure on the nerves and blood vessels.

Nonsteroidal anti-inflammatory medications. Drugs like naproxen and ibuprofen can ease the pain and reduce swelling.

Weight loss. If you are overweight, your doctor may recommend that you begin a weight loss program. Being overweight can stress the shoulder muscles that support your collarbone.

Lifestyle changes. You may need to change your workstation layout, avoid strenuous activities, and even modify everyday activities that aggravate your symptoms.

Surgical Treatment

If nonsurgical treatment does not relieve your symptoms, your doctor may offer surgery.

Surgery for thoracic outlet syndrome may involve removing a portion of an abnormal first rib, releasing a muscle that joins the neck and chest, or sometimes both.

Prevention

If you have symptoms of thoracic outlet syndrome, avoid carrying heavy bags over your shoulder because this depresses the collarbone and increases pressure on the important structures in the thoracic outlet.

You should also do some simple exercises to keep your shoulder muscles strong. Here are four that you can try—10 repetitions of each exercise should be done twice daily:

Corner Stretch – Stand in a corner (about 1 foot from the corner) with your hands at shoulder height, one on each wall. Lean into the corner until you feel a gentle stretch across your chest. Hold for 5 seconds.
Neck Stretch – Put your left hand on your head, and your right hand behind your back. Pull your head toward your left shoulder until you feel a gentle stretch on the right side of your neck. Hold for 5 seconds. Switch hand positions and repeat the exercise in the opposite direction.
Shoulder Rolls – Shrug your shoulders up, back, and then down in a circular motion.
Neck Retraction – Pull your head straight back, keeping your jaw level. Hold for 5 seconds.

As with all exercise programs, if any of these movements cause pain, stop immediately.

corner stretch for thoracic outlet syndrome

Corner stretch. You should feel this stretch in the front of your shoulder, your chest, and upper back.

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SHOULDER ARTHROSCOPY

What is Shoulder Arthroscopy?

Shoulder AnatomyArthroscopy is a minimally invasive diagnostic and surgical procedure performed for joint problems. Shoulder arthroscopy is performed using a pencil-sized instrument called an Arthroscope. The arthroscope consists of a light system and camera to project images to a computer screen for your surgeon to view the surgical site. Arthroscopy is used to treat disease conditions and injuries involving the bones, cartilage, tendons, ligaments, and muscles of the shoulder joint.

Shoulder Arthroscopy

The shoulder joint is made up of a ball and socket joint, where the head of the humerus (upper arm bone) articulates with the socket of the scapula (shoulder blade) called the glenoid. The two articulating surfaces of the bones are covered with cartilage, which prevents friction between the moving bones enabling smooth movement. Tendons and ligaments around the shoulder joint provide strength and stability to the joint.

Disease Overview

Injury and disease to the bones or soft tissues of the shoulder joint can make it instable, and lead to pain, inflammation and reduced mobility.

Indications of Shoulder Arthroscopy

Shoulder arthroscopy is indicated to treat the following shoulder conditions when conservative treatment such as medication and therapy fails to relieve pain and disability:

Shoulder Impingement: this occurs when the shoulder blade applies pressure on the underlying soft tissues when the arm is lifted
Rotator cuff tear
Frozen shoulder or stiffness of the shoulder joint
Shoulder Instability this occurs when the head of the upper arm bone slips out of the socket of the shoulder blade’s glenoid cavity either due to injury or overuse
Biceps rupture occurs when the tendons attaching the bicep muscle to the shoulder or elbow tears
Damaged cartilage or ligaments
Bone spurs or bony projections
Arthritis of the collarbone

Shoulder Arthroscopy Procedure

Your surgeon performs shoulder arthroscopy under general or regional anesthesia. You may be positioned lying down on your side with your arm propped up or sitting in a semi-seated position. Sterile fluid is injected into the shoulder joint to expand the surgical area so your surgeon has a clear view of the damage and room to work. A button-sized hole is made in the shoulder and the arthroscope is inserted. Your surgeon can view images captured by the camera in the arthroscope on a large monitor. Surgical instruments are introduced into the joint through separate small holes to remove and repair the damage to the joint. After surgery, the instruments are removed and the incisions are closed with stitches or small sterile bandage strips.

Post-operative Care for Shoulder Arthroscopy

After the surgery, the small surgical wounds take a few days to heal and the surgical dressing is replaced by simple Band-Aids. The recovery time depends on the type and extent of problem for which the procedure was performed. Pain medications are prescribed to keep you comfortable. The arm of the affected shoulder is placed in a sling for a short period as recommended by your doctor. Physical therapy is advised to improve shoulder mobility and strength after the surgery.

Advantages of Shoulder Arthroscopy

The advantages of arthroscopy compared to open surgery with a large incision include

Less pain
Fewer complications
Shorter hospital stay
Faster recovery

Risks and Complications of Shoulder Arthroscopy

Complications of shoulder arthroscopy include infection, bleeding, damage to nearby nerves or blood vessels, or delayed healing after the surgery. In certain cases, stiffness of the shoulder joint may occur after the surgery. It is important to participate actively in your physical therapy to prevent this from occurring.

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Shoulder Anatomy

The shoulder joint (glenohumeral joint) is a ball and socket joint, where the head of the upper arm bone (humerus) attaches to the shoulder socket (glenoid cavity). The shoulder socket is extremely shallow and therefore needs additional support to keep the shoulder bones from dislocating. The labrum, a cuff of cartilage that encircles the shoulder socket, helps serve this purpose by forming a cup for the humeral head to move within. It provides stability to the joint, enabling a wide range of movements.

What is a Bankart Tear?

The labrum can sometimes tear during a shoulder injury. A specific type of labral tear that occurs when the shoulder dislocates is called a Bankart tear. This is a tear to a part of the labrum called the inferior glenohumeral ligament and is common in younger patients who sustain a dislocation of the shoulder. A Bankart tear makes the shoulder prone to repeat dislocation in patients under 30 years of age.

Diagnosis of a Bankart Tear

Your physician will ask about your medical history and perform a thorough physical examination of your shoulder. Your doctor may recommend additional studies such as X-rays or an MRI.

Treatment of a Bankart Tear

Conservative treatment measures for a Bankart tear include rest and immobilization with a sling followed by physical therapy.

Bankart repair surgery is indicated when conservative treatment measures do not improve the condition and repeated shoulder joint dislocations occur.

Arthroscopic Bankart Repair Procedure

Bankart surgery can be performed by a minimally invasive surgical technique called arthroscopy.

During an arthroscopic Bankart procedure, your surgeon makes a few small incisions over your shoulder joint. An arthroscope, a slender tubular device attached with a light and a small video camera at the end is inserted through one of the incisions into your shoulder joint. The video camera transmits the image of the inside of your shoulder joint onto a television monitor for your surgeon to view. Your surgeon then uses small surgical instruments through the other tiny incisions to trim the edges of your glenoid cavity. Suture anchors are then inserted to reattach the detached labrum to the glenoid. The tiny incisions are then closed and covered with a bandage.

Arthroscopy causes minimal disruption to the other shoulder structures and does not require your surgeon to detach and reattach the overlying shoulder muscle (subscapularis) as with the open technique.

Post-operative Care for Arthroscopic Bankart Repair

The following are the Post-operative care details following arthroscopic Bankart repair:

After your surgery, you will spend about an hour in the recovery room.
Your physical therapist will start you on shoulder exercises the day following your surgery to strengthen and improve the range of motion of your shoulder joint.
You will be allowed to perform your daily activities as tolerated, but without lifting objects heavier than a plate or glass while you heal.
Your arm may be placed in a sling for three weeks to restrict use of your operated shoulder.
You may resume light low-risk activities, like jogging and swimming 8 to 10 weeks after surgery, and may be advised to avoid contact sports for some time.

Risks and Complications of Arthroscopic Bankart Repair

Arthroscopic Bankart repair is a relatively safe procedure. Being minimally invasive it is associated with fewer risks and a quicker recovery. Some of the potential risks associated include:

Infection
Injury to adjacent nerves or blood vessels
Stiffness of the joint
Pain

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Shoulder Anatomy

The shoulder joint (glenohumeral joint) is a ball and socket joint, where the head of the upper arm bone (humerus) attaches to the shoulder socket (glenoid cavity). The shoulder socket is extremely shallow and therefore needs additional support to keep the shoulder bones from dislocating. The labrum, a cuff of cartilage that encircles the shoulder socket, helps serve this purpose by forming a cup for the humeral head to move within. It provides stability to the joint, enabling a wide range of movements.

What is a Bankart Tear?

The labrum can sometimes tear during a shoulder injury. A specific type of labral tear that occurs when the shoulder dislocates is called a Bankart tear. This is a tear to a part of the labrum called the inferior glenohumeral ligament and is common in younger patients who sustain a dislocation of the shoulder. A Bankart tear makes the shoulder prone to repeat dislocation in patients under 30 years of age.

Diagnosis of a Bankart Tear

Your physician will ask about your medical history and perform a thorough physical examination of your shoulder. Your doctor may recommend additional studies such as X-rays or an MRI.

Treatment of a Bankart Tear

Conservative treatment measures for a Bankart tear include rest and immobilization with a sling followed by physical therapy.

Bankart repair surgery is indicated when conservative treatment measures do not improve the condition and repeated shoulder joint dislocations occur.

Arthroscopic Bankart Repair Procedure

Bankart surgery can be performed by a minimally invasive surgical technique called arthroscopy.

During an arthroscopic Bankart procedure, your surgeon makes a few small incisions over your shoulder joint. An arthroscope, a slender tubular device attached with a light and a small video camera at the end is inserted through one of the incisions into your shoulder joint. The video camera transmits the image of the inside of your shoulder joint onto a television monitor for your surgeon to view. Your surgeon then uses small surgical instruments through the other tiny incisions to trim the edges of your glenoid cavity. Suture anchors are then inserted to reattach the detached labrum to the glenoid. The tiny incisions are then closed and covered with a bandage.

Arthroscopy causes minimal disruption to the other shoulder structures and does not require your surgeon to detach and reattach the overlying shoulder muscle (subscapularis) as with the open technique.

Post-operative Care for Arthroscopic Bankart Repair

The following are the Post-operative care details following arthroscopic Bankart repair:

After your surgery, you will spend about an hour in the recovery room.
Your physical therapist will start you on shoulder exercises the day following your surgery to strengthen and improve the range of motion of your shoulder joint.
You will be allowed to perform your daily activities as tolerated, but without lifting objects heavier than a plate or glass while you heal.
Your arm may be placed in a sling for three weeks to restrict use of your operated shoulder.
You may resume light low-risk activities, like jogging and swimming 8 to 10 weeks after surgery, and may be advised to avoid contact sports for some time.

Risks and Complications of Arthroscopic Bankart Repair

Arthroscopic Bankart repair is a relatively safe procedure. Being minimally invasive it is associated with fewer risks and a quicker recovery. Some of the potential risks associated include:

Infection
Injury to adjacent nerves or blood vessels
Stiffness of the joint
Pain

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What is Reverse Shoulder Replacement?

Reverse total shoulder replacement, is an advanced surgical technique specifically designed for rotator cuff tear arthropathy, a condition where the patient suffers from both shoulder arthritis and a rotator cuff tear.

Shoulder Anatomy

The shoulder joint is a ball and socket joint formed by the union of the head of the upper arm bone (humerus) and the shoulder socket (glenoid). The rotator cuff is a group of four tendons that join the head of the humerus to the deeper shoulder muscles to provide stability and mobility to the shoulder joint.

Rotator Cuff Arthropathy

When the rotator cuff is torn, it can cause wear and tear to the shoulder joint and lead to shoulder arthritis. Conventional surgical methods such as total shoulder joint replacement have been shown to be significantly ineffective in the treatment of Rotator cuff arthropathy.

Symptoms of Rotator Cuff Arthropathy

Patients with rotator cuff arthropathy may feel pain (usually at night) and weakness within the involved shoulder. Patients may have had a prior rotator cuff repair or a history of multiple repairs. The most common symptom is the inability to raise the arm above the shoulder to perform overhead activities.

Differences between Conventional and Reverse Shoulder Replacement

Conventional shoulder replacement surgery involves replacing the ball of the arm bone (humerus) with a metal ball and the socket (glenoid cavity) of the shoulder blade (scapula) with a plastic socket. If this surgery is used to treat rotator cuff arthropathy, it may result in loosening of the implants due to the torn rotator cuff. Therefore, a specifically designed surgery was developed called reverse total shoulder replacement to be employed in such cases.

In reverse total shoulder replacement, the placement of the artificial components is essentially reversed. In other words, the humeral ball is placed in the glenoid cavity of the shoulder blade (scapula) and the plastic socket is placed on top of the arm bone. This design makes efficient use of the deltoid muscle, the large shoulder muscle, to compensate for the torn rotator cuff.

Ideal Candidates for Reverse Shoulder Replacement

Reverse total shoulder replacement may be recommended for the following situations:

Completely torn rotator cuff that is difficult to repair
Presence of cuff tear arthropathy
Previous unsuccessful shoulder replacement
Severe shoulder pain and difficulty in performing overhead activities
Continued pain despite other treatments such as rest, medications, cortisone injections, and physical therapy

Reverse Shoulder Replacement Procedure

Reverse total shoulder replacement surgery is performed with the patient under general anesthesia.

Your surgeon makes an incision over the affected shoulder to expose the shoulder joint
The humerus is separated from the glenoid socket of the scapula (shoulder blade)
The arthritic parts of the humeral head and the socket are removed and prepared for insertion of the artificial components
The artificial components include the metal ball that is screwed into the shoulder socket and the plastic cup that is cemented into the upper arm bone
The artificial components are then fixed in place
The joint capsule is stitched together, the tissues approximated and the wound is closed with sutures.

Post-operative Care for Reverse Shoulder Replacement

Patients can get out of the bed on the same day of the surgery, but usually stay in the hospital for 1-2 days. General Post-operative instructions include:

Take all prescribed medications as instructed
Undergo gentle range of motion exercises to increase your shoulder mobility
Physical therapy will be recommended to strengthen the shoulder and improve flexibility
Avoid overhead activities for at least 6 weeks
Don’t push yourself up out of a chair or bed using your shoulder muscles
Avoid lifting heavy objects

Risks and Complications of Reverse Shoulder Replacement

Possible risks and complications associated with reverse total shoulder replacement surgery include:

Infection
Dislocation or instability of the implanted joint
Fracture of the humerus or scapula
Damage to nerves or blood vessels
Blood clots (deep vein thrombosis)
Wound irritation
Arm length discrepancies
Wearing out of the components

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What is the Latarjet Procedure?

The shoulder joint provides a wide range of movement to the upper extremity but overuse or trauma can cause instability to the joint. The Latarjet procedure is a surgical procedure performed to treat shoulder instability by relocating a piece of bone with an attached tendon to the shoulder joint.

The shoulder joint is a ball and socket joint with the head of the humerus (long arm bone) forming the ball, and a cup shaped depression on the shoulder blade (glenoid fossa) forming the socket.

The joint is stabilized by the labrum, a cartilaginous rim of the glenoid cavity, and the capsule, a series of ligaments that enclose the joint. Injury and trauma can tear or stretch the labrum and/or ligaments, causing instability and dislocation of the joint. The shoulder can dislocate in front (anterior), down (inferior) or behind (posterior), but anterior dislocation is the most common. Tearing of the labrum due to trauma is called a Bankart tear, which sometimes involves the breaking of bone along with the labrum. This is referred to as a bony Bankart tear. Shoulder instability can lead to pain and a feeling of giving way.

Indications for the Latarjet Procedure

The Latarjet procedure is indicated for anterior shoulder instability that is recurrent and caused by a bony Bankart lesion. The surgery is considered when a surgical repair of the labrum does not correct the damage of the shoulder joint.

Latarjet Procedure

The Latarjet procedure is performed under general anesthesia with the patient in a semi-reclined or beach-chair position.

An incision of 5 cm is made from your shoulder blade towards the armpit.
Retractors are used to separate the muscles of the shoulder and chest, and expose the coracoid process (a small hook-like process of the shoulder bone) and its attached tendons.
The coracoid process is freed of its attachments and along with the conjoined tendon is transected from its base.
Holes are drilled into the transected coracoid process.
The subscapularis muscle, which passes in front of the shoulder joint is split in line with its fibers.
The capsule of the shoulder joint is entered and the glenoid is exposed and prepared to receive the coracoid.
The transected coracoid with the conjoined tendon is passed through the separated subscapularis muscle and fixed to the glenoid rim with screws through the previously drilled holes. This increases the glenoid surface and stabilizes the joint. The conjoined tendon and subscapularis muscle provide additional stability by acting as a sling.
Upon completion, the instruments are withdrawn, the incision is closed and covered with a sterile bandage.

Post-procedure Care following the Latarjet Procedure

Following the procedure your arm is placed in a sling to rest the shoulder and promote healing. You may remain in the hospital the night of the surgery and discharged the next day. Pain is controlled with medication and ice packs. You will be instructed to keep the surgical wound dry and to wear your sling while sleeping for a few weeks after the procedure. The sling may be removed in 3 to 6 weeks.

Rehabilitation usually begins early on the first post-operative day with finger movements and passive assisted range of motion exercises. A physical therapy program is recommended for 3 months after which you can return to your regular activities.

Risks and Complications of the Latarjet Procedure

The Latarjet procedure usually provides good results but as with all surgical procedures, complications can occur and include:

Hematoma (bleeding)
Fracture or failure of union of the coracoid.
Stiffness due to inadequate rehabilitation
Recurrence of instability and infection

Dr. Ujjval Deliwala

Arthroscopic Surgeon

call time: 9.30 am to 6 pm

Problems (ગોઠણ ની તકલીફો )

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Dr. Ujjval Deliwala

Arthroscopic Surgeon

Shoulder

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Anatomy

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Stage 1: Freezing

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