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Shoulder Surgery
• Rotator Cuff • Impingement •
Your shoulder is the most flexible joint in your body. It allows
you to place and rotate your arm in many positions in front, above, to
the side and behind your body. This flexibility also makes your
shoulder susceptible to instability and injury. This brochure will
help you understand how your shoulder works and the common causes of
shoulder problems, the available treatment options and exercises and
activities to enable you to regain pain-free use of your shoulder.
Depending on the nature of the problem, conservative nonoperative
methods of treatment often are recommended before surgery. However, in
some instances, delaying the surgical repair of a shoulder can
increase the likelihood that the problem will be more difficult to
treat later. Early, correct diagnosis and treatment of shoulder
problems can make a significant difference in the long run.
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How the Normal Shoulder Works
The shoulder is a ball-and-socket joint. It is made up of three bones:
the upper arm bone (humerus), shoulder blade (scapula) and
collarbone (clavicle).
The ball at the top end of the arm bone fits into the small socket (glenoid)
of the shoulder blade to form the shoulder joint (glenohumeral joint).
The socket of the glenoid is surrounded by a soft-tissue rim (labrum).
A smooth, durable surface (articular cartilage) on the head of the
arm bone, and a thin inner lining (synovium) of the joint allows
the smooth motion of the shoulder joint.
| The upper part of the shoulder blade (acromion)
projects over the shoulder joint. One end of the collarbone is joined
with the shoulder blade by the acromioclavicular (AC) joint;
the other end of the collarbone is joined with the breastbone
(sternum) by the sternoclavicular joint.
The joint capsule is a thin sheet of fibers that surrounds the
shoulder joint. The capsule allows a wide range of motion yet provides
stability. The rotator cuff is a group of muscles and tendons that
attach your upper arm to your shoulder blade. The rotator cuff covers
the shoulder joint and joint capsule. The muscles attached to the
rotator cuff enable you to lift your arm, reach overhead, and take
part in activities such as throwing or swimming.
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A sac-like membrane (bursa) between the
rotator cuff and the shoulder blade cushions and helps lubricate the
motion between these two structures.
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Shoulder Problems and Treatments
Bursitis or Tendinitis can occur with overuse from
repetitive activities such as swimming, painting or weight lifting. These
activities cause rubbing or squeezing (impingement) of the rotator cuff
under the acromion and in the acromioclavicular joint. Initially, these
problems are treated by modifying the activity which causes the symptoms
of pain and with a rehabilitation program for the shoulder.
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Impingement and Partial Rotator Cuff Tears
Partial thickness rotator cuff tears can be associated with chronic
inflammation and the development of spurs on the underside of the
acromion or the AC joint. The conservative nonoperative treatment is
modification of activity, light exercise and occasionally, a cortisone
injection. Nonoperative treatment is successful in a majority of
cases, but if it is not successful, surgery often is needed to remove
the spurs on the underside of the acromion and to repair the rotator
cuff.
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| Full Thickness Rotator Cuff Tears are
most often the result of impingement, partial thickness rotator cuff
tears, heavy lifting or falls. Nonoperative treatment with
modification of activity is successful in a majority of cases. If you
continue to have pain, surgery may be needed. Surgery may be necessary
to repair full thickness rotator cuff tears. Arthroscopic techniques
allow shaving of spurs, evaluation of the rotator cuff and repair of
some tears. Both techniques require extensive rehabilitation to
restore the function of the shoulder.
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Instability occurs when the head of the
upper arm bone is forced out of the shoulder socket. This can happen
as a result of sudden injury or from overuse of the shoulder
ligaments.
The two basic forms of shoulder instability are subluxations and
dislocations. A subluxation is a partial or incomplete dislocation. If
your shoulder is partially out of the shoulder socket, it eventually
may dislocate. Even a minor injury may push the arm bone out of its
socket. A dislocation is when the head of the arm bone slips out of
the shoulder socket. Some patients have chronic instability—shoulder
dislocations occur repeatedly.
Patients with repeat dislocation usually require surgery.
Open surgical repair may require a short stay in the hospital.
Arthroscopic surgical repair is often done on an
outpatient basis. Following either procedure, extensive
rehabilitation, often including physical therapy, is necessary for
healing.
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| Fractured Collarbone and AC Joint Separation
are common injuries of children and others who fall on the side of
their shoulder when playing. Most of these injuries are treated
nonoperatively with slings or splints. Severe displaced fractures or
AC joint separation may require surgical repair.
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Fractured Head of the Arm Bone is a
common result of falls on an outstretched arm, particularly by older
people with osteoporosis. If fragmented or displaced, it may require
open surgical repair and possibly replacement with an artificial joint
(prosthesis).
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Osteoarthritis and Rheumatoid Arthritis
can cause destruction of the shoulder joint and surrounding tissue, as
well as degeneration and tearing of the capsule or the rotator cuff.
Osteoarthritis occurs when the articular surface of the joint wears
thin. Rheumatoid arthritis is associated with chronic inflammation of
the synovium lining which can produce chemicals that eventually
destroy the inner lining of the joint, including the articular
surface.
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| Shoulder replacement is recommended for patients with
painful shoulders and limited motion. The treatment options are either
replacement of the head of the bone or replacement of the entire
socket. Your orthopaedic surgeon will discuss with you the best
option.
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Orthopaedic Evaluation
The orthopaedic evaluation of your shoulder consists of three
components:
 | A medical history to gather information about current
complaints; duration of symptoms, pain and limitations; injuries; and
past treatment with medications or surgery.
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| A physical examination to assess swelling, tenderness, range
of motion, strength or weakness, instability and/or deformity of the
shoulder.
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| Diagnostic tests such as X-rays taken with the shoulder in
various positions. An MRI (Magnetic Resonance Imaging) may be helpful in
assessing soft tissues in the shoulder. A CT (Computerized Tomography)
scan may be used to evaluate the bony parts of your shoulder.
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Your orthopaedic surgeon will review the results of
your evaluation with you and discuss the best treatment. You and your
doctor may agree that surgery is the best treatment option. He or she
will explain the potential risks and complications that may occur.
Your doctor may discuss donating your own blood to be used if needed
during surgery.
Some surgical procedures require you to be hospitalized for a
number of days. Your doctor may discuss planning for the period after
surgery. You may need to either stay in an extended care facility or
have someone help you when you return home.
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Types of Surgical Procedures
| You may be given the option to have an arthroscopic
procedure or an open surgical procedure.
Arthroscopy allows the orthopaedic surgeon to insert a
pencil-thin device with a small lens and lighting system into tiny
incisions to look inside the joint. The images inside the joint are
relayed to a TV monitor, allowing the doctor to make a diagnosis.
Other surgical instruments can be inserted to make repairs, based on
what is with the arthroscope. Arthroscopy often can be done on an
outpatient basis.
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Open surgery may be necessary and, in some
cases, associated with better results than arthroscopy; open surgery
often can be done through small incisions of just a few inches.
Recovery and rehabilitation is related to the type of surgery
performed inside the shoulder, rather than whether there was an
arthroscopic or open surgical procedure.
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Possible Complications After Surgery
There are always some risks with any surgery, even arthroscopic
procedures. These include possible infection, and damage to surrounding
nerves and blood vessels. However, modern surgical techniques and close
monitoring have significantly minimized the occurrence of these problems.
After surgery, some pain, tenderness and stiffness is normal. You
should be alert for certain signs and symptoms that may suggest the
development of complications.
Be sure to call your doctor if you develop any of these symptoms after
surgery.
Prevention of Future Problems
It’s important that you continue a shoulder exercise program with daily
stretching and strengthening. In general, patients who faithfully comply
with the therapies and exercises prescribed by their orthopaedic surgeon
and physical therapist will have the best medical outcome after surgery.
Your orthopaedic surgeon is a medical doctor with extensive training in
the diagnosis and nonsurgical and surgical treatment of the
musculoskeletal system, including bones, joints, ligaments, tendons,
muscles and nerves.
This brochure has been prepared by the American Academy of Orthopaedic
Surgeons and is intended to contain current information on the subject
from recognized authorities. However, it does not represent official
policy of the Academy and its text should not be construed as excluding
other acceptable viewpoints. Persons with questions about a medical
condition should consult a physician who is informed about the condition
and the various modes of treatment available.
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