Shoulder problems affect people of all ages.
These can be due to sudden injury or simple overuse and repetitive activity. Arthritis can be another common cause of shoulder pain and dysfunction.
Sports involving repetitive overhead motions like tennis, volleyball, baseball, Olympic lifting, HIIT training, and swimming can make you more prone to shoulder injuries. As patients age into their 50’s and 60’s, it is common to develop symptoms related to the rotator cuff tendons or arthritis.
Our fellowship-trained surgeons and mid-level providers offer comprehensive detailed evaluations and a wide variety of treatment strategies. As board-certified, fellowship-trained specialists who actively participate in national and international academic sports medicine and shoulder societies, we offer the highest levels of evidence-based medicine and state-of-the-art techniques to optimize your care.
Shoulder Evaluation
A hands-on evaluation of your shoulder will help assist in determining the cause of your shoulder problems. Appropriate evaluation typically includes:
- A history of your injury or pain
- Focused physical examination
- X-rays when needed
- Appropriate advanced imaging studies, (e.g. MRI or CT scan) if necessary
- Selective injections can be used to determine where your pain originates
Treatment of Shoulder Pain
The causes of your shoulder injury or condition, as well as your level of activity, will lead your doctor to develop a personalized treatment plan with you. In most cases, non-surgical treatment methods are preferred. But in certain cases, you may have poor outcomes if surgical intervention is delayed. Helping you through this decision-making process is one of the most important parts of our jobs as surgeons.
We direct treatment alternatives based on your problem. Conservative options range from methods activity modification to physical therapy, regenerative medicine techniques, and injections. Surgical interventions are also considered, including advanced arthroscopic techniques and the latest in orthobiologics or even bone-marrow-derived stem cells.
Arthroscopic and Minimally Invasive Surgery
Our orthopedic specialists are trained in the most up-to-date, minimally invasive techniques. We have the training and skills needed to repair nearly any shoulder problem with arthroscopic methods. In fact, minimally invasive arthroscopic techniques are our standard practice for nearly every shoulder surgery besides fracture care or replacements.
Arthroscopic repair can be performed for all of the following conditions and more:
- Rotator Cuff Repair
- SLAP Repair
- Labrum Repair
- Instability Repair
- HAGL Repair
Rotator Cuff Tears
Rotator cuff tears are very common problems. But the treatment can vary greatly depending on the patient’s age, activity level, and severity of the tear. Partial tears can often be treated without surgery, but new techniques like arthroscopic RegentenTM application can use bioinductive healing to repair your partial tear with only two days of sling use.
Typical tears of the rotator cuff are treated with an arthroscopic repair, using sutures and anchors to re-attach the cuff to the bone. But some tears can be too large or old to repair. In these situations, we sometimes need to reconstruct the missing cuff tendon with a patch in a process known as a superior capsular reconstruction.
Shoulder Replacement
The coronavirus pandemic helped us to accelerate the trend toward outpatient joint replacement. And that includes shoulders. Advances in shoulder replacement surgery allow us to get many people home the same day as their surgery. This is often actually safer, with lower rates of infection and other complications when people are able to stay out of the hospital.
People who have both arthritis and a rotator cuff tear require a special type of surgery called a reverse total shoulder replacement. And even this can be performed as same-day surgery now!
A shoulder separation, or AC separation, is a very frequent injury among certain athletes.
In this injury the clavicle (collar bone) separates from the acromion (part of the shoulder blade). It is commonly caused by a fall directly on the “point” of the shoulder. This commonly occurs when football players are tackled, hockey players get checked into the boards, or mountain bikers go over their handlebars.
Most AC injuries don’t require surgery. Most patients recover with full function of the shoulder. Recovery can take a few days to 12 weeks depending on the severity of the separation. Disruption of the AC joint results in pain and weakness in the entire shoulder and arm. The pain is most severe when the patient attempts overhead movements or tries to sleep on the affected side.
It is important to note that surgery is recommended only due to severity of injury. Surgery will not get you back to normal faster in the case of mild injuries. Surgery is only beneficial when the injury is so severe that it would leave permanent disability. Most pro athletes are able to return to sport without surgery after a shoulder separation.
How do we know which AC injuries need surgery?
The severity of an acromioclavicular joint injury depends on which supporting structures are damaged, and the extent of that damage. Tearing of the acromioclavicular capsule alone is not a serious injury, but when the additional ligaments are ruptured the collarbone can become permanently unstable.
Simple AC injuries are classified in three grades ranging from a mild dislocation to a complete separation. AC Separations of Grade 1 through 3 will usually heal well without surgery, leaving minimal long-term problems.
- Grade 1 - A slight displacement of the joint. The acromioclavicular ligament may be stretched or partially torn. This is the most common type of injury to the AC joint.
- Grade 2 - A partial dislocation of the joint in which there may be some displacement that may only be seen on xray. The acromioclavicular ligament is completely torn, while the coracoclavicular ligaments remain intact.
- Grade 3 - A complete separation of the joint. The coracoclavicular ligaments and the capsule surrounding the joint are torn. Usually, a bump at the site of injury is obvious though a lot of that bump is blood and swelling from the injury. It will get smaller over time.
Complex AC separations are Grades 4 through 6 are very rare and are usually the result of a high-energy injury such as one that might occur in a motor vehicle accident. They are all treated surgically because of the severe disruption of all the ligamentous support for the arm and shoulder. They usually involve complete separation of the collarbone from the acromion, disruption of all the ligaments, and displacement of the clavicle into the surrounding muscles.
Pain, stiffness, and loss of motion in your shoulder joint are signs of a frozen shoulder.
Bone and Joint Specialists of Winchester helps treat frozen shoulders. You can schedule appointments with our surgeons or physical therapists for evaluation and treatment. Our therapists can see you for initial evaluation and treatment for two weeks without a prescription. For more information, call us today or schedule an appointment online.
What is the main cause of frozen shoulder?
The ligaments, bones, and tendons that make up your shoulder joint are encased in a capsule of connective tissue. A frozen shoulder occurs when this capsule thickens around the shoulder joint, becoming less flexible and restricting its movement. The clinic name for this process is adhesive capsulitis. Doctors are not fully sure why most cases of frozen shoulder occur, or why this happens to the shoulder but not other joints. But we do know it is more likely in patients with diabetes, females over the age of 40, females, thyroid disorders, and Parkinson’s disease. Other people can develop frozen shoulder after previous shoulder surgery, or if they have disorders of the cervical discs in the neck. Frozen shoulders will often develop after injuries such as rotator cuff tears, arthritis, and fractures of the shoulder too.
What are the signs of a frozen shoulder?
Frozen shoulder usually begins with intense pain both at rest and with motion. Movement of the shoulder becomes very stiff. Eventually it becomes hard to move the shoulder even with forceful stretching. The pain can radiate from the neck to the upper arm.
How is a frozen shoulder diagnosed?
A physical exam is normally enough to diagnose a frozen shoulder but X-rays and MRI will usually be ordered to identify additional problems or injuries.
What happens if the frozen shoulder is not treated?
Medical experts refer to a frozen shoulder as a “self-limiting” condition, which means that it will eventually go away on its own. However, this can take months or years to happens. And studies suggest that people get more of their motion back if they seek medical treatment for the shoulder. If a frozen shoulder is not treated, then people may not be able to regain their full range of motion, and they might even notice that their affected shoulder pops up slightly higher than the other shoulder when they raise their arms over their head. Active medical care of frozen shoulder can shorten the time it takes to get back to normal and also get more of your motion back.
What treatment options are available for frozen shoulder?
There are a number of treatment options available if your symptoms are intense and don’t improve over time. Physical therapy, steroid injections, shoulder manipulation, and arthroscopic release of adhesions are all good treatment options. Platelet rich plasma injections may also benefit people with frozen shoulder.
If you think you have a frozen shoulder or have any questions about treatment, then we encourage you to contact us or book an appointment through our website. Our team of medical professionals at Bone and Joint Specialists of Winchester treat frozen shoulders and offer ways to prevent it.
PRP – platelet rich plasma – is a special preparation of your own blood used to treat soft tissue injuries.
A special centrifuge allows us to extract the plasma with its platelets and growth factors from your own blood. For injuries to muscles, tendons, and ligaments, we also include concentrated white blood cells to promote healing, reduce pain, and improve function.
Many famous athletes — golfer Tiger Woods, tennis star Rafael Nadal, and several others — have received PRP for various problems, such as sprained knees and chronic tendon injuries. These types of conditions have typically been treated with medications, physical therapy, or even surgery. Some athletes have credited PRP with their being able to return more quickly to competition.
What makes LR-PRP special?
For soft tissue injuries and tendinitis, we use LR-PRP, meaning Leukocyte Rich PRP. Leukocytes are white blood cells, and seem to help promote healing of the soft tissues when concentrated and injected as part of a PRP preparation.
How do we get PRP?
The process begins with a simple blood draw in our office. You do not need to go to the hospital or fast before the procedure. In fact, we prefer that you eat and drink normally to stay well hydrated. The syringe with your blood is then placed into a centrifuge where it is spun at high speed to separate the different components of your blood into different layers in the same tube. The specialized centrifuge then uses photon cytometry to selectively remove the plasma, platelets, and white cells from this syringe and collect them for re-injection into the damaged tissue.
How does it work?
PRP concentrates your body’s own growth factors, derived from the platelets and plasma. In fact, PRP can contain 1500 protein-based bioactive factors.
Platelets are part of the clot which forms at any injury. And when they clot, they release various growth factors to help start the healing process. By concentrating them we can provide that same healing response to a damaged joint.
The white cells in LR-PRP also seem to play a beneficial role in processing the injured tissue and speeding healing.
Growth factors in PRP can help increase collagen production, decrease destructive enzyme activity in the joint, and reduce inflammation.
These growth factors include:
- Platelet derived growth factor (PDGF) - Enhances collagen synthesis, proliferation of bone cells, fibroblast chemotaxis and proliferative activity, macrophage activation
- Transforming growth factor ß (TGF-ß) - Enhances synthesis of type I collagen, promotes angiogenesis, stimulates chemotaxis of immune cells, inhibits osteoclast formation and bone resorption
- Vascular endothelial growth factor (VEGF) - Stimulates angiogenesis, migration and mitosis of endothelial cells, increases permeability of the vessels, stimulates chemotaxis of macrophages and neutrophils
- Epidermal growth factor (EGF) - Stimulates cellular proliferation, differentiation of epithelial cells, promotes cytokine secretion by mesenchymal and epithelial cells
- Insulin-like growth factor (IGF) - Promotes cell growth, differentiation, recruitment in bone, blood vessel, skin and other tissues, stimulates collagen synthesis together with PDGF
- Fibroblast growth factor (FGF) - Promotes proliferation of mesenchymal cells, chondrocytes and osteoblasts, stimulates the growth and differentiation of chondrocytes and osteoblasts
What does PRP treat?
LR-PRP is generally used to treat both acute and chronic injuries to tendons, ligaments, and muscles. Some of the most common applications include
- Tennis Elbow
- Golfer’s Elbow
- Patellar Tendonitis
- Achilles Tendonitis
- Muscle Tears
Typically, we use PRP as a final treatment option for these conditions before attempting surgery. But because it is usually an out-of-pocket expense, not everyone is willing to try it. But if you are not a candidate for surgery, and have had no luck with other treatments, it may be one additional option.
Like any treatment for these conditions, it doesn’t work for everybody. And because it works by stimulating your own healing mechanisms, it takes 3-6 weeks to see improvement, and up to a few months for maximum benefit.
Generally, we see little benefit to adding PRP at the time of surgery.
Is it covered by insurance?
Unfortunately, most private insurers and Medicare do not cover any form of PRP. But Worker’s Comp insurance frequently does. For all other insurers this is an out-of-pocket treatment for patients. We are always conscious of the cost of care to our patients which is why we charge far less than other providers closer to the big cities. While we can’t provide specific numbers online, our rates are usually a fraction of what we’ve seen other physicians charge.
Surgeons Providing PRP Injections
Regeneten can help you heal your rotator cuff quickly and easily – with less time in a sling!
Regeneten is part of the regenerative medicine revolution! It is an orthobiologic product that is revolutionizing the way we treat partial rotator cuff tears. This lets us treat the failing biology behind cuff tears early, so they heal quickly and prevent bigger injuries in the future.
That means you may only need to wear a sling for TWO DAYS after surgery!
Previously, we could sew a tendon down. But it was up to the tendon to heal. That meant 6 weeks in a sling and months of rehab. But with Regeneten we have a new tool to induce that healing and boost your own body’s ability to repair itself.
At Bone and Joint Specialists of Winchester, Dr. James Larson is our shoulder specialist and one of the only surgeons in the area to offer this revolutionary treatment.
What is Regeneten?
The Regeneten implant is a patch of Type I collagen about the size of a postage stamp. Type I Collagen is found throughout your body, especially in tendons. The special weave and structure of the implant helps to induce healing in the rotator cuff, allowing it to thicken and even grow back to the bone. That helps it repair partial cuff tears before they become complete tears.
Using the Regeneten implant can drastically reduce your downtime after surgery. If you are a candidate for this treatment, you can be out of your sling just two days after surgery. That means a return to normal activity like work, driving, and taking care of your family weeks sooner than with other methods of treating partial rotator cuff tears.
There will still be some pain after the surgery. And you need to be careful to avoid injuring the healing cuff tissue. But you have far more freedom than you would with other rotator cuff surgeries.
How does Regeneten work?
Placement of the Regeneten implant is done through outpatient arthroscopic surgery at the surgery center. The implant is spread over the damaged area of the rotator cuff and then attached with several small absorbable staples.
The Regeneten patch induces a healing response in the tendon, increasing the tendon thickness on both sides. This allows the cuff tendon to restore its natural attachment points to the bone. It is indistinguishable from native tendon after only three months. The implant is completely absorbed by sox months, and we can see continued growth of the tendon for up to 12 months.
Why is the recovery so much quicker with Regeneten?
Previously, partial thickness tears were a difficult problem to treat. They would often cause pain and difficulty with everyday activities like sports, sleeping, or even simply getting dressed. But surgery required 6 weeks in sling and a lot of rehab.
That’s because the older methods of treating partial cuff tears required us to complete the tear (make it go all the way through) and then repair it to the bone with sutures and anchors. Then it took six weeks for the tendon to heal and allow you to safely use it.
But when the Regeneten implant is applied to the cuff, we don’t have to cut away any more tendon. That means it is as strong after surgery as it was the day before. After two days, we know the healing has begun and the implant is well fixed to the tendon so you can safely come out of the sling and use it for light everyday activities.
What is Reverse shoulder replacement surgery?
A reverse shoulder replacement is similar to a standard total shoulder replacement in that we replace the arthritic ball and socket of the shoulder with metal and plastic replacement parts. But a standard shoulder replacement only works well when your rotator cuff is normal. If your rotator cuff is torn, a regular shoulder replacement won’t work well, leaving you with pain and weakness.
The reverse shoulder replacement is specially designed for patients who have both arthritis and a rotator cuff tear. A reverse shoulder replacement can also be performed for people with large rotator cuff tears that cannot be repaired. A reverse shoulder replacement gets rid of the pain from arthritis and also restores the strength and motion lost due to the rotator cuff tear.
How is a Reverse different from a standard shoulder replacement?
This could more accurately be called an “inverse” shoulder replacement. Most of the steps of this surgery are the same, however the implants reverse the position of the ball and socket. After removing the arthritic surface of the bones, ball is placed on top of the old socket and a socket is placed where the old ball of the joint was.
This changes the leverage and pivot points in the shoulder to allow the remaining muscles to lift the arm without the rotator cuff.
Who is a candidate for a reverse shoulder replacement?
The ideal patient for a reverse shoulder replacement is:
- over 65 years of age
- does not engage in heavy lifting or hard labor
- has a torn rotator cuff with arthritis
- has significant loss of strength and motion
- has significant and persistent pain in the shoulder
Some patients who are over 75 may be candidates as well because of concerns over the ability of their rotator cuff to heal properly after a standard shoulder replacement. Certain patients with severe shoulder fractures may also benefit from a reverse shoulder replacement. Patients that require the use of a walker or other device to walk may decide to go with the reverse instead of a total because it allows them to bear weight immediately after surgery. That allows them to use the walker and get around immediately after surgery instead of being stuck in a sling.
Who performs shoulder replacements?
Sports Medicine specialists are often specially trained at both standard and reverse shoulder replacements. At Bone and Joint Specialists of Winchester, Dr. James Larson and Dr. Steven Pancio perform total shoulder replacements and reverse shoulder replacements.
Diagnosing shoulder arthritis
The basic diagnosis of shoulder arthritis is made with plain X-Rays. If you’ve had X-Rays at an outside facility, our physicians may request that you get new ones in our office. This is usually because specific angles are required to see the shoulder joint clearly, and other offices my not have obtained these specialized views of the shoulder. We may also need radiographs on our own system in order to properly plan for surgery.
Sometimes we may also order an MRI to check for rotator cuff tears. If you have both arthritis and a cuff tear, you will often have better results with a reverse shoulder replacement instead of a standard shoulder replacement. A CT scan may be ordered so that we can plan for any bone loss or create patient-specific guides for your surgery.
Can shoulder replacements be performed as an outpatient?
Yes, both standard and reverse shoulder replacements can be performed as an outpatient. This is the result of decades of refinement to surgical techniques and improvements to anesthesia. These have greatly reduced the risks of bleeding and other complications, allowing you to have your surgery and safely go home with friends or family the same day. The decision to have shoulder replacement as an outpatient will be made between you and your surgeon and depends on your other medical conditions as well as home support.
What are other options to shoulder replacement?
We always reserve surgery for when other options have failed to relive the pain of arthritis. Other treatments for shoulder arthritis include:
- Steroid injections
- PRP injections
- Physical Therapy
- Oral Anti-Inflammatories
How is shoulder replacement performed?
In reverse shoulder replacement surgery, the damaged humeral head (the ball of the joint) is replaced with a metal tray and plastic socket while the glenoid cavity (the joint socket) is implanted with a metallic base plate and screws that hold a metal ball
Anesthesia for reverse shoulder replacement surgery
During a total shoulder replacement, the patient will usually have both regional anesthesia and general anesthesia. Regional anesthesia is usually performed by administration of a nerve block to the shoulder. This results in the entire arm being numb during the surgery. That means you need less anesthesia and narcotic medications during surgery. And that helps prevent nausea, vomiting, grogginess, and other side effects of the anesthesia.
How long does a reverse shoulder replacement take?
While an uncomplicated shoulder replacement usually takes less than an hour, it can take up to a couple of hours in some cases. If you have severe arthritis, osteoporosis, large bone spurs, loss of bone, or severe contractures of the joint, surgery may be longer than usual so that these problems can be properly addressed.
What are the risks of a reverse shoulder replacement?
Complications are rare in total shoulder replacement. In general, there is less than 2% risk of major complications. But these can include:
- dislocation (the ball slipping out of the socket)
- infection
- nerve damage
- implant loosening
- stiffness*
*An arthritic shoulder is often very tight prior to surgery. Physical therapy after surgery is usually needed to restore motion back to normal. Continuous physical therapy efforts are usually effective in restoring shoulder motion and strength.
How long does it take to recover from a reverse shoulder replacement?
After a reverse shoulder replacement, you are allowed to start using the shoulder as quickly as pain allows. You can even use the arm to support your weight on a walker or cane the day after surgery.
Time-lime for recovery after shoulder replacement:
- Immediately after surgery – The patient may use the whole arm, including shoulder, for light activity and weight bearing as pain allows.
- After two weeks – formal physical therapy will be started.
- By two months – Most patients have only mild pain. Range of motion has improved to about half or three quarters of normal. People usually still have to work on strengthening and experience some weakness.
- Six months – Most patients are pain-free (although they may experience pain during certain weather conditions. Motion and strength are approaching normal.
- One year – Approximately 95% of shoulder replacement patients will be pain-free. The remaining 5% will usually have no more than a weather-related ache or an occasional pain due to excessive activity. Strength and motion will be at their maximum.
Returning to work
The exact time a person can return to work depends greatly on the motion and strength of the shoulder and how the patient is progressing. But it usually takes two to three weeks to return to desk though don’t expect to type with the surgical arm. Four months or more of recovery is required for heavier, physical labor.
In all cases, proper and extensive postoperative rehabilitation are key factors in achieving the maximum benefit of shoulder replacement surgery.
Bone and Joint Specialists of Winchester provides advanced rotator cuff surgery options
Are you one of the millions of adults who suffer from shoulder pain? If so, you may be considering surgery to repair your rotator cuff. We are at an amazing time for rotator cuff surgery, with new techniques and advanced options helping to decrease healing time and improve results. In this blog post, we’ll take a closer look at advanced rotator cuff surgery and advice on how to choose the right procedure for you. So if you’re considering surgery, be sure to read on!
All surgeons at Bone and Joint Specialists of Winchester perform minimally invasive rotator cuff repairs. But Dr. Larson is an expert on all kinds of shoulder injuries and surgery. Dr. Larson happily accepts patients for second opinions on rotator cuff injuries. Many other surgeons in our area refer patients to Dr. Larson for treatment of rotator cuff tears that require advanced management.
What is The Rotator Cuff?
The rotator cuff is a set of four muscles deep in the shoulder. The supraspinatus is the most commonly injured one of them. The rotator cuff keeps the shoulder in place and helps to lift the arm overhead.
Do I have a rotator cuff tear?
You might have a rotator cuff tear if you have the following signs or symptoms:
- Pain in the shoulder and upper arm especially when trying to raise the arm overhead.
- Pain when lowering the arm from overhead
- Lifting light objects may cause more pain than lifting heavy objects
- Weakness in the shoulder
- Pain at night when sleeping on the shoulder
Although it is possible to tear the rotator cuff through an injury such as a fall, many people tear their rotator cuff slowly through repetitive use also.
What are the options for rotator cuff surgery?
There are several options available for rotator cuff surgery. The most common is arthroscopic surgery, which involves making small incisions in the shoulder and inserting a tiny camera called an arthroscope. This allows the surgeon to see the inside of the joint and make repairs without having to make a large incision. Most rotator cuff tears, even large ones, are treated with an arthroscopic repair at Bone and Joint Specialists.
Another option is open surgery, which involves making a larger incision in the shoulder so that the surgeon can get a better view of the joint. This type of surgery is usually only necessary if the damage to the rotator cuff is severe.
But there are advanced options too beyond the basic repairs that can help you heal better and faster. These include:
- Regeneten Bio-Inductive Implant
- Superior Capsule Reconstruction
- Double Row Repair
- Bone Marrow Injection
What is a Rotator Cuff repair?
There are a number of ways to perform a rotator cuff repair. Most of the time we can repair standard tears via arthroscopic techniques, using instruments through small “poke hole” incisions. Arthroscopy allows for better visualization, more precise surgery, less shoulder trauma, less postoperative pain and a better cosmetic appearance, all while having the same ultimate healing, function and pain. Sometimes larger tears may require a larger incision in order to repair the cuff tear directly.
No matter what the incisions are like, the surgery is performed in roughly the same way. Small anchors are placed in the bone where the cuff tendon should be attached. Stitches attached to these anchors are then passed through the rotator cuff tendon. As these stitches are tied together, it brings the rotator cuff back to the bone and locks it into place until it can heal.
What are the restrictions after rotator cuff repair?
For a standard cuff repair, the arm and shoulder must be immobilized in a sling for about six weeks after surgery. We usually start an accelerated therapy protocol within a couple weeks of surgery. But if you do too much, it’s possible to damage the repair.
Sometimes, you will be able to get out of the sling quickly. Regeneten repair for partial cuff tears allows you to be out of the sling after 2 days. The same is true if reverse shoulder replacement is needed for your tear. Other surgeries, like superior capsule reconstruction may require strict use of the sling without therapy at all for the first six weeks.
What happens on the day of rotator cuff surgery?
Rotator cuff repairs are performed as an outpatient. The anesthesiologist will put you to sleep for the surgery. But before that they will administer a nerve block by doing an injection near the collarbone. This will numb your arm and shoulder so that you feel less pain. This also allows them to give you less anesthetic and narcotic medication while you are asleep. That means less nausea, vomiting, or grogginess after surgery.
Once asleep, you will be properly positioned and prepared for surgery. The surgery usually takes an hour or less, but bigger tears may take longer. Once the surgery is completed, a dressing and sling are applied. You are awakened from anesthesia and taken to the recovery area. Once you are awake, drinking, and recovered, the nurses will help you dress and then you are able to go home.
What if my rotator cuff tear is not repairable?
If your tear is not repairable but non-operative treatments are unsuccessful, there are other options:
- Arthroscopic Debridement
- Partial Rotator Cuff Repair
- Copeland hemiarthroplasty
- Superior Capsular Reconstruction
- Reverse Total Shoulder Replacement
Arthroscopic Debridement
Even though your torn rotator cuff may not be repairable, sometimes cleaning out the shoulder joint and removing other causes of pain may help you feel better. This won’t prevent you from having any other treatments for the shoulder down the line. And it can give you some improvement in pain and function.
Partial Rotator Cuff Repair
Sometimes we can repair only a portion of the rotator cuff. But that can provide significant pain relief and improved function. This is because some parts of your rotator cuff are more important that others. By repairing those we can get you closer to normal even though the shoulder isn’t perfect.
Copeland Hemiarthroplasty
A partial replacement of the joint can provide some relief of pain and improved function of the shoulder. The Copeland is a steel cap that fits over the ball of the shoulder joint. It allows the shoulder to move while preventing pain from the lack of rotator cuff. When the shoulder feels better, it is able to move better. This is an option for non-repairable rotator cuff tears in people too young for a reverse shoulder replacement or those who still lead very active athletic lifestyles.
Superior Capsular Reconstruction
Superior Capsular Reconstruction is an advanced arthroscopic surgery where we place a thick tissue patch over the top of the shoulder joint. This is attached to the top of the humerus and the top of the socket. It is also sewn together with any remaining rotator cuff tissue and can help improve pain, strength, and motion. Unfortunately, it takes several months for the repair to heal in well and to get back to normal. But it is a good option for people with non-repairable tears who are too young for reverse shoulder replacements.
Reverse Total Shoulder Replacement
You can read more about this in our full article on it. But in brief, this is a special type of shoulder replacement intended for people with arthritis and cuff tears, or else a huge irreparable cuff tear and loss of motion of the shoulder. The ball and socket are placed in different positions in order to allow for improved leverage of the remaining shoulders to restore function and eliminate pain.
Traumatic injuries may cause a fracture of the humerus (ball), scapula (shoulder blade), or clavicle (collarbone) of the shoulder.
The majority of these injuries can be treated without surgery and heal well. Some fractures are better treated with surgery because they may carry a high risk of arthritis if left alone.
Fractures are either described as being displaced or non-displaced. Fortunately, nearly 80 percent of all shoulder fractures are non-displaced. “Non-displaced” means that the broken pieces remain near their normal position and can heal if immobilized in a sling. Most shoulder fractures heal in about six weeks.
The remaining 20 percent of shoulder fractures are displaced and may require some type of surgery. Surgery is used to bring widely displaced fracture pieces back together and lock them in place so they can heal well. Surgery doesn’t usually help non-displaced fractures heal faster.
What are my treatment options?
Conservative care for shoulder fractures
Most non-displaced fractures require immobilization in a sling until the fracture heals enough to be permit motion without risk of dislodging the fracture fragments. X-rays are used to determine if sufficient healing has occurred to permit motion exercises.
If the arm is moved too early, this can delay healing, but too little movement will result in stiffness. So you need to work with your doctor and therapist to move the shoulder at the right time. It is vital to maintain flexibility of the elbow, wrist and fingers while resting the shoulder. So you will often be allowed to stretch the hand, wrist, and elbow while still protecting the shoulder.
Surgical
ORIF – If the fracture fragments are displaced, surgical procedures may be necessary to bring the pieces together and fix them with wires, pins, plates or screws. This is called an “Open Reduction and Internal Fixation (ORIF).”
Shoulder Replacement – If the ball portion of the upper arm is broken, split or crushed, a shoulder replacement may become necessary.
Reverse Shoulder Replacement – If the ball is badly damaged and the rotator cuff is also torn, a reverse total shoulder may be your best option to return to normal and re3duce risk of further surgeries.
Shoulder Anatomy
The Shoulder is a complex joint between the arm bone, shoulder blade, and collar bone. Fractures can occur at any of these three bones. They can happen after major injuries when younger, or after simple falls as we age.
What is the recovery time after shoulder fracture?
Most shoulder fractures can be treated without surgery. It usually takes about 6-8 weeks for enough healing to occur and allow for full motion. Rehab can take several months to return you to normal strength and motion.
Surgical recovery can vary. Some treatments, like shoulder replacement and ORIF can take just as long as non-surgical care. Reverse shoulder replacement allows for earlier motion, but almost the same time to return to normal strength.
What are the long-term problems after shoulder fractures?
The biggest problem after shoulder fractures is stiffness. This seems to depend more on the severity of the injury than how they are treated. If the injury is bad enough to require surgery, you will likely have some loss of motion after healing has completed.
What causes rotator cuff impingement syndrome?
Rotator cuff impingement syndrome happens when there is not enough room for the rotator cuff tendons to move freely under the acromion, a bony bump on top of the shoulder blade. The tendons of the rotator cuff get pinched under the acromion and become inflamed.
What is the rotator cuff?
The rotator cuff is a group of four muscles and tendons in the shoulder joint. They help you move your arm by rotating it, raising it up, and pulling it out to the side. The rotator cuff also helps keep your shoulder stable when you lift something heavy or do other activities with your arm.
What are the symptoms of rotator cuff impingement syndrome?
The rotator cuff tendons on the top of the shoulder can get pinched. If this happens, you might feel pain when lifting your arm above your head or bringing it across your body. You might also have a stabbing pain in the front of your shoulder or side of the shoulder. Pain is usually worse while lying on that side at night. It may also be more painful when lifting light objects, like a cup of coffee, but less painful when lifting heavier objects.
How is rotator cuff impingement syndrome treated?
Treatment for rotator cuff impingement syndrome includes resting from activities that cause pain, ultrasound treatment, physical therapy exercises, anti-inflammatory medication, steroid injections into the shoulder bursa, and occasionally surgery.
Bone and Joint Specialists of Winchester provides advanced shoulder labrum repair options.
All of our surgeons perform arthroscopic repair shoulder labrum tears. Dr. Larson’s primary focus is on shoulder care and he is happy to see patients for second opinions on shoulder labrum injuries. Many other surgeons in our area refer patients to Dr. Larson for treatment of shoulder labrum tears that require advanced management.
What is the shoulder labrum?
The shoulder labrum is ring of cartilage that circles the socket of the shoulder joint. It helps to keep the shoulder from dislocating and provides and anchor for many ligaments and some tendons of the shoulder.
Do I have a shoulder labrum tear?
You might have a shoulder labrum tear if you have the following signs or symptoms:
- Pain in the shoulder when throwing or lifting weights
- Pain when reaching behind you
- Weakness in the shoulder
- Pain at night when sleeping on the shoulder
Although it is possible to tear the shoulder labrum through an injury such as a fall, many people tear their shoulder labrum slowly through repetitive use also. Labrum tears are common in shoulder-focused athletics such as pitching, baseball or softball, volleyball, swimming, and weight lifting.
What shoulder labrum surgery do you need?
Most shoulder labrum tears can be repaired, but not all of them need to be. Sometimes a simple arthroscopic shaving of the damaged area is all that’s needed to get you back to normal function. What surgery is best for you depends on your age, activity level, symptoms and goals, as well as characteristics of the labrum tear.
What is a shoulder labrum repair?
Most of the time we can repair labrum tears of the shoulder tears via arthroscopic techniques, using small instruments through “poke hole” incisions. Arthroscopy allows for better visualization, more precise surgery, less shoulder trauma, less postoperative pain and a better cosmetic appearance, all while having the same healing, function, and pain relief.
First the tear is identified. Then any scar tissue is removed from the site of damage and the surface of the bone is roughened to allow better healing. Then small anchors are placed in the bone where the labrum should be attached. Stitches attached to these anchors are then around the labrum. As these stitches are tied down, it brings the labrum back to the bone and locks it into place until it can heal.
What are the restrictions after shoulder labrum repair?
After a simple cleanup of the labrum, you can usually be out of the sling within a couple days. But after a repair, the arm and shoulder must be immobilized in a sling for about four to six weeks after surgery. This depends on the size of tear and how it could be repaired. We usually start an accelerated therapy protocol within a couple weeks of surgery. But if you do too much, it’s possible to damage the repair.
What happens on the day of shoulder labrum surgery?
Shoulder labrum repairs are performed as an outpatient. The anesthesiologist will put you to sleep for the surgery. But before that they will administer a nerve block by doing an injection near the collarbone. This will numb your arm and shoulder so that you feel less pain. This also allows them to give you less anesthetic and narcotic medication while you are asleep. That means less nausea, vomiting, or grogginess after surgery.
Once asleep, you will be properly positioned and prepared for surgery. The surgery usually takes an hour or less, but bigger tears may take longer. Once the surgery is completed, a dressing and sling are applied. You are awakened from anesthesia and taken to the recovery area. Once you are awake, drinking, and recovered, the nurses will help you dress and then you are able to go home.
What if my shoulder labrum tear is not repairable?
If your tear is not repairable but non-operative treatments are unsuccessful, there are other options:
- Arthroscopic Debridement
- Partial Shoulder labrum Repair
- Copeland hemiarthroplasty
- Superior Capsular Reconstruction
- Reverse Total Shoulder Replacement
Arthroscopic Debridement
Even though your torn shoulder labrum may not be repairable, sometimes cleaning out the shoulder joint and removing other causes of pain may help you feel better. This won’t prevent you from having any other treatments for the shoulder down the line. And it can give you some improvement in pain and function.
Partial Shoulder labrum Repair
Sometimes we can repair only a portion of the shoulder labrum. But that can provide significant pain relief and improved function. This is because some parts of your shoulder labrum are more important that others. By repairing those we can get you closer to normal even though the shoulder isn’t perfect.
Copeland Hemiarthroplasty
A partial replacement of the joint can provide some relief of pain and improved function of the shoulder. The Copeland is a steel cap that fits over the ball of the shoulder joint. It allows the shoulder to move while preventing pain from the lack of shoulder labrum.
Total shoulder replacement is a very successful procedure to reduce pain and restore mobility in patients with end-stage shoulder arthritis or after a severe shoulder fracture.
Shoulder replacement surgery relieves pain, improves motion, and restores strength and function to the shoulder. By one year from surgery the vast majority of patients have returned to playing golf or tennis, swimming, doing yoga, yardwork, or even lifting weights.
What is shoulder replacement surgery?
Total shoulder replacement, also known as total shoulder arthroplasty, is the removal of arthritic portions of the shoulder joint which are replaced with metal and polyethylene implants. This helps to reduce pain and restore range of motion. It is very successful for treating the severe pain, stiffness, and grinding caused by shoulder arthritis.
Shoulder arthritis is a condition in which the smooth cartilage in the shoulder joint breaks up and peels away. In a healthy shoulder, cartilage allows the bones to glide almost without friction. When these cartilage surfaces disappear, the bones come into direct contact, increasing friction and causing pain.
What causes the conditions treated by shoulder replacement surgery?
There are two basic types of arthritis that affect the shoulder.
Osteoarthritis (OA): This is due to wear and tear on the shoulder. Osteoarthritis in the shoulder is more common in exceptionally active people (even at younger ages), such as tennis players, weightlifters, gymnasts and other athletes who put continual pressure on their shoulders. People that work overhead like pipefitters, plumbers, and electricians are also prone to shoulder OA.
Inflammatory arthritis (IA): This is an umbrella term for several autoimmune diseases. The most common of these is rheumatoid arthritis. These patients can also benefit from shoulder replacement but they do have higher risks of complications.
Who performs shoulder replacements?
Sports Medicine specialists are often specially trained at both standard and reverse shoulder replacements. At Bone and Joint Specialists of Winchester, Dr. James Larson and Dr. Steven Pancio perform total shoulder replacements and reverse shoulder replacements. Dr. Richard Patterson performs total shoulder replacements as well.
How do I know if I need a shoulder replacement?
People who have developed painful end-stage arthritis are candidates for shoulder replacement surgery. The most important parts of deciding to replace the shoulder are how much pain and loss of function the arthritis causes. If your xrays show arthritis but you have minimal pain along with good strength and motion, a replacement can often be delayed until the pain is more severe.
Diagnosing shoulder arthritis
The basic diagnosis of shoulder arthritis is made with plain X-Rays. If you’ve had X-Rays at an outside facility, our physicians may request that you get new ones in our office. This is usually because specific angles are required to see the shoulder joint clearly, and other offices my not have obtained these specialized views of the shoulder. We may also need radiographs on our own system in order to properly plan for surgery.
Sometimes we may also order an MRI to check for rotator cuff tears. Or a CT scan may be ordered so that we can plan for any bone loss or create patient-specific guides for your surgery.
Can shoulder replacements be performed as an outpatient?
Yes, both standard and reverse shoulder replacements can be performed as an outpatient. This is the result of decades of refinement to surgical techniques and improvements to anesthesia. These have greatly reduced the risks of bleeding and other complications, allowing you to have your surgery and safely go home with friends or family the same day. The decision to have shoulder replacement as an outpatient will be made between you and your surgeon and depends on your other medical conditions as well as home support.
What are other options to shoulder replacement?
We always reserve surgery for when other options have failed to relive the pain of arthritis. Other treatments for shoulder arthritis include:
- Steroid injections
- PRP injections
- Physical Therapy
- Oral Anti-Inflammatories
How is shoulder replacement performed?
In traditional shoulder replacement surgery, the damaged humeral head (the ball of the joint) is replaced with a metal ball, and the glenoid cavity (the joint socket) is replaced with a smooth plastic cup. This metal-on-plastic implant system (rather than metal-on-metal) is used in virtually all shoulder replacement. In some patients, such as those with severe shoulder fractures of the humeral head, a partial shoulder replacement, or hemiarthroplasty, may be recommended.
Anesthesia for shoulder replacement surgery
During a total shoulder replacement, the patient will usually have both regional anesthesia and general anesthesia. Regional anesthesia is usually performed by administration of a nerve block to the shoulder. This results in the entire arm being numb during the surgery. That means you need less anesthesia and narcotic medications during surgery. And that helps prevent nausea, vomiting, grogginess, and other side effects of the anesthesia.
How long does a shoulder replacement take?
While an uncomplicated shoulder replacement usually takes less than an hour, it can take up to a couple of hours in some cases. If you have severe arthritis, osteoporosis, large bone spurs, loss of bone, or severe contractures of the joint, surgery may be longer than usual so that these problems can be properly addressed.
What are the risks of a shoulder replacement?
We always reserve surgery for when other options have failed to relive the pain of arthritis. Other treatments for shoulder arthritis include
- dislocation (the ball slipping out of the socket)
- infection
- nerve damage
- implant loosening
- stiffness*
*An arthritic shoulder is often very tight prior to surgery. Physical therapy after surgery is usually needed to restore motion back to normal. Continuous physical therapy efforts are usually effective in restoring shoulder motion and strength.
How long does it take to recover from a shoulder replacement?
After a standard shoulder replacement, you will need to be in a sling for about 6 weeks after surgery. This is to allow the rotator cuff to heal, otherwise the new shoulder will be weak and more likely to dislocate. It may be several months before a patient may do heavy labor or strenuous strength exercises.
Time-lime for recovery after shoulder replacement:
- After Six weeks – The patient may use the whole arm, including shoulder, for light activity.
- After Eight weeks – The patient may begin unrestricted, active use of the arm and shoulder.
- By Three months – Most patients have only mild pain. Range of motion has improved to about half or three quarters of normal. They usually still have to work on strengthening and experience some weakness.
- Six months – Most patients are pain-free (although they may experience pain during certain weather conditions. Motion and strength are approaching normal.
- One year – Approximately 95% of shoulder replacement patients will be pain-free. The remaining 5% will usually have no more than a weather-related ache or an occasional pain due to excessive activity. Likewise, there will probably not be significant strength limitations, depending on the condition of the deltoid and rotator cuff, particularly if both these muscle groups were normal before surgery.
Returning to work
The exact time a person can return to work depends greatly on the motion and strength of the shoulder and how the patient is progressing. But it usually takes two to three weeks to return to desk though don’t expect to type with the surgical arm. Four months or more of recovery is required for heavier, physical labor.
In all cases, proper and extensive postoperative rehabilitation are key factors in achieving the maximum benefit of shoulder replacement surgery.
What is a reverse shoulder replacement?
A reverse shoulder replacement is a design in which the positions of the ball and socket are switched: A metal ball is placed where the patient’s own natural socket was, and a plastic socket implant is placed on the head of the humeral head. It might be better called an “inverse” shoulder replacement. We don’t simply put the old parts in new positions, these implants are specific to this style of replacement.
The reverse shoulder replacement is done for a few reasons, usually involving the rotator cuff. People with arthritis AND a tear of the rotator cuff, or people with an irreparable tear of the rotator cuff and loss of motion are candidates for a reverse shoulder replacement. This reverse design has more stability and does not need the tendons to hold it in place. It’s motion is controlled by the deltoid muscle rather than the rotator cuff tendon.
