Introduction

Shoulder instability can be a common problem after a shoulder dislocation. Instability means that the shoulder is too loose and has a tendency to slip out of the socket (or glenoid). If the shoulder slips completely out of the socket, it has become dislocated. Repeated dislocations are not only a nuisance, but can cause further injury to the shoulder and can lead to arthritis of the shoulder if not treated.

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

The tendons of four muscles form the rotator cuff. Tendons attach muscles to bones. These muscles are called the supraspinatus, infraspinatus, teres minor, and subscapularis. Muscles move bones by pulling on tendons. When the rotator cuff muscles contract, they also hold the humerus tightly in the socket (glenoid) of the scapula. Strong rotator cuff muscles can help stabilize the shoulder.

The shoulder joint is completely surrounded by a bag of tissue that forms a watertight capsule around the joint. A series of ligaments join together to form this capsule.

A ligament is a soft structure made up of connective tissue. Ligaments attach bones to bones. The ligaments that make up the joint capsule have a considerable amount of slack, or looseness, so that the shoulder is unrestricted as it moves through its rather large range of motion. If the shoulder moves too far, the ligaments become tight and stop any further motion.

Sometimes the shoulder does not completely dislocate, but slips partially out and then returns to its normal position. This is called subluxation.

Ninety-seven percent of dislocations are anterior, meaning that the humerus slips out of the front of the shoulder socket. Only three percent dislocate posteriorly, or out the back.

Causes

Shoulder instability typically results from an injury that made the shoulder dislocate. This initial injury is usually serious enough to require that the shoulder be reduced, or put back into the socket, by a physician.

After the initial dislocation, the shoulder may remain unstable. The ligaments that are supposed to hold the shoulder in the socket may not heal properly, or they may remain stretched and too loose to keep the shoulder in the socket in certain positions. This can result in repeated episodes of dislocation, even during normal activities.

In some cases, instability may be present without an initial dislocation. The initial injury may not have been severe enough to cause a dislocation. Sometimes a genetic problem with the connective tissue of the body can lead to ligaments that are too elastic and stretch too easily. All the joints of the body may be too loose and some joints, such as the shoulder, may be easily dislocated. These people are sometimes referred to as double jointed.

Symptoms

A shoulder dislocation is usually obvious. The injury is very painful and the shoulder looks abnormal. Any movement is extremely painful.

A dislocated shoulder may cause damage to the nerves around the shoulder joint. If the nerves have been stretched, there will usually be a patch of numbness on the outside of the arm just below the shoulder. Several of the muscles around the shoulder may be slightly weak. This condition is usually temporary and will be corrected when the nerves recover.

Chronic instability causes several symptoms. The shoulder may slip, or sublux, in certain positions, such as when the hand is raised above the head in a throwing motion. Subluxation of the shoulder usually causes a quick feeling of pain, like something is slipping or pinching, in the shoulder.

The shoulder may become so loose that it dislocates frequently, severely restricting your ability to move.

Diagnosis

Correctly diagnosing shoulder instability depends upon knowing a history of your condition and performing a physical examination. For the dislocated shoulder, X-rays are necessary to rule out a fracture of the shoulder. X-rays are usually done after the shoulder is relocated to ensure it is back in place and no fractures are present.

For chronic instability, the diagnosis relies on a history of a dislocation (or confirmation by an X-ray) and a physical examination that suggests a loose shoulder. During the physical examination, your physician will stress the shoulder to test the ligaments. When the shoulder is stretched in certain directions, you may get the feeling that the shoulder is going to dislocate. This is a very important sign of instability and is called an apprehension sign. (Unless your shoulder is very loose, the shoulder will not dislocate during this test.)

In some cases where the diagnosis is in question, special tests, such as examining the shoulder while the patient is under general anesthesia or arthroscopy, may be suggested. This will allow the doctor to test the ligaments of the shoulder while the patient is asleep and the muscles around the shoulder are paralyzed.

Remember that the muscles play an important role in the stability of the shoulder, and it is sometimes difficult to test the ligaments alone if the patient is awake and tightening these muscles during the exam.

Treatment

The treatment of shoulder instability begins with a well-designed physical therapy program. The muscles and the ligaments around the shoulder add major stability. If the ligaments have been weakened by injury, the muscles can be strengthened to compensate to some extent. The important muscles are the rotator cuff muscles, since these are the muscles that pull the humerus into the socket when they are contracted. Most typical weight lifting programs do not focus on these muscles. Patients should consult a physical therapist for the proper exercises.

If rehabilitation fails to stabilize the shoulder, surgery may be suggested. Many types of shoulder operations are designed to stabilize the shoulder. Nearly all of these operations attempt to tighten the ligaments that are loose, usually the ligaments at the front of the shoulder.

One of the most popular methods for surgically stabilizing the shoulder that dislocates anteriorly (out the front) is a procedure known as a Bankart repair.

This procedure was developed based on the idea that the primary reason the shoulder is dislocating is that the ligaments in the front of the joint have been torn from their attachment on the front end of the socket (glenoid) of the shoulder joint. In this operation, the ligaments are sewn, or stapled, back into their original position and allowed to heal so that the shoulder is once again stable.

Typically this operation is done through an incision at the front of the shoulder, but some physicians prefer to perform a similar operation with the aid of the arthroscope. This is a new technique and not yet widely practiced.

Introduction

The shoulder joint has great range-of-motion, but not much stability. The rotator cuff tendons are one of the key reasons that the shoulder is so useful. However, the tendons are prone to damage due to wear and tear and injury, or both.

The tendons can be subject to a considerable amount of wear and tear or degeneration as we use our arms, especially during overhead activities. This wear and tear can lead to weakening of the rotator cuff tendons through a condition known as impingement. The rotator cuff tendons are also subject to degeneration as we age. An injury to these tendons can result in a weak and painful shoulder due to tearing of the rotator cuff tendons.

Anatomy

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

Tendons attach muscles to bones. The tendons of four muscles form the rotator cuff. These muscles are called the supraspinatus, infraspinatus, teres minor and subscapularis. Muscles are able to move bones by pulling on tendons.

The rotator cuff tendons connect the humerus with the scapula (shoulder blade) and helps raise and rotate the arm.

As the arm is raised, the rotator cuff also holds the humerus tightly in the socket (glenoid) of the scapula.

The part of the scapula that makes up the roof of the shoulder is called the acromion. Between the acromion and the rotator cuff tendons, there is a structure called a bursa. The bursa is a lubricated sac of tissue that protects the muscles and tendons as they move against one another. There are many bursae all over the body where tissues must move against one another. The bursa allows the moving parts to slide against one another without too much friction.

Causes

Rotator cuff tears usually occur in areas of the tendon that were not normal to begin with and have been weakened by degeneration and impingement. Many studies have shown that the rotator cuff tendons have areas where there is a poor blood supply. Adequate blood supply to the tissue allows it to repair itself from day-to-day wear and tear.

Poor blood supply in the tendon makes the rotator cuff tendons especially vulnerable to degeneration with aging. As we age, our body’s ability to provide an adequate blood supply to the body diminishes so areas already receiving an inadequate supply become further strained.

The weakened rotator cuff tendons can be injured and torn by an excessive force, such as trying to catch a falling heavy object or lifting an extremely heavy object with the arm extended. This can occur even in a young person.

Typically, a rotator cuff tear occurs in people who are nearing the end of their middle-aged years. They have usually experienced problems with the shoulder for some time before the event that causes the tear. A tear usually occurs when lifting something that exceeds the strength of the tendons. The tendon tear usually results in an inability to raise the arm and may be accompanied by pain.

Symptoms

Rotator cuff tears cause two main problems, pain and weakness. In some cases, a rotator cuff tear may involve only a partial tear of the tendons. You may have pain, but can continue to move the arm in a normal range of motion. In other cases, a complete rupture of the tendons occurs, and the arm can no longer be moved in a normal range of motion. A complete rotator cuff tear usually results in an inability to raise the arm away from the side without assistance.

Most rotator cuff tears cause a vague pain in the shoulder area and may result in a “catching” sensation when the arm is moved. The larger the tear in the tendon, the more weakness there is when trying to move the arm. Most people report an inability to sleep on the affected side due to pain.

Diagnosis

A rotator cuff tear can usually be identified during a physical examination. A complete tear is usually very obvious. If your doctor can move the arm in a normal range of motion, but you are unable to move the arm using your own strength, there is a high likelihood of a tear in the tendons.

X-rays may show the rotator cuff tear, but a test called an arthrogram is usually required. This test is done by injecting dye into the shoulder joint and taking several X-rays. If the dye leaks out of the shoulder joint where it was placed, it suggests that there is a tear in the rotator cuff tendons.

The magnetic resonance imaging (MRI) scan can also be used to look at the rotator cuff tendons and determine whether or not they are torn. An MRI scan is a special radiological test where magnetic waves are used to create pictures that look like slices of the shoulder. The MRI scan shows the shoulder bones and whether the tendons have been torn. The MRI scan is painless and requires no needles or dye to be injected. The arthrogram is an older test, but the tests are still widely used.

Treatment

Initial treatment for a suspected rotator cuff tear is rest and anti-inflammatory medication, mainly to control pain. While a true rotator cuff tear will not heal, some partial tears will become very tolerable and may not require a surgical repair. As soon as pain tolerance permits, physical therapy to regain motion can begin.

A cortisone injection may be suggested if you are still experiencing pain after several weeks of conservative care. After a reasonable time, if the pain is not tolerable or the motion of the arm is not acceptable, an arthrogram or MRI scan may be suggested to plan for surgery.

Surgery

Small tears of the rotator cuff can be sometimes treated with arthroscopic debridement. The surgeon uses an arthroscope to help him see any torn fibers within the tendon and remove (debride) them. An arthroscope is a tiny camera that helps surgeons perform procedures through a small incision.

Surgeons can also use an arthroscope to perform surgery to repair a torn rotator cuff. In most cases, repairing the tendons involves first removing any unhealthy, degenerative rotator cuff tissue. Then, an area of the humerus (the upper arm bone) where the tendon was torn is prepared for reattachment of the tendon. The soft tissue is removed on an area of the humerus to form a raw bony area for attachment of the torn tendon.

Drill holes are made in the humerus to allow sutures to be placed through the bone to re-attach the tendon.

The tear in the tendon is then sewn together. Other sutures are used to attach the tendons to the bone of the humerus by looping the sutures through the drill holes. The tendon heals to the bone over time and reattaches itself. In some cases, surgeons may also use suture anchors which are fasteners that can anchor the rotator cuff to the humerus.

In some instances, rotator cuff repair must be performed by open surgery. Open surgery involves the surgeon cutting through the muscles and tissues at the front of the shoulder to access the rotator cuff and repair the shoulder.

If you are a candidate for arthroscopic repair, you may be able to go home from the hospital the same day. Following open surgery, you may spend one or two nights in the hospital.

Expect to begin physical therapy soon after surgery. The repair must be protected, mainly to keep the sutures from pulling free, but early range of motion exercises will lead to a quicker recovery. Three to six weeks following surgery, the therapist will begin more active exercises to start regaining the strength in the rotator cuff muscles. Recovery from shoulder surgery can take several months. Getting the shoulder moving as quickly as possible is important, but this must be balanced with the need to protect the healing muscles and tissues.

As mentioned earlier, a rotator cuff tear does not usually occur in a normal shoulder. Most shoulders that have suffered a rotator cuff tear have other problems as well. The same problems that caused the rotator cuff tear will most likely affect the rest of the shoulder. These can include acromioclavicular (AC) joint arthrosis and impingement syndrome. When surgery is suggested, the surgical procedure may have to address these conditions as well.

Finally, not all rotator cuff tears are repairable. Sometimes, the tendon has been torn for too long. This can lead to the tendon and muscle contracting. The muscle and tendon cannot be stretched enough to be re-attached to its original position. In other cases, the tendon tissue has simply worn away, and the remaining tendon is not strong enough to hold the stitches necessary to attach the tendon to bone. In these circumstances, simply removing all the torn tissue and fixing any other problems in the shoulder, such as AC joint arthrosis and impingement syndrome, may reduce your pain. It will probably not increase the strength or motion of the shoulder. It may actually decrease the motion.

If all of these attempts to improve your shoulder fail to give you a useable shoulder, there are other more complex and involved procedures that include tendon grafts and muscle transfers. These are rarely necessary, but your doctor will discuss these options with you if suggested by your situation.

Introduction

Since orthopaedic surgeons began using the arthroscope to diagnose and treat shoulder problems, several new conditions have recently been discovered. One of these is an injury to a small structure in the shoulder called the labrum. A labral tear can be very difficult to diagnose, but typically it involves pain, unusual movement and the sensation of instability in the shoulder.

Anatomy

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone) and the clavicle (collarbone). A part of the scapula, called the glenoid, makes up the socket of the shoulder. Because this socket is very shallow and flat, a rim of soft tissue, called the labrum, acts like a gasket and turns the flat glenoid surface into a deeper socket that molds to the head of the humerus for a better fit. Several shoulder tendons and ligaments attach to the labrum to help maintain shoulder stability.

The labrum can become caught between the socket and the humerus and tear. This flap of tissue can move in and out of the joint and become caught between the humeral head and glenoid socket, causing pain, catching, and shoulder instability.

Causes

The labrum can become caught between the socket and the humerus and tear. This flap of tissue can move in and out of the joint and become caught between the humeral head and glenoid socket, causing pain, catching, and shoulder instability.

Symptoms

The main symptom of a labral tear is usually a sharp, catching type sensation in the shoulder with movement. A vague aching for several hours may follow this. This catching feeling may occur only with certain movements of the shoulder, while otherwise the shoulder may feel normal and pain-free.

Diagnosis

The diagnosis of a labral tear may be suggested by the history of the condition and a physical examination. Several specific movements may cause the symptoms. With the arm raised overhead, there may be pain, and the catching sensation may be felt as the arm is raised. If the arm is raised in front of the body, with the palm of the hand facing upward, pain may be felt when downward pressure is applied.

Labral tears are sometimes visible on a magnetic resonance imaging (MRI) scan or in a computerized axial tomography (CAT) scan when a special dye has been injected into the shoulder. An MRI scan is a special radiological test where magnetic waves are used to create pictures that look like slices of the shoulder. The MRI scan shows the bones, tendons and ligaments of the shoulder.

A CAT scan is an older test that uses computer enhanced X-rays to show slices of the shoulder. Because the CAT scan uses X-rays, the soft tissues do not show up. The special dye is necessary to show the outline of the labrum. If there is a tear, the dye may leak into the tear and show up on the CAT scan. These two tests are not very accurate in detecting this problem.

Diagnosing a labral tear can be extremely difficult, and the diagnosis may rely on looking into the shoulder with the arthroscope, which is a small TV camera that can be inserted into the shoulder joint. The shoulder joint is viewed on a TV monitor. This allows the surgeon to look directly at the labrum and see if it is torn.

Treatment

Since the symptoms of a labral tear may be made worse by instability, a rehabilitation program to strengthen the rotator cuff muscles may be started by a physical therapist. Anti-inflammatory medications, such as aspirin or ibuprofen, may help the pain. If the problem persists, surgery may be required to confirm the diagnosis and attempt to treat the problem.

Surgical treatment for this condition is still evolving, since the problem has not been recognized for long enough to adequately evaluate the results of different treatments through surgery. The arthroscope can be used to treat the torn labrum in many cases. If the tear is small and is primarily getting caught as the shoulder moves, simply removing the loose part of the labrum may help the symptoms.

If the tear is larger, the shoulder may also be unstable, meaning that it is too loose. If this is the case, the labral tear may need to be repaired instead of removed. Several new techniques allow the surgeon to place small staples into the labrum through the arthroscope and attach the labrum to the bone of the shoulder socket (glenoid). If the tear is too large to repair through the arthroscope, an incision may have to be made in the front of the shoulder to repair the torn labrum

Introduction

The design of the shoulder gives it an extensive range-of-motion, but little stability. An injury to the shoulder or wear and tear of the joint can lead to pain or stiffness.

Pain in the shoulder may be mistakenly called bursitis. Bursitis refers only to inflammation in the bursa. Many problems can lead to inflammation of the bursa, or bursitis, including impingement.

Anatomy

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

The tendons of four muscles form the rotator cuff

These muscles include the supraspinatus, infraspinatus, teres minor and subscapularis. Tendons attach muscles to bones, and muscles move bones by pulling on the tendons. The rotator cuff tendon connects the humerus with the scapula (shoulder blade) and helps raise and rotate the arm.

As the arm is raised, the rotator cuff also holds the humerus tightly in the socket (glenoid) of the scapula. The part of the scapula that makes up the roof of the shoulder is called the acromion.

Between the acromion and the rotator cuff tendons is a bursa. There are many bursae all over the body where tissues must move against one another. The bursa is a lubricated sac of tissue that protects the muscles and tendons by allowing the moving parts to slide against one another with minimal friction.

Causes

Usually, there is enough room between the acromion and the rotator cuff to allow the tendons to slide easily underneath the acromion as the arm is raised. Each time the arms are raised, there is rubbing on the tendons and the bursa between the tendons and the acromion, which is called impingement.

Impingement is normal and is caused by day-to-day activities when the arm is above shoulder level. Continuously working with the arms raised overhead, such as during repeated throwing activities or other repetitive actions of the arm, can cause impingement to become a problem. Raising the arm tends to force the humerus against the edge of the acromion. With overuse, this can cause irritation and swelling of the bursa.

Conditions that decrease the space between the acromion and the rotator cuff tendon worsen the impingement. Bone spurs can further reduce the space available for the bursa and tendons to move under the acromion.

Wear and tear of the joint between the collarbone and the scapula, the acromioclavicular (AC) joint, is a fairly common cause of bone spurs. Because this joint is directly above the bursa and rotator cuff tendons, if bone spurs develop underneath the joint, the normal impingement action can become painful and cause complications.

Symptoms

Early symptoms of impingement syndrome include generalized aching of the shoulder and pain when raising the arm out from the side or in front of the body. Most patients complain of difficulty sleeping due to pain, especially when they roll over on the affected shoulder.

A very reliable sign of impingement is a sharp pain when trying to reach into your back pocket. As the process continues, discomfort increases, and the joint may become stiffer. Sometimes a “catching” sensation is felt when the arm is lowered. Weakness and inability to raise the arm may be an indication that the rotator cuff tendons are torn.

Diagnosis

The diagnosis of impingement and bursitis is made after a history and physical examination. Your doctor will be interested in your daily activities and activities related to your job, because this condition is frequently related to continuous overhead motion.

Some people have a misshapen anatomy of the acromion, where the bone tilts too far down and reduces the space between the acromion and the rotator cuff. X-rays may be used to look for this abnormal type of acromion or bone spurs from the acromioclavicular (AC) joint. Either the MRI scan or arthrogram may be performed if there is a suspected tear of the rotator cuff tendons.

An MRI scan is a special radiological test where magnetic waves are used to create pictures that look like slices of the shoulder. The MRI scan shows the bones of the shoulder and whether the tendons have been torn. The MRI scan is painless and requires no needles or dye to be injected.

The arthrogram requires injecting dye into the shoulder joint and taking several x-rays. If the dye leaks out of the shoulder joint where it was placed, the rotator cuff tendons may be torn. Both tests are widely used.

Sometimes it is unclear whether the pain is coming from the neck or the shoulder. An injection of a local anesthetic (like novocaine) into the bursa can be used to make the correct diagnosis.

If the pain goes away immediately after the bursa is injected with novocaine, then most likely the bursa is the cause of the pain. Pain from a pinched nerve in the neck would not normally be removed by injecting the shoulder with novocaine.

Prevention/Treatments

Rest: Your physician or therapist may prescribe a sling to provide adequate rest to the shoulder. It is crucial that the sling be removed several times daily while you perform your home exercises to prevent a stiff or “frozen” shoulder.

Ice: Ice decreases the size of blood vessels in the sore area, halting inflammation and relieving pain. Choices of application include cold packs, ice bags, or ice massage. Ice massage is an easy and effective way to provide first aid. Simply freeze water in a paper cup. When needed, tear off the top inch, exposing the ice. Rub three to five minutes around the sore area until it feels numb.

Medications: Your physician may prescribe anti-inflammatory medications. These include aspirin and ibuprofen. If these measures fail to reduce your pain, an injection of cortisone into the bursa may reduce the inflammation and control the pain. Cortisone is a very strong anti-inflammatory medication and can reduce the inflammation in the bursa and tendons of the rotator cuff.

Physical Therapy: It is very important to maintain the strength in the muscles of the rotator cuff since these muscles help control the stability of the shoulder joint. Strengthening these muscles can decrease the impingement of the acromion on the rotator cuff tendons and bursa. Long-term management of this problem should also address worksite alterations to reduce the need for overhead activity.

A posterior capsular stretching program and rotator cuff strengthening program may be started by your physical therapist. These programs are simply a set of exercises that will help keep the shoulder strong and flexible and help reduce the irritation from impingement. Your therapist will make sure you understand the exercises and are doing them correctly before allowing you to do them on your own.

Surgery

Surgery is commonly used to relieve the constant rubbing of impingement. The major goal of surgery is to increase the space between the acromion and the rotator cuff tendons. Initially, bone spurs under the acromion that are rubbing on the rotator cuff tendons and the bursa are removed.

Usually a small part of the acromion may also be removed to give the tendons more space and allow them to move without rubbing on the underside of the acromion. In patients who have an abnormal tilt to the acromion, more of the bone may need to be removed.

Impingement may not be the only problem in a shoulder that has begun to show wear and tear due to aging and overuse. It is very common to see degenerative (wear and tear) arthritis in the AC joint in addition to impingement. If there is reason to believe that the AC joint is arthritic, the end of the clavicle may be removed as well.

This procedure is called a resection arthroplasty. After removal of about one inch of the clavicle, scar tissue fills the space left between the clavicle and the acromion to form a false joint. This stops the arthritic pain in the AC joint caused by bone rubbing against bone. The scar tissue that forms creates a stable, flexible connection between the clavicle and the scapula.

In some cases, this can be done using arthroscopy where a small TV camera is inserted into the joint through a minor incision. Through similar incisions around the joint, the surgeon can insert special instruments to cut and burr away bone while viewing the TV screen. If your surgery is done with the arthroscope, you may go home the same day.

In other cases, an open incision of 3 or 4 inches is made over the top of the shoulder to allow removal of the bone. Bone spurs are removed, along with part of the acromion, and then smoothed. If necessary, the end of the clavicle is removed to perform the resection arthroplasty of the AC joint. This surgery may require a hospital stay of one or two nights.

Physical therapy will probably be needed for several weeks after your surgery, but recovery from shoulder surgery can take several months. Getting the shoulder moving as fast as possible is important, but this must be balanced with the need to protect the healing muscles and tissues.

Introduction

Calcific tendonitis of the shoulder occurs when calcium deposits form on the tendons of your shoulder. The tissues around the deposit can become inflamed, causing a great deal of shoulder pain. This condition is fairly common and most often affects people over the age of forty.

Anatomy

Calcific tendonitis occurs in the tendons of the rotator cuff. The rotator cuff is actually made up of several tendons connecting the muscles around your shoulder to the larger bone of the upper arm (the humerus). Calcium deposits usually form on the tendon in the rotator cuff called the supraspinatus tendon.

There are two different types of calcific tendonitis of the shoulder: degenerative calcification and reactive calcification. Wear and tear of aging is the primary cause of degenerative calcification. As we age, blood flow to the tendons of the rotator cuff decreases and makes the tendon weaker. The fibers of the tendons begin to fray and tear, like a worn-out rope. Calcium deposits form in the damaged tendons as a part of the healing process.

Reactive calcification doesn’t seem to be related to degeneration. Why this type of calcification occurs is somewhat unclear, but it is more likely to cause pain in the shoulder than degenerative calcification. Doctors think of reactive calcification in three stages. In the pre-calcific stage, the tendon changes in ways that make calcium deposits more likely to form. In the calcific stage, calcium crystals are deposited in the tendons and begin to disappear; the body simply reabsorbs the calcium deposits. It is during this stage that pain is most likely to occur. In the post-calcific stage, the body heals the tendon, and the tendon is “remodeled” with new tissue.

Caues

No one really knows what causes calcific tendonitis. Severe wear and tear, aging, or a combination of the two are involved in degenerative calcification. Some researchers think calcium deposits form because there is not enough oxygen to the tendon tissues. Others feel pressure on the tendons can damage them, causing the calcium deposits to form. Reactive calcification occurs in younger patients and seems to go away by itself in many cases.

Symptoms

While the calcium is deposited in the early calcific stage, you may feel only mild to moderate pain, or even no pain at all. Calcific tendonitis becomes very painful when the deposits are being reabsorbed. The pain and stiffness of calcific tendonitis can cause loss of motion in your shoulder. Lifting your arm may become painful. At its most severe point, the pain may interfere with your sleep.

Diagnosis

Your doctor will take a detailed medical history and do a thorough physical exam of your shoulder. The pain of calcific tendonitis can be confused with other conditions that cause shoulder pain. An X-ray is usually necessary to confirm the presence of calcium deposits and will also help pinpoint the exact location of the deposits.

You will probably need to get several X-rays over time. This will help your doctor keep track of the changes in the amount of calcification. By following the changes in the calcium deposits, your doctor can determine whether the condition will heal by itself or perhaps require surgery.

Treatment

Non-Surgical Treatment

Your doctor’s first goal will be to control your pain and inflammation. Initial treatment is likely to be rest and anti-inflammatory medication, such as ibuprofen. Your doctor may suggest a cortisone injection if your pain worsens. Cortisone can be very effective at temporarily easing inflammation and swelling.

When the calcium deposits are being reabsorbed, the pain can be especially bad. Your doctor may suggest trying to remove the calcium deposit by inserting two large needles into the area and rinsing with sterile saline, a saltwater solution. This procedure is called lavage. Sometimes lavage breaks the calcium particles loose. They can then be removed with the needles. Getting rid of the calcium deposits can help speed up the healing. Even when lavage fails to remove calcium deposits, it reduces pressure in the tendon, leading to less pain.

Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. At first, therapy focuses on easing your pain and inflammation. Treatments may include heat or ice. Hands-on treatments and various types of exercises are used to improve the range of motion in your shoulder. Strengthening exercises will help you improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This helps your shoulder move smoothly during all your activities. You may need therapy treatments for up to six or eight weeks. Most patients are able to get back to their activities with full use of their arm within this time.

Surgical Treatment

If the pain and loss of movement continue to get worse or interfere with your daily life, you may need surgery. Surgery for calcific tendonitis does not require patients to stay in the hospital overnight, but anesthesia is required.

Most surgeries to correct calcific tendonitis of the shoulder are arthroscopic surgeries. The arthroscope is a special TV camera that can be inserted into the shoulder joint through a small incision in the skin. Other small incisions allow the surgeon to insert small surgical instruments into the joint as well. The surgeon uses the arthroscope to locate the calcium deposit in the rotator cuff tendon. Once the deposit is found, the surgeon uses the small instruments to remove the calcium deposits and rinse the area. Loose calcium crystals must be removed or they can irritate the surrounding tissues.

In rare instances, open surgery is necessary. In open surgery, the doctor gets to the calcium deposit by cutting through muscles and other surrounding tissues. The tendon itself is cut so the calcium deposits can be removed. The doctor then rinses the area to get rid of calcium crystals and stitches the muscle and skin together.

Rehabilitation

You may need to follow a program of rehabilitation exercises, whether or not you need surgery. Your doctor may recommend you work with a physical or occupational therapist. Your therapist can create an individualized program of strengthening and stretching for your shoulder.

It is very important to strengthen the muscles of the rotator cuff, as these muscles help control the stability of the shoulder joint. Strengthening these muscles can actually decrease the pressure on the calcium deposits in the tendon. Simple changes in the way you sit or stand can ease pain and help you avoid further problems.

Rehabilitation after shoulder surgery can be a slow process. You will probably need to attend therapy sessions for several weeks, and you should expect full recovery to take several months. Getting the shoulder moving as soon as possible is important. However, this must be balanced with the need to protect the healing tissues.

You may be required to wear a sling to support and protect the shoulder for a few days after surgery. Ice and electrical stimulation treatments may be used during the first few therapy sessions to help control pain and swelling from the surgery. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasms and pain.

Therapy can progress quickly after a simple arthroscopic resection. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You should avoid doing too much, too quickly.

Your exercises are designed to get your shoulder working in ways that are similar to your tasks and activities. A therapist will help you find ways to do tasks that don’t put too much stress on your shoulder. You will also learn new ways to avoid future problems.

Introduction

A shoulder separation is a fairly common injury, especially in certain sports. Most shoulder separations are actually injuries to the acromioclavicular (AC) joint. The AC joint is the connection between the scapula (shoulder blade) and the clavicle (collarbone). Shoulder dislocations and AC joint separations are often mistaken for each other. But they are very different injuries.

Anatomy

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone). The part of the scapula that makes up the top part of the shoulder is called the acromion. The AC joint is where the acromion and the clavicle meet. One set of ligaments surrounds the AC joint, forming the joint capsule. Two other ligaments hold the clavicle down and attach it to a bony knob on the scapula called the coracoid process.

The AC joint can be injured in different ways. The simplest type of injury is a simple sprain of the ligaments around the joint, normally referred to as a grade one injury. The injury is more severe when the ligaments around the joint actually tear (grade two injury). If the ligaments around the joint and the ligaments that attach the clavicle to the coracoid process tears, the injury results in an obvious bump on the shoulder (grade three injury).

Causes

The most common cause of an AC joint separation is falling on the shoulder (Fig. 3). As the shoulder strikes the ground, the force from the fall pushes the scapula down. The collarbone cannot move enough to follow the motion of the scapula. The ligaments around the AC joint begin to tear, dislocating the joint.

Symptoms

The symptoms of AC joint separation range from tenderness over the joint to the intense pain of a complete dislocation. Grade two and three separations can cause a considerable amount of swelling. Bruising may occur several days after the injury. Grade three separations usually cause a noticeable bump on the shoulder.

Diagnosis

Your doctor will need to get information about your injury and a detailed medical history. You will need to answer questions about past injuries to your shoulder. You may be asked to rate your pain on a scale of one to ten.

Diagnosis is usually made by the physical examination. Your doctor may move and feel your joint. This may hurt, but it is very important that your doctor understand exactly where your joint hurts and what movements cause you pain.

Your doctor may order X-rays. X-rays can show the dislocation, and they may be necessary to rule out a fracture of the clavicle. In some cases, X-rays are taken while holding a weight in each hand to stress the joint and show how unstable it is.

Non-Surgical Treatment

The majority of AC injuries do not require surgical treatment. Treatment for a grade one or grade two separation usually consists of pain medications and a short period of rest using a shoulder sling. Your rehabilitation program may be directed by a physical or occupational therapist. A permanent rehabilitation program for the AC joint may be needed.

Surgical Treatment

Surgery involves relocating the joint and repairing the torn ligaments (Fig. 4). This surgery is done through a four-to-five inch incision over the AC joint. A screw or some other type of fixation may be used to hold the clavicle in place while the ligaments heal. The screw is usually removed six to eight weeks after the surgery.

Rehabilitation

If surgery is not needed, a physical or occupational therapist may recommend range-of-motion exercises that should be started as pain eases, followed by a strengthening program. At first, exercises are done with the arm kept below shoulder level. The program advances to include strength exercises for the rotator cuff and shoulder blade muscles.

After surgery, your doctor may have you wear a sling to support and protect the shoulder for a few days. A physical or occupational therapist will probably direct your recovery program. The first few therapy treatments will focus on controlling the pain and swelling from surgery. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapists usually wait four weeks before starting range-of-motion exercises. You will begin with passive exercises. In passive exercises, the shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm.

Active therapy starts six to eight weeks after surgery, giving the ligaments time to anchor solidly to the bone. Active range-of-motion exercises help you regain shoulder movement using your own muscle power. You may begin with light strengthening exercises that work the muscles without straining the joint.

After three months, you will start more active strengthening. Exercises will focus on improving strength and control of the rotator cuff muscles and the muscles around the shoulder blade. This helps the shoulder move smoothly during all your activities.

Recovery from shoulder surgery can take some time. You will need to be patient and adhere to your therapy program. Some of the exercises you’ll do are designed to get your shoulder working in ways that are similar to your everyday activities. Before your therapy sessions end, your therapist will teach you a number of ways to help avoid future problems.