Experiencing a painful, weak, achy, stiff, or restricted shoulder?
The shoulder has the greatest range of motion of any joint in the body, but that very flexibility makes it prone to injury and wear. Many problems may be caused by repeated overhead motions for an extended period of time. Athletes and do-it-yourselfers are especially vulnerable to overuse problems, which can lead to serious shoulder pain, weakness, and make it difficult to perform even simple tasks like lifting groceries or getting dressed.
The shoulder is a ball-and-socket joint that enables you to raise, twist and bend your arm. It also lets you move your arm forward, to the side and behind you. In a normal shoulder, the rounded end of the upper arm bone (head of the humerus) glides against the small dish-like socket (glenoid) in the shoulder blade (scapula). These joint surfaces are normally covered with smooth cartilage. They allow the shoulder to rotate through a greater range of motion than any other joint in the body.
What could be causing shoulder pain?
Shoulder pain may often be caused by injury or trauma from lifting heavy objects or strenuous exercise. It could also be caused by the inflammation or loss of cartilage in the shoulder joint, also known as Arthritis.
The surrounding muscles and tendons provide stability and support. Unfortunately, with overuse, injury, or trauma a loss of cartilage and mechanical deterioration of the shoulder joint may occur. The result can be pain. You can have a stiff shoulder that grinds or clunks, leading to loss of strength, decreased range of motion in the shoulder and impaired function. X-rays of the shoulder would show:
- Loss of the normal cartilage joint space
- Flattening or irregularity in the shape of the bone
- Bone spurs
- Loose pieces of bone and cartilage floating inside the joint
In severe cases, bone-on-bone arthritis may lead to erosion--wearing away of the bone.
Osteoarthritis, sometimes called “wear-and-tear” arthritis, is a common reason people may have shoulder replacement surgery. It affects mainly older individuals in all walks of life and over time, the shoulder joint slowly becomes stiff and painful. Unfortunately, there is no way to prevent the development of osteoarthritis.
Patients with arthritis typically describe a deep ache within the shoulder joint. Initially, the pain feels worse with movement and activity, and eases with rest. As the arthritis progresses, the pain may occur even when you rest. By the time a patient sees a physician for the shoulder pain, he or she often has pain at night. This pain may be severe enough to prevent a good night's sleep. The patient's shoulder may make grinding or grating noises when moved. Or the shoulder may catch, grab, clunk or lock up. Over time, the patient may notice loss of motion and/or weakness in the affected shoulder. Simple daily activities like reaching into a cupboard, dressing, toileting and washing the opposite armpit may become increasingly difficult.
Severe fracture of the shoulder is another common reason people seek treatment for shoulder pain. When the shoulder is injured by a hard fall or car accident, it may be very difficult for a doctor to put the pieces back together. When the head of the upper arm bone is shattered, the blood supply to the bone pieces is interrupted. In this case, a surgeon may recommend a shoulder replacement. Older patients with osteoporosis are most at risk for a severe shoulder fracture.
Patients with a massive long-standing rotator cuff tear may develop cuff tear arthropathy. In this injury, the changes in the shoulder joint due to the rotator cuff tear may lead to arthritis and destruction of the joint cartilage.
Avascular necrosis is a condition in which the bone of the humeral head dies due to lack of blood supply. Chronic steroid use, deep sea diving, severe fracture of the shoulder, sickle cell disease and heavy alcohol use are risk factors for avascular necrosis.
An injury to the rotator cuff — the group of muscles and tendons that keep your shoulder in place — can happen suddenly on the playing field or at work, develop gradually or simply occur as a result of aging.
Common symptoms of a rotator cuff tear include:
- Recurrent pain, especially with certain activities
- Pain that prevents you from sleeping on your injured side
- Grating or cracking sounds when moving your arm
- Limited ability to move your arm
- Muscle weakness
If your symptoms and/or tendon tears are mild, orthopedic specialists will usually first recommend nonsurgical options, including rest, physical therapy or anti-inflammatory injections. But, if the pain worsens and continues to limit your life, surgery may be the best option to help restore mobility and provide relief.
If a severely injured shoulder is keeping you from living like you used to, you may be a candidate for rotator cuff surgery. At Mimbres Valley Medical Group, the orthopedic surgeons specialize in arthroscopic rotator cuff repair, a minimally invasive option that can help get your shoulder, and life, back in motion.
What are the available treatment options?
Non-Surgical Treatment Options
Treatment of an arthritic shoulder starts with rest, exercise and taking arthritis medications. Resting the shoulder and applying moist heat can ease mild pain. After strenuous activity, an ice pack may be more effective at decreasing pain and swelling.
Physical therapy may be helpful when arthritis is in early stages, as it helps maintain joint motion and strengthen the shoulder muscles. Physical therapy is less effective when the arthritis has advanced to the point that bone rubs on bone. When this is the case, physical therapy may make the shoulder hurt more.
Arthritis medications, called nonsteroidal anti-inflammatories (NSAIDs), can control arthritis pain. Certain NSAIDs may be purchased over-the-counter, while others require a prescription. Periodic cortisone injections into the shoulder joint can provide temporary pain relief, but excessive cortisone shots could have adverse effects.
Rotator Cuff - Arthroscopic Repair
In the past, surgery to repair the rotator cuff tendonitis has been done through a large shoulder incision, and the muscle over the rotator cuff had to be separated. But newer, arthroscopic techniques, like those offered by Mimbres Valley Medical Group surgeons, can be done with just a few small incisions and with minimal disruption to surrounding tissue.
The procedure involves inserting specialized, miniature instruments, including a small camera called an arthroscope. The camera displays the image of the joint on a large monitor, allowing the surgeon to pinpoint and repair the damaged area.
Arthroscopic rotator cuff repair may offer a variety of benefits compared to open surgery. These benefits may include:
- Less post-operative pain
- Less scarring
- Fewer complications
- Faster healing time
- Easier rehabilitation
- More shoulder flexibility and function
At Mimbres Valley Medical Group we usually perform arthroscopy on an outpatient basis, allowing you to leave the hospital the same day and recover comfortably at home. Be sure to talk to your orthopedic specialist about the details of what will happen during the procedure and what kind of results can be expected.
Surgical Joint Replacement Options
If nonoperative treatments fail, shoulder replacement surgery may be needed. Shoulder replacement surgery is highly technical and should be performed by a surgical team with experience in this procedure. Your surgeon will evaluate your situation carefully before making any decisions. Do not hesitate to ask what type of implant will be used in your situation and why that choice is right for you.
Shoulder replacement surgery started in the United States in the 1950s and was used as a treatment for severe shoulder fractures. Over the years, this surgery has come to be used for many other painful conditions of the shoulder, including:
- Osteoarthritis (degenerative joint disease)
- Rheumatoid arthritis
- Post-traumatic arthritis
- Rotator cuff tear arthropathy (a combination of severe arthritis and a massive non-reparable rotator cuff tendon tear)
- Avascular necrosis (osteonecrosis)
- Failed previous shoulder replacement surgery
- Severe fractures
There are several different types of shoulder replacements. The usual total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem, and a plastic socket.
The components come in various sizes. If the bone is of good quality, your surgeon may choose to use a non-cemented or press-fit humeral component. If the bone is soft, the humeral component may be implanted with bone cement. In most cases, an all-plastic glenoid component is implanted with bone cement. Implantation of a glenoid component is not advised if:
- the glenoid has good cartilage.
- the glenoid bone is severely deficient.
- the rotator cuff tendons are irreparably torn.
Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement.
Depending on the condition of the shoulder, your surgeon may replace only the ball. Sometimes, this decision is made in the operating room at the time of the surgery. Some surgeons replace the ball when it is severely fractured, and the socket is normal.
Another type of shoulder replacement is called reverse total shoulder replacement. This surgery was developed in Europe in the 1980s. It was approved by the Food and Drug Administration (FDA) for use in the United States in 2004. Reverse total shoulder replacement is used for people who have:
- completely torn rotator cuffs and
- the effects of severe arthritis (cuff tear arthropathy) or
- had a previous shoulder replacement that failed
For these individuals, a conventional total shoulder replacement can still leave them with pain. They may also be unable to lift their arm up past a 90-degree angle. Not being unable to lift one's arm away from the side can be severely debilitating. In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder bone and a plastic socket is attached to the upper arm bone. This allows the patient to use the deltoid muscle instead of the torn rotator cuff to lift the arm.
What to expect before surgery?
Before surgery, patients see their internist or family practice physician for a preoperative medical evaluation. Cardiac patients should see their cardiologist as well. Two weeks before surgery, you should stop taking the following medications that thin the blood and can lead to excessive bleeding during surgery:
- Nonsteroidal anti-inflammatory medications (aspirin and ibuprofen such as Motrin®and Advil®)
- Most arthritis medications
The surgery is performed on an inpatient basis with most patients discharged from the hospital on the second or third day after the operation.
A careful, well-planned rehabilitation program is critical to the success of a shoulder replacement. You usually start gentle physical therapy on the first day after the operation. You wear an arm sling during the day for the first several weeks after surgery. You wear the sling at night for 4 to 6 weeks. Most patients are able to perform simple activities such as eating, dressing and grooming within 2 weeks after surgery. Driving a car is not allowed for 6 weeks after surgery.
Here are some "do's and don'ts" for when you return home:
- Don't use the arm to push yourself up in bed or from a chair because this requires forceful contraction of muscles.
- Do follow the program of home exercises prescribed for you. You may need to do the exercises 4 to 5 times a day for a month or more.
- Don't overdo it! If your shoulder pain was severe before the surgery, the experience of pain-free motion may lull you into thinking that you can do more than is prescribed. Early overuse of the shoulder may result in severe limitations in motion.
- Don't lift anything heavier than a glass of water for the first 6 weeks after surgery.
- Do ask for assistance. Your physician may be able to recommend an agency or facility if you do not have home support.
- Don't participate in contact sports or do any repetitive heavy lifting after your shoulder replacement.
- Do avoid placing your arm in any extreme position, such as straight out to the side or behind your body for the first 6 weeks after surgery.
Many thousands of patients have experienced an improved quality of life after shoulder joint replacement surgery and have experienced less pain, improved motion and strength, and better function.
*Patient results may vary. Consult with your physician about the benefits and risks of any surgical procedure or treatment.
Adam Bevevino, MD
Kelly V. Fitzpatrick, DO
Gens Goodman, DO, FAAOS
Joseph Lanzi, MD