Shoulder and Elbow Surgery

Osteoarthritis is a degeneration of a joint.  It is a progressive condition that typically worsens over time.  The protective surface covering the end of the bones is called articular cartilage.  This cartilage allows the joint to move smoothly and painlessly.  Over time, this cartilage becomes damaged and wears away.  Once the cartilage wears away, the bones change shape and density as a reaction to the increased stress on them. These changes result in stiffness and pain.

Osteoarthritis is typically thought of as a “wear and tear” problem.  Many times, the actual cause of osteoarthritis is not clear.  Different factors, however, have been identified as possibly contributing to the development of osteoarthritis.  These factors include: trauma to the shoulder, prior shoulder surgery, overuse of the shoulder (especially with heavy weights), and inflammatory conditions that affect the joints (i.e. Rheumatoid Arthritis).  Osteoarthritis many times develops in individuals who engage in high-intensity overhead activity (i.e. weight-lifting, tennis, baseball). Arthritis can also occur when patients have had a large, chronic rotator cuff tear. This causes a slightly different type of arthritis called "cuff tear arthropathy".

Patients with osteoarthritis of the shoulder classically complain of stiffness and pain.  This pain can be associated with movement, or with sleep (typically on the affected side).  Nighttime pain may become so severe that it wakes a patient up at night. Many times, patients also notice a loss of range of motion of the shoulder.  Occasionally, “catching,” “crunching,” or “noise” may be heard or felt during shoulder motion.

Osteoarthritis is usually diagnosed by a combination of the clinical examination, history of patients’ complaints and imaging studies.  X-rays are typically performed to evaluate the extent of the damage to the joint, which may help to determine the best treatment option.  A diagnosis of osteoarthritis can typically be made based on X-rays.  A CT scan of the shoulder may also be used to assess the damage to the joint if there is concern for extensive damage to the bones.  Magnetic resonance imaging (MRI) is occasionally used to assess the quality of the muscles and tendons surrounding the shoulder joint.  This information is sometimes useful in determining the best treatment option for a patient with arthritis. There is no blood test to check for arthritis.

Non-operative treatment options are usually attempted first in the treatment of osteoarthritis.  These options may include:

1. Physical therapy – used to help prevent worsening stiffness and loss of shoulder motion.  Strengthening the muscles around the shoulder may also help keep pressure off the painful areas, providing some pain relief.
2. Anti-inflammatory medications – since most of the pain from osteoarthritis is inflammatory in nature, anti-inflammatory pain medications may be taken to provide symptomatic relief.  Although these medications may provide temporary pain relief, they do not cure arthritis or stop the progression of the disease.
3. Steroid injections – can be used to provide short-term relief in a patient with a lot of pain from arthritis.  The amount of time that a steroid injection provides pain is quite unpredictable and varies widely among patients.  Some patients experience pain relief for months, while others only a few weeks.  Repeated injections should be avoided since they can cause further damage to the joint and the surrounding tissues.

Unfortunately, there are no injections or medications that have been shown to re-grow cartilage in the setting of osteoarthritis.  Stem cells have not been shown to slow or stop the rate of progression of shoulder arthritis.  Certain injections, such as hyaluronic acid, may help to lubricate the joint during motion, but do not slow or stop the progression of arthritis.

After non-operative treatments have been exhausted, surgery may be indicated to treat osteoarthritis of the shoulder.  A number of surgical options do exist, and your surgeon may recommend one to you based on your history and diagnosis.

1. Arthroscopy – shoulder arthroscopy for osteoarthritis is not typically used in the setting of shoulder arthritis.  In rare instances, arthroscopy can be used to remove large bone spurs and inflamed tissue.
2. Shoulder replacement – in cases when non-operative management has not provided sufficient pain relief, shoulder replacement surgery is often performed.  Shoulder replacement surgery has a very successful history, with high levels of patient satisfaction.  Shoulder replacement surgery has been shown to improve pain scores and patient function.  For the treatment of arthritis, shoulder replacement surgery typically involves one of two specific replacements:
   • Total Shoulder Arthroplasty (TSA) -- is used if the rotator cuff muscles and tendons are not torn or degenerated.  If the rotator cuff muscles are functioning, a total shoulder arthroplasty (which relies on the rotator cuff muscles for power) is typically performed.
   • Reverse Total Shoulder Arthroplasy (RTSA) – is used if the rotator cuff muscles are torn or degenerated.  This type of shoulder replacement relies on the deltoid muscle for power (eliminating the need for healthy rotator cuff muscles and tendons).

Some patients go home the same day as their shoulder replacement surgery, while others spend one night in the hospital. All patients are sent home with pain medication. Patients are required to wear a sling for at least 2-6 weeks following surgery.

The best way to prevent shoulder arthritis is to live a healthy lifestyle. This includes maintaining a healthy weight while doing your normal routines.  Remain active to maintain muscle strength and range of motion.  Attempt to limit high intensity, overhead exercise or work.  Focus, instead, on range of motion and flexibility.  It is important to stay active, and avoid using the shoulder only in the setting of severe pain.  

The rotator cuff is a sleeve of 4 muscles that come off of the scapula and attach to the humeral head.  The rotator cuff has several functions:  it helps initiate motion and rotate the arm in space; it acts as a dynamic stabilizer of the shoulder, keeping the shoulder in the joint.  

Rotator cuff tears are very common, especially in people over the age of 65.  Up to 50% of people over 65 have a rotator cuff tear, and many of these patients have no symptoms. 

Tears are classified based on the type of tears, and how large the tear is.  In many patients, there is inflammation or impingement only, and the rotator cuff tendon is intact with just tendon degeneration.  In other patients, there may be partial tearing or degeneration of the rotator cuff, while others have full thickness tears and symptoms of shoulder pain and weakness. 

The most common symptoms of rotator cuff tears are pain at night, pain with overhead activity, and difficulty doing sports and activities of daily living such as lifting objects off of shelves.  If the tear gets larger, patients will have some weakness as well. 

For degenerative tears, the best initial treatment for most patients is a 6-12 week course of physical therapy. This often leads to an improvement in symptoms and the ability to return to activities and sports.  Anti-inflammatory medications such as aleve or ibuprofen can help as well as they decrease the inflammation associated with rotator cuff problems. Steroid injections function by rapidly decreasing inflammation above the rotator cuff and can be very effective in relieving pain.

Non operative treatments will often make symptoms improved, but full thickness tears will not heal.  Over the course of 5 years, about 50% of full thickness tears will get larger (only 30% of partial tears will get bigger in 5 years).  In some cases, the muscle quality of the rotator cuff can deteriorate as well.  In most cases, if the tear does get larger, then patients will develop more pain and weakness. 

The most common injection used in the shoulder is a corticosteroid injection combined with an anesthetic agent like Marcaine.  This is very effective in relieving the pain associated with inflammation, and is thought to be safe.  There is no absolute number of injections that can be done, but it is typically recommended to be evaluated by an orthopaedic surgeon if multiple injections have been required. 

For non-acute tear, surgery is done for rotator cuff tears after patients have tried physical therapy, activity modification, and anti-inflammatory medication.  The best indications for surgery in patients with a full thickness rotator cuff tear is an inability to do normal daily activities and an inability to return to recreational activities.  In patients that are not able to return to these activities despite a course of non-operative treatment, surgical may be indicated and lead to an improvement in outcomes.  The surgery is typically arthroscopic, and performed on an outpatient basis.  It typically takes 6 weeks in a sling for the repair to heal, and up to 6 months for a return to full activities. 

The shoulder joint is the body's most mobile joint. It can turn in many directions but this advantage also makes the shoulder an easy joint to dislocate. Shoulder instability/ partial dislocation (subluxation) means the head of the upper arm bone (humerus) is partially out of the socket (glenoid). A complete dislocation means it is all the way out of the socket. Both partial and complete dislocation cause pain and unsteadiness in the shoulder.

Since the shoulder is inherently unstable, the shoulder is the most commonly dislocated joint. They tend to happen more frequently in contact and collision sports such as football, lacrosse, hockey, basketball, but can also happen in sports such as skiing and snowboarding.

When the shoulder dislocates, a majority of the time the shoulder comes out the front of the shoulder, and either the patient or a medical professional manipulates the shoulder back into place. X-rays are usually taken to confirm that the shoulder is back in. When the shoulder dislocates, the labrum, which is a little bumper that goes around the glenoid socket, is torn (90% of the time) and there can be a bone injury called a Hill Sachs injury on the back of the ball of the shoulder. These injuries are usually diagnosed on MRI. Sometimes, with repeated dislocations, there can be loss of bone which can make the shoulder more unstable, and additional imaging with a CT scan may be helpful.

Usually patients have pain and instability for 1-2 weeks after the injury, but over time the shoulder will feel better and better. After the pain and swelling go down, the doctor will prescribe rehabilitation exercises for you. This helps restore the shoulder's range of motion and strengthen the muscles which provide much of the stability to the shoulder. Rehabilitation may also help prevent dislocating the shoulder again in the future. Rehabilitation will begin with gentle muscle toning exercises. Later, weight training can be added. If shoulder dislocation becomes a chronic condition, a brace can sometimes help. However, if therapy and bracing fail, surgery may be needed to repair or tighten the torn or stretched ligaments that help hold the joint in place, particularly in young athletes.

The best treatment for a shoulder dislocation depends on how many times it has happened, the type of sport one participates in, and the age of dislocation. For a first time dislocator, treatment can be physical therapy followed by a return to sports. If the shoulder feels good, then it is OK to return to sports (on average 4-6 weeks after the injury). Treatment for selected individuals may also be surgical depending on a number of factors patients should consult with their surgeons about.

For people who have recurrent dislocations, or people who continue to feel unstable after the shoulder injury, arthroscopic surgery can be recommended to improve the stability of the shoulder. During the surgery, the torn labrum is reattached to the socket with small anchors. This surgery has a high success rate to return patients to sports/activities.

For people who have had so many shoulder dislocations that the socket is affected, surgery may require more advanced bony augmentation procedures that patients should consult with their surgeons about.

If there are no more dislocations, then the shoulder likely will be fine over time. However, repeated dislocations can cause progressive bone loss and can predispose the shoulder to arthritis. Patients with recurrent instability often change their activities as well to avoid dislocations.

Biceps tendinitis is inflammation of the long head of biceps tendon which connects the biceps muscle to the shoulder blade. Another fancier name for biceps tendinitis is biceps tenosynovitis which means the same thing and refers to irritation to the tissue that surrounds the tendon. The tendon can become red, swollen, and quite painful.

The biceps tendon connects the muscle belly of the biceps muscle to the shoulder blade. It runs in a groove in the front of the humerus bone and tracts in to the shoulder joint to insert on the shoulder blade. There are actually two biceps tendons, a long head and a short head. The short head tendon inserts outside the shoulder joint and is rarely the cause of pain; however, the long head tendon is the frequent culprit for shoulder pain as it is covered with tissue that is rich in nerve endings and easily can be inflamed. The main job of the biceps muscle is to help supinate the forearm; which means rotating your forearm from palm down to palm up.

Because the long head of the biceps runs in a groove in the front of humerus bone and then courses in the shoulder joint to attach to upper part of the glenoid (scapula bone), the pain is classically in the front of the shoulder along the tendon. The tendon is also tender to touch when the doctor presses on it in the front of the shoulder and that is the most common method an orthopedic surgeon makes the diagnosis.

Biceps tendinitis can occur at any age, but typically affects people age 20-50 and is common in people who lift weights or objects in front of the body or overhead.  In patients that are over the age of 40, biceps tendinitis can occur with other problems in the shoulder like rotator cuff tears.

Initial treatment consists of rest and anti-inflammatories. That means taking a break from the activities that cause the irritation such as overhead sports, lifting weights, push-ups, and lifting heavy objects. The goal is to get the inflammation that surrounds that tendon to calm down. Physical therapy can also be helpful as you will need to strengthen the muscles surrounding the shoulder so that when you perform your favorite overhead or lifting activities, your shoulder will be strong and supported throughout the motion. Another treatment strategy involves injecting the tendon with a strong anti-inflammatory medication called cortisone. Again, the goal is to get the tendon and surrounding nerve fibers to calm down by decreasing inflammation. 

Yes, but only after non-operative treatment strategies have failed. The biceps tendon can be cut from within the shoulder joint and allowed to retract out of the shoulder joint. This is called a tenotomy. Another treatment is cutting the tendon from within the shoulder joint and re-attaching it outside the shoulder joint, but toward the top of the humerus bone. This is called a tenodesis. The goal is get the diseased and painful tendon out of the shoulder joint so that it stops causing you pain.

No, the biceps muscle is not the main flexor of the arm, it’s another muscle called the brachialis; therefore, cutting this tendon will have no noticeable difference in arm flexion. 

The long head of the biceps is what ruptures from its insertion in the shoulder joint. It is not actually the main flexor of the arm and therefore does not need to be fixed. When it happens, it can sometimes have a different contour in the arm and is called a “Popeye deformity.”  The short head tendon is still intact and the muscle will still actually function. It is important to differentiate where the tendon ruptures from; however, because if it ruptures from the most distal insertion on the radius (a bone in the forearm), it might need to be fixed with surgery.

Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move. Frozen shoulder occurs in about 2% of the general population. It most commonly affects people between the ages of 40 and 60, and occurs in women more often than men.

In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint. The hallmark sign of this condition is being unable to move your shoulder - either on your own or with the help of someone else. It develops in three stages: In the "freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months. Pain may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

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

Diabetes: Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.

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

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

Diagnosis is made on physical exam--typically a loss of motion in more than one plain with active and passive motion.  
Other tests that may help your doctor rule out other causes of stiffness and pain include:

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

Magnetic resonance imaging (MRI) and ultrasound: These studies can create better images of problems with soft tissues, such as a torn rotator cuff.  An MRI is not necessary for the diagnosis of frozen shoulder, but can help rule out other problems. 

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

Nonsurgical Treatment:  More than 90% of patients improve with relatively simple treatments to control pain and restore motion.

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

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

Physical therapy: Specific exercises will help restore motion. These may be under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before the stretching exercises. In general, a combination of anti-inflammatories and hands-on physical therapy can be very effective in returning range of motion and improving pain.  Physical therapy is often prescribed, and an ultrasound guided injection can be given to decrease pain and inflammation if the loss of range of motion has been going on for a while or the pain is quite severe.

Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse. Recent studies show that tennis elbow is often due to damage to a specific forearm muscle. The extensor carpi radialis brevis (ECRB) muscle helps stabilize the wrist when the elbow is straight. When the ECRB is weakened from overuse, microscopic tears form in the tendon where it attaches to the lateral epicondyle. This leads to inflammation and pain on the outside of the elbow. The forearm muscles and tendons become damaged from overuse — repeating the same motions again and again. 

Athletes are not the only people who get tennis elbow. Most people who get tennis elbow are between the ages of 30 and 50, although anyone can get tennis elbow if they have the risk factors. Many people with tennis elbow participate in work or recreational activities that require repetitive and vigorous use of the forearm muscle.
Painters, plumbers, and carpenters are particularly prone to developing tennis elbow. Studies have shown that auto workers, cooks, and even butchers get tennis elbow more often than the rest of the population. It is thought that the repetition and weight lifting required in these occupations leads to injury.

Common signs and symptoms of tennis elbow include: Pain or burning on the outer part of your elbow and a weakened grip strength
The symptoms are often worsened with forearm activity, such as holding a racquet, turning a wrench, or shaking hands. Your dominant arm is most often affected; however both arms can be affected.

Approximately 80% to 95% of patients have success with nonsurgical treatment.

Rest: The first step toward recovery is to give your arm proper rest. This means that you will have to stop participation in sports or heavy work activities for several weeks.

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

Physical therapy: Specific exercises are helpful for strengthening the muscles of the forearm. Your therapist may also perform ultrasound, ice massage, or muscle-stimulating techniques to improve muscle healing.

Brace: Using a brace centered over the back of your forearm may also help relieve symptoms of tennis elbow. This can reduce symptoms by resting the muscles and tendons.

Steroid injections: Steroids, such as cortisone, are very effective anti-inflammatory medicines. A steroid injection to the painful area around your lateral epicondyle may relieve your symptoms.

Equipment check: If you participate in a racquet sport, you may want to get your equipment checked for a proper fit. Stiffer racquets and looser-strung racquets often can reduce the stress on the forearm, which means that the forearm muscles do not have to work as hard. If you use an oversized racquet, changing to a smaller head may help prevent symptoms from recurring.

If your symptoms do not respond after 6 to 12 months of nonsurgical treatments, you may benefit from surgical management.  

Surgical procedures for tennis elbow involve removing diseased muscle and reattaching healthy muscle back to bone.

The olecranon bursa is a potential space between the bony surface of the olecranon and the skin.  It normally is filled with a minimal amount of fluid and allows for easy gliding between the skin and the bone on the back of the elbow.  Olecranon bursitis is when this potential space gets inflamed and the bursa begins to produce fluid in response to the inflammation, filling the potential space.

There are many causes of olecranon bursitis.  This includes trauma, prolonged pressure from resting elbows on hard surfaces, infection like an insect bite or a puncture wound, or medical conditions like rheumatoid arthritis. 

Swelling is the most common symptom and the first to appear.  The skin on the back of the elbow is loose, and oftentimes early swelling may not be appreciated.  

Pain is another common symptom.  As the swelling increases and the bursa stretches, this can cause pain.  Direct pressure on an inflamed bursa can also cause pain.  If the swelling progresses, there can be some limitation in motion at the elbow.  

Redness and warmth can be signs that the bursa is infected.  

Non-surgical management is the mainstay of treatment for olecranon bursitis.  These treatment options can include elbow pads or compression sleeves, activity modification to reduce the amount of pressure placed on the elbow, or medications like anti-inflammatories (aleve, ibuprofen, diclofenac).  Sometimes, if the fluid in the elbow persists, removal of some of the fluid may be performed.  Additionally, if there is concern for an infection in the bursa, some fluid may be removed and analyzed.  Sometimes, corticosteroid injections into the bursa may help reduce inflammation. 

Surgery is typically performed only after exhausting non-surgical treatments in an inflamed bursa that is causing symptoms, or in cases of an infected olecranon bursitis.

There will be a splint on your arm after the surgery. This is to allow the skin and soft tissues to rest and heal.  The skin and soft tissue on the back of the elbow can be tenuous in nature, so care must be taken to allow the surgical incisions to heal well.  The splint is typically removed at the first post-operative visit 10-14 days after surgery, a compression bandage is placed for the next 6 weeks, and gentle elbow motion is performed.  Total recovery time is between 4-6 weeks if the wound heals well.