Shoulder Injuries

Cause

The labrum can be torn in a variety of ways.  Overhead athletes are particularly vulnerable to labral tears specifically, SLAP tears, due to the stress on the shoulder during sport.  The labrum can tear due to direct trauma to the labrum such as landing on our arm or shoulder.  Football linemen are also particularly vulnerable to labrum tears, specifically the posterior labrum, due to the force of pushing into the shoulder during play.  The labrum can also be torn by repetitive trauma like pitching a baseball or spiking a volleyball due to peeling back and tearing of the labrum.

Anatomy

The shoulder is made up of the humerus articulating with the glenoid, which is part of the scapula.  The shoulder is analogous to a golf ball on a tee, in which the humerus is the golf ball and the tee is the glenoid.  The labrum is a ring of tissue that surrounds the glenoid and helps give stability to the shoulder joint.  The labrum would represent the extra lip on the tee to keep the ball staying on the tee.  One head of the biceps also has a tendon that inserts at the top of the labrum.  A SLAP tear occurs when the biceps tendon pulls on this portion of the labrum and tears the labrum in this position, often due to repetitive overhead motions like throwing.  The front on the labrum is commonly torn with a shoulder dislocation.  The back of the labrum is commonly torn with a fall or repetitive force with the arms out in front of you like a football lineman.  A portion of the labrum or several portions of the labrum can be torn with injuries.

Imaging

X-rays are typically taken in order to evaluate for any arthritis or bone damage that may have occurred.  An MRI is typically performed in order to evaluate if the labrum is torn and the complexity of the tear

Treatment

Depending on your injury, labral tears can often be treated initially with physical therapy, which is offered at our Rochester, MI or Shelby Township, MI locations or we can recommend a therapist near you.  However, depending on your specific sport or activity as well as your response to therapy, surgery may be of most benefit.  Surgery is performed arthroscopically and strong suture is used to repair your torn labrum back down to the glenoid using suture anchors.  This will allow the labrum to heal back to the torn area.

Recovery

If you undergo surgery, this is offered at our Rochester, MI location at Crittenton Hospital or at our Shelby Township, MI location at 23 mile and Romeo Plank.  After surgery you will typically be in a sling for about 3-4 weeks.  The steps to healing include initial immobilization to allow the labrum to heal while beginning initial range of motion.  After initial healing of the labrum, strengthening of the shoulder can then begin.  The whole process can take anywhere from 4-6 months depending on your activity level and longer depending on your sport.

Cause

Often times a shoulder dislocation is caused by a traumatic event.  Patients with seizures are at increased risk for shoulder dislocations.  If the shoulder continues to be unstable, it may even become dislocated by minor events.

Anatomy

The shoulder is composed of the humerus and the glenoid, which is a part of the scapula.  The shoulder is a relatively unconstrained joint and therefore requires several other stabilizing structures to keep it in place.  The labrum is a ring of tissue that surrounds the glenoid and give stability to the shoulder.  The rotator cuff also provides compression and stability to the shoulder as well as the surround shoulder muscles.  The most common shoulder dislocation is anterior or out the front and almost always tears the front of the labrum and sometimes some bone as well.  This labral tear is known as a Bankart lesion and can lead to continued instability of the shoulder if not treated.

Imaging

X-rays are typically taken in order to evaluate for any fractures or bone loss from the dislocation as well as make sure the shoulder is currently located.  An MRI is typically performed in order to evaluate the extent of soft tissue damage including the labrum.  A CT scan may also be ordered to evaluate the bone if significant bone loss is a concern.

Treatment

Multiple factors come into consideration when treating a shoulder dislocation.  The main goal is to provide a functional shoulder and prevent re-dislocation.  The younger you are and the more physical sport or activity you play, the more likely you are to have another dislocation.  Initial treatment is allowing the soft tissues to heal and begin some physical therapy for more stability in the shoulder.  After discussion about your options, if surgery is decided, surgery will involve repair of the torn labrum using strong suture and anchors in the glenoid.  In some instances, if too much bone is lost, additional procedures at the same time would be needed to replace bone loss, this is known as a coracoid transfer or latarjet procedure.

Recovery

If you undergo surgery, this is offered at our Rochester, MI location at Crittenton Hospital or at our Shelby Township, MI location at 23 mile and Romeo Plank.  After surgery you will typically be in a sling for about 3-4 weeks.  The steps to healing include initial immobilization to allow the shoulder to heal while beginning initial range of motion.  After initial healing of the shoulder, strengthening can begin.

Cause

Shoulder separations are caused by a direct fall onto the shoulder. This is commonly seen in football players going down after a tackle or soccer goalies diving for a ball. This can also happen with any type of fall and can commonly be seen falling from a bike.

Anatomy

The clavicle is attached to the scapula at the acromion known as the acromioclavicular joint (AC joint). The clavicle is secured in place by strong AC ligaments as well as ligaments from the coracoid process to the clavicle (CC ligaments, conoid and trapezoid). A tear in these ligaments occurs first at the AC joint and will more severe trauma can advance to tear the CC ligaments. Due to tearing of the ligaments, the clavicle will then be elevated above the shoulder. This will result in a prominence of the clavicle at the skin.

Imaging

X-ray imaging is typically all that is needed to diagnose this injury and can often compare to the other shoulder.

Treatment

Treatment for these injuries depends on multiple factors. The degree of tear and amount of elevation is a key factor toward deciding if surgical or non-surgical treatment is warranted. Another factor is your activity level and the amount of stress you will be putting on your shoulder. Non-surgical treatment typically involves a period of relative rest to allow for inflammation to get under control and pain to be managed. This can be aided at times by physical therapy as needed. Surgical treatment involves arthroscopic surgery combined with a small incision on the top of your clavicle. The procedure typically uses a graft to replace your torn ligaments and a strong suture and button to secure the clavicle down in the proper position.

Recovery

Again recovery will depend on the extent of your injury and can be anywhere from 2-6 weeks with non-operative treatment. Surgical treatment will require initial sling use followed by time to allow the ligaments to heal in place and will typically requires months to recover fully.

Cause

Often times the cause of shoulder impingement or bursitis is caused by overuse or repetitive trauma to the bursa.  There can sometimes be an overgrowth of the acromion, which can make some individuals more prone to impingement.  Overall, the cause of impingement is from inflammation or swelling of the bursa above the rotator cuff.  The bursa is a layer of tissue that aids in gliding of the shoulder.  With inflammation of the bursa, the bursa gets larger and swollen and creates pain and impingement with movement of the shoulder.

Anatomy

Above the rotator cuff is a layer of tissue called the bursa.  The bursa aids in movement of the shoulder between the rotator cuff and from the acromion bone above (the bone you can feel on the top of your shoulder).  When this tissue gets inflammed, it causes impingement of the bursa with the acromion when raising the arm above your head or certain positions.

Imaging

X-rays are typically used to assess the bony anatomy and determine any spur formations causing impingement as well as any arthritis.  Often times the diagnosis is made on physical exam, but an MRI my be needed to evaluate for other issues when indicated.

Treatment

Impingement and bursitis can often be treated with antiinflammatories and physical therapy.  Sometimes an injection into the shoulder known as a subacromial injection can place direct antiinflammatory medication into the inflammed tissue.  If these do not solve the issue, surgery may be indicated to clear the inflammed tissue and clear more space for movement, while addressing any other issues in the shoulder.

Recovery

Often times, physical therapy is done for 6 weeks, but an injection in the shoulder can give relief in as little at 2 days and may last depending on symptoms.  If surgery is done, depending on what is done, requires a period of mobilization of the shoulder and then strengthening with most recovery obtained after a couple of months.

Biceps tendonitis can be a common cause of shoulder pain.  This occurs because of inflammation in the biceps tendon, typically due to overuse.

Cause

The biceps tendon is located in the front of the shoulder and can become quite irritated leading to inflammation of the tendon and the surrounding tissues.  There are multiple reasons the tendon can become inflammed, but it is commonly due to repetitive activities and overuse of the arm.

Anatomy

The biceps muscle is made up of two heads, the short and long head.  The tendon of the long head of the biceps runs in a groove on the front part of the humerus and inserts into the shoulder joint.  Issues with the biceps tendon can happen at any course during this path.  There can be inflammation of the tendon in the groove and all the way into the joint, to the point where the tendon can flip in and out of the groove.

Imaging

X-ray imaging is typically performed to evaluate for any arthritis in the joint that may be causing issues.  An MRI may be obtained if there is concern for other issues including a rotator cuff tear or a labrum tear.

Treatment

Biceps tendonitis is typically treated without surgery initially with anti-inflammatories to decrease the inflammation around the tendon.  A direct anti-inflammatory such as a steroid can be injected directly into the tendon sheath to significantly decrease the inflammation of the tendon.  If this does not fix the issue, or if there are other issues that may need surgery like a rotator cuff repair, the biceps tendon can then be secured into the groove known as a biceps tenodesis.  This tenodesis is used because it will prevent any further movement of the biceps in the inflammed area and get rid of any inflammed tissue.  This does not lead to any strength loss.  Sometimes the tendon can rupture from either a trauma or wear out over time and this may lead to a “reverse Popeye” deformity at the arm.  This can be treated the same way with a biceps tenodesis or sometimes left as is. 

Recovery

Recovery will depend on your treatment, but an injection often times leads to immediate relief within a day or so.  If surgery is performed, we must allow time for the tendon to heal in place, however, the majority of function to the shoulder can be resumed.

Shoulder arthritis involves wear and tear of the cartilage in your shoulder.  Arthritis can develop in the shoulder joint itself (involving the humerus and glenoid) or at the AC joint, where the clavicle articulates with the scapula.

Cause

Most arthritis is caused by wear and tear of the joint to the point where the cartilage begins to wear out.  As the cartilage wears down, the joint does not move as easy and can begin grinding.  This can cause significant pain and stiffness in the shoulder.  When involved in the AC joint, this involves pain on the top of the shoulder and more pain with cross body movements.

Anatomy

The shoulder joint is made up of a ball and cup with the humerus as the ball the the glenoid (a portion of the scapula) as the cup.  Wear and tear of this joint leading to arthritis typically causes pain and grinding with most range of motion.  The AC or acromioclavicular joint is a connection of the clavicle to the scapula (known as the acromion).  This joint can wear out as well and typically pain is noticed with pressure to this joint, mostly with direct pressure or crossing your arm to reach to the other side.

Imaging

X-rays can help confirm the diagnosis as we can see decreased joint space with loss of the cartilage as well as bone spur formation around the joint.  MRI may be needed in some cases if surgery is planned.

Treatment

Treatment for shoulder arthritis as well as AC joint arthritis is initially non-operative which involves direct injection of steroids in the joint to decrease inflammation that causes pain as well as symptomatic treatment.  Surgery for AC joint arthritis involves arthroscopic surgery in which a small portion of the clavicle that has the damaged cartilage is removed.  This removes the damaged cartilage causing pain.  Treatment for shoulder arthritis involves a total shoulder replacement.  Depending on the function of your rotator cuff and the amount of wear in your joint will determine if you benefit more from a normal total shoulder replacement or a reverse total shoulder replacement.  A shoulder replacement involves an incision on the front of the shoulder and removal of the damaged cartilage on the humeral head and glenoid and replacement with metal and plastic parts.

Recovery

Recovery after AC joint arthritis treatment typically involves allowing the tissue to heal and the inflammation to calm down after surgery.  This involves regaining shoulder range of motion and any strength deficits after surgery.  Recovery is typically a month or so.

Recovery after a total shoulder replacement is much different.  Most of our shoulder replacements are still done as outpatient surgery, but you will be in a sling for at least a few weeks to allow for healing.  It then takes time to regain shoulder range of motion and full strength, with overall recovery at several months.

A pec (pectoralis major) tendon tear is a significant injury that is commonly experienced with lifting weights or performing a bench press.  As one of the major muscles of the upper body, it is important to regain function of this muscle.

Cause

A pec tendon tear commonly occurs with weight lifting, most commonly during bench press when bringing the bar down to the chest.  It can occur by other trauma in which the muscle faces significant force.

Anatomy

The pectoralis major tendon inserts onto the humerus.  The muscle originates from the chest wall and at the sternum.  The pec tendon also forms the front fold of the arm pit.  Therefore, with a tear of the tendon, you lose the contour of the arm pit and the tendon may retract medially.

Imaging

An MRI is often performed in order to evaluate the amount the tendon is torn as well as the location of the tear, being off the bone or in the muscle.

Treatment

Pec tendon tears will typically require surgery to repair the tendon, also certain types of tears my be treated without surgery.  The surgery to repair the tendon involves an incision over the front of the shoulder and strong suture is used to secure the tendon back to the bone using either metal buttons or suture anchors to secure the tendon back to bone.

Recovery

Recovery after Pec tendon repair is initially not using the arm or placing force on the shoulder to allow the tendon time to heal.  Once the tendon is healed, more range of motion of the shoulder can begin.  After full healing of the tendon, strengthening with resume and full activity can begin including weight lifting after strength has returned.

Adhesive capsulitis, more commonly known as frozen shoulder, can begin without a specific inciting event.  It will typically go through three stages known as the freezing, frozen and thawing stages.

Cause

Adhesive capsulitis is commonly caused by a metabolic abnormality that causes the shoulder capsule to become stiff and therefore cause limited motion and pain in the shoulder.  The most difficult movements become reaching behind the back and specifically external rotation.  There are several specific causes, but it is known to occur more commonly in diabetes and thyroid disorders.

Anatomy

The capsule of the shoulder is involved in frozen shoulder.  The overall capsule becomes tight and limits motion to the shoulder.  Specifically, the anterior and superior portion of the capsule becomes involved.

Imaging

The diagnosis is mainly based on physical exam and history, but MRI can be helpful if other causes may be a concern.

Treatment

The majority of the time, frozen shoulder can be treated without surgery.  The frozen stage can be quite painful, so the objective is to control the pain and begin to regain motion.  Often times a steroid injection into the shoulder can help with the pain and allow for therapy to be more successful with regaining full shoulder range of motion.  Surgery can sometimes be necessary if motion is not returning.  Surgery involves arthroscopic surgery and release of the capsule and tight tissue to regain shoulder range of motion.

Recovery

This can be a very difficult condition because it can take months and months to get better.  Although difficult, it is important to be patient and allow any injections to help and physical therapy and home exercises to do their work and improve your pain and range of motion.

The overhead athlete presents with many unique issues that can be difficult to deal with without extensive knowledge of the challenges these athletes may face.  The most common overhead sport that comes to mind are baseball players, specifically baseball pitchers.  However, any sport that requires overhead throwing or activity can lead to the same issues.  These sports would also include softball, volleyball, swimming, football (quarterback), and track and field (javelin).  Because of the motion the shoulder goes through during throwing, the muscles, joint capsule, ligament, cartilage, tendons and cartilage all go through changes to adapt to these repetitive stresses.  There are many issues that occur in the shoulder that are common in throwers and should not be mistaken for true injury.  It is important to focus on when the pain occurs, where in the shoulder it occurs and if there are any associated issues.  Physical exam is very important as this will help to focus in on the true injury, rather than the chronic issues that may be present in the shoulder.  We have done a good amount of research in throwing athletes including changes in shoulder range of motion and the result of Tommy John surgery or injuries that often times are the result of abnormal mechanics in the shoulder.  Our team works together to properly diagnose your shoulder issue and work with experienced team members to develop a plan to get you returned to your throwing sport at peak levels.