At OCV most rotator cuff, bicep surgery and instability repairs are done as an outpatient without a major incision. Dr. Morgan notes that while the arthroscopic methods have largely done away with large incisions, full recovery from many of these procedures may still take several months.
- Dr. Kropac specializes in Workers Compensation shoulder injuries and evaluations. He provides non-surgical care for both neck and shoulder problems.
- Dr. Belcher performs surgery on arthritic shoulders, and examination and conservative treatment of other shoulder problems.
- Dr. Branson and Dr. Morgan perform evaluation of shoulder problems. arthroscopic shoulder surgery, shoulder replacements and reverse shoulder replacements.
- Gregory Southers, PA performs shoulder evaluations working closely with the doctors to provide faster access to specialty care.
What to expect at your appointment:
The doctor will take a history of your problem. “If you listen to your patients, they will always tell you what is wrong.” Take a few moments to jot down significant history. The checklist below has a few reminders to help you in the process.
Examination: The doctor will evaluate your range of motion, strength, stability and perform a neurologic exam. Wear a tank top or similar shirt that will allow the doctor to see the front, side and back of your shoulder.
Studies: The doctor will review xrays, MRI and nerve conduction studies. Be sure to tell the staff about studies you have had. It is important for you to bring copies of reports and DISKS of the studies with you to your appointment. Facilities do not send studies to our office. Our doctors review images of your studies as well as the report. If the images or reports are not available, full diagnosis of your problem may be delayed.
Treatment: After evaluating your problem, the doctor will explain what is going on with your shoulder and begin appropriate treatment. Injections may be performed at the time of the visit.
Strength, Stability and Mobility:
From lifting hundreds of pounds over head to sewing or fixing a watch, shoulder function is critical to everything we do. Shoulder mobility allows us to put our hand where it needs to be. Strength and stability keeps our hands steady for fine motor functions, and links our arm to the more powerful muscles of our torso and legs. For this reason, shoulder problems may impact almost everything we do in day to day life.
How does your shoulder provide both mobility and stability? The hip joint is a ball in socket type joint. The socket provides significant stability. In contrast, the shoulder is more like a ball on a plate. Ligaments, labrum (cartilage) and the rotator cuff muscles are required stabilize the joint. Treating your shoulder problem involves understanding the function of these structures and what happens to the shoulder when each structure is injured.
Is it a SHOULDER problem?
Many problems may cause shoulder pain. When you make your appointment, be sure to let the doctor know if you have any of the following problems or symptoms, as they may cause some or all of your shoulder symptoms:
- Left shoulder pain: Heart problems, angina, heart attack, unstable high blood pressure
- Neck problems: Pain on the side of the neck, back of the shoulder (as shown on the image) pain radiating below the elbow or to the fingers, finger numbness
- Prior neck surgery
- Carpal tunnel syndrome: Night time awakening with numbness of the fingers, particularly the thumb and index finger
- Pain radiating up to the neck
- Upper abdominal pain / gallbladder pain / significant change in bowel habits
- You have been told you have rheumatoid arthritis, psoriatic arthritis or other inflammatory arthritis
- Prior surgery on the shoulder
- Stroke or TIA
All of these issues will be evaluated to formulate a comprehensive treatment plan for your shoulder problem. If you have a history of neck surgery and cervical pain, Dr. Kropac may perform the screening examinations.
When should you see the doctor?
Self directed treatment: Minor injuries and overuse may respond to over the counter medications (ibuprofen, naproxen, tylenol), heat, ice and gentle stretching. As a general rule for minor injuries, it is important to maintain gentle motion. Immobilization of the shoulder may result in stiffness after only a few days. If you are unsure whether your injury is minor, it is probably better to be checked by the doctor. Severe loss of movement, swelling or numbness in the fingers may indicate more serious problems that should be evaluated sooner.
Patients under age 25 In this age group most shoulder problems are related to trauma or overuse. For acute fractures or dislocations, immediate attention is suggested. Follow up of acute injuries, or for less severe injuries, we typically recommend evaluation within 1 to 3 weeks after the injury. In some cases, surgery may be recommended. The final treatment plan, including decision to have surgery is usually made within the first 3 weeks following the injury. For young, active patients early surgical intervention for dislocations and ligament injuries may improve the outlook for the future. The doctors will determine if you are a candidate for early stabilization procedures. For this group of patients, an arthroscopic reconstruction allows visualization and primary repair of torn ligaments. Primary anatomic repair may decrease the risk of future instability, and maintains a greater range of motion compared to late repair.
Age 30 to 40: Rotator cuff problems become more frequent. Tendonitis / bursitis and traumatic tears are common. The doctor will work with you to identify the best surgical and non surgical treatment options. Non surgical treaments include NSAID / anti-inflammatory medications, injections and physical therapy. Surgical options in this age group most often involve arthroscopy. Arthroscopy is an outpatient procedure where small incisions are used with specialized instruments to repair injured muscles, ligaments and tendons
In the 50 -60 year range, degenerative changes in the rotator cuff and shoulder joint are more common. OCV doctors will differentiate conditions that require surgery from those that can be managed with non-operative methods. When you should see the doctor depends on the severity of your symptoms, degree of weakness and loss of motion. If you have significant weakness, or substantial loss of motion, early intervention may shorten the overall treatment course. Often seeing the doctor within 4-6 weeks is sufficient.
Above 65, arthritis and rotator cuff insufficiency are more common. For routine problems, seeing the doctor within 4-6 weeks of onset of symptoms is usually sufficient, while other patients may wait months to be checked. The OCV physicians will carefully assess your condition and discuss best surgical and non-surgical options. Some loss of function is normal with advancing age. Proper care can help improve the quality of life and function. In some cases, earlier intervention may improve long term prognosis for function.
See the doctor if you are experiencing decreased range of motion, significant persisting pain or weakness in your arm. Above the age of 70, the percentage of good to excellent results for rotator cuff repair is lower. In arthritic shoulders, total shoulder or reverse total shoulder plays more of a role. Specific treatment for your problem and the role of surgery will be clearly explained by the doctor. It is important to know that over 50% of patients in this age group with no shoulder symptoms may have a rotator cuff tear on MRI. Many patients with abnormal MR studies may still be managed without surgery.
COMMON SHOULDER PROBLEMS:
Shoulder pain and loss of motion can be caused by disorders fo the burse, tendons, muscles and bones of the shoulder.
Full evaluation of the shoulder will include history, physical examination with evaluation of mobility, stability, strength and neurologic function.
is the mainstay of minimally invasive surgery for shoulders. At OCV, most shoulder surgery other than replacement is done without a big incision. OCV physicians have a special interest in advanced arthroscopic techniques for rotator cuff repair and shoulder dislocation. Dr. Branson and Dr. Morgan have been using these advanced techniiques to treat rotator cuff tear, instability and dislocations since 1992.
Dr. Branson did research on computer modeling of rotator cuff surgery with the visible human project. Actual anatomic specimens were converted to 3 D digital models to better understand how to position small incisions to do major surgery with small incisions without injuring nerves and blood vessels. He also did primary research on the repair of rotator cuff tears without a large incision. The research was presented to an international congress on minimally invasive surgery.
A bursa is a sack adjacent to tendons that allow tendons to move smoothly around other muscles tendons or bones. Bursitis is inflammation of that sack. Bursitis can cause pain and a feeling of grinding or popping in the shoulder. Bursitis is often treated with NSAID medications, exercise, physical therapy and cortisone injection.
The major tendons of the shoulder are the tendons of the rotator cuff, biceps and pectoral muscle. The rotator cuff consists of the tendons of the supraspinatus, infraspinatus subscapularis and teres minor. Rotator cuff tendonitis may cause dull ache in the shoulder, pain with lifting the arm away from the body and pain at night. Bursitis, tendonitis and rotator cuff tear may have similar symptoms. Tendonitis may be differentiated from rotator cuff tear on exam, or by MR imaging or arthroscopy. On exam, strength is usually preserved in tendonitis, and decreased with rotator cuff tear. Rotator cuff tendonitis often treated with NSAID medications, exercise, physical therapy and cortisone injection. If the shoulder does not respond to these treatments, then MRI or arthroscopy may be useful to determine if the cuff tendons are torn.
Impingement refers to the pinching of the supraspinatus, biceps tendon and subuacromial bursa when the arm is brought overhead. When the arm as brought away from the body (abducted) these structures are pinched between the humerus bone and the overlying acromion. In some cases, the acromion has a hook or spur that decreases the clearance for movement of the shoulder which increases the pinch effect with shoulder movement. Impingement and internal impingement are common problems for overhead throwing athletes and Weight lifters. Impingement may be treated for several months before considering surgical procedures. Non-surgical treatment includes modification of activities, physical therapy, exercise and injections. For throwing athletes, correction of throwing mechanics often improves impingement. For isolated impingement, arthroscopic decompression may be performed. In decompression, some bone is removed from the undersurface of the acromion to decrease the pinching of the rotator cuff.
Rotator cuff tear:
The rotator cuff muscles include the supraspinatus, infraspinatus, teres minor and subscapularis. These muscles control the movement of the humerus (ball) on the glenoid (socket) . When the function of the rotator cuff muscles is disrupted, the deltoid muscle becomes less effective. This results in weakness in oving the arm away from the body. The most common rotator cuff tear tear is in the Supraspinatus. The rotator cuff guides the bones to allow smooth movement of the arm to the side (abduction) forward (forward flexion) outward from the body with the arm at the side (external rotation) and in toward the belly (internal rotation). The doctor will test your strength in many positions to determine the function of each cuff muscle. Pain from bursitis or tendonitis may limit strength, mimicking the exam findings of cuff tear.
Rotator cuff tears are commonly caused by injury in patients under the age of 45. Such tears are frequently repaired using the arthroscope. In many traumatic tears, the muscle and tendons are in good condition. Arthroscopic repair of traumatic tears with good tissue often yield good to excellent return to function. In contrast, tears in patients older than 60 may be related to wear and tear. In some cases, advancing age with poor quality tissue may result in failure of the repair, or limit the ability to regain strength and function. Since up to 50% of patients over the age of 60 with no shoulder symptoms may have a tear on MRI, the decision to have surgery must be carefully considered.
Labral Tears or SLAP lesions:
The labrum is a tough cartilage structure attached to glenoid (socket) sidte of the shoulder. In addition to its attachment to the bone, the labrum is attached to the ligaments of the shoulder and the long head of the biceps. Labral tears can result in deep aching pain in the shoulder, posterior shoulder pain and painful catches or popping. Labral tears may be the result of athletic injuries in the younger athletes, or associated with the wear and tear of aging.
Patient age and size, location and severity of the tear determine treatment options. For many tears, modification of activity and physical therapy may restore sufficient function. For high demand athletes under the age of 35, arthroscopic repair of the labrum may improve function. For bicep tendon tears or large labral tears particularly in patients above the age of 40, biceps tenotomy or tenodesis may relieve the pain associated with tears. Biceps tenotomy is the simple release of the biceps from the labrum, which decreases traction on the injured tissue. Tenotomy may result in a permanent cosmetic deformity of the biceps. (“popeye”) In biceps tenodesis, the biceps tendon is cut, then fastened to the humerus bone near the shoulder. Tenodesis involves more surgery than tenotomy, but for most patients it will eliminate the “popeye” deformity. Releasing the tendon while retaining function of the biceps is possible since the muscle has two attachments near the shoulder.
Arthrofibrosis / Frozen Shoulder:
Some patients experience gradual painful loss of motion in the shoulder. Motion is restricted under muscle power (active) and when someone else moves the arm (passive). This condition is more common in diabetics. Frozen shoulder may be related to an injury, but frequently happens out of the blue. Early evaluation and treatment usually shortens the time to recovery. Treatment involves physical therapy, medication and injections. In some cases, manipulation under anesthesia or arthroscopy may be required. Manipulation is an outpatient procedure. The doctor moves your shoulder to release scar tissue while you are under anesthesia. The arthroscopic release is an outpatient procedure where the scar tissue is surgically divided or removed. With either option, physical therapy and aggressive motion exercises will be required to prevent the scar tissue from coming back.
Like all joints, the shoulder is susceptible to damage to the smooth cartilage surfaces of the humeral head (ball) and glenoid (socket) The arthritis may be a primary, due to injuries, or caised by injury or inflammation.. Arthritis causes painful motion that may be associated with grinding or catching in the shoulder. Arthritis is more common with advancing age. Longstanding rotator cuff insufficiency can cause significant arthritis as well.
In the early stages arthritis, treatment goal is to maintain motion and control pain. Cortisone injections and medications may give temporary relieve.
In later stages, total shoulder replacement surgery is the main option to reduce pain and regain function. For shoulders with a functioning rotator cuff, Total shoulder replacement is an option. For shoulders lacking rotator cuff function or strength, reverse shoulder replacement may be considered.
Reverse Total Shoulder:
Reverse total shoulder can restore motion and relieve pain for patients wit chronic rotator cuff tears. In the reverse shoulder, the ball and socket aspects of the shoulder are reversed. In a normal shoulder, the round part is on the humeral (arm) side. In a reverse shoulder, the ball part is attached to the glenoid or socket. The “reversal” allows the deltoid muscle to move the arm without a functioning rotator cuff.
Clinical examination shows atrophy or loss of rotator cuff muscle and weakness in moving the arm away from the side of the body. MRI may be used to plan surgery, and determine the condition of the rotator cuff. If the rotator cuff is repairable, standard total shoulder may be considered. If the cuff is absent or irrepairable, reverse shoulder may be more appropriate.
For patients with arthritis with a functioning rotator cuff, the arthritic surfaces of the ball and socket of the shoulder are replaced with metal and plastic implants. (Prostheses). The rotator cuff muscles are repaired. Rotator cuff function is required to regain good motion and strength following the surgery.
Both total shoulder and reverse total shoulder are typically done in the hospital with a 1-2 day hospital stay. Physical therapy is required following the surgery to regain motion and strength.