Shoulder Information

Background 

The rotator cuff consists of 4 muscle-tendon units (supraspinatus, infraspinatus, teres minor, subscapularis) originating on the scapula and inserting around the proximal humerus. The rotator cuff is critical to shoulder function, working as a force couple to help center the humeral head on the glenoid (keeps the golf ball centered on the tee) as the shoulder moves through range of motion. 

Rotator cuff tears are extremely common and increase in prevalence with age. Tears can happen acutely during sports or traumatic events such as shoulder dislocation, but more commonly happen with gradual wear and tear over time. Rotator cuff injury can be a spectrum of pathology from tendonitis and bursitis, to partial tearing, to complete tears of varying tear pattern and size. 

A torn rotator cuff can lead to significant shoulder pain and dysfunction. In large or full thickness tears, patients will often experience weakness with raising the arm or rotation of the shoulder. The specific functional deficit depends on which tendon(s) are torn. 

Management

Partial thickness tears and rotator cuff tendinosis (wear of the tendon without discrete tearing) can usually be treated without surgery. As always, non-operative treatment does not mean “no treatment”. Patients with partial thickness tears will often greatly benefit from a rest period from heavy overhead activity, physical therapy to work on strengthening and coordination of surrounding muscles, and sometimes injections for pain relief. 

Indications for surgery are patient specific and depend on many factors including size of the tear, chronicity, patient age, symptoms, goals and expectations and muscle/tissue quality on MRI. In general, full thickness tears causing shoulder weakness benefit from surgical repair, which is performed arthroscopically whenever possible. 

In some cases of very chronic retracted tears where the muscle has atrophied and been replaced by fat, standard repair is not possible, and/or re-tear rates are extremely high even with successful technical repair. In these situations, options may include reverse total shoulder replacement, or repair augmented with allograft or tendon transfer. 

Recovery and Prognosis 

Full recovery from rotator cuff repair surgery may take 6 months or more. Patients are typically placed in a sling for 6 weeks, followed by gradual progression of range of motion and strengthening guided by a skilled physical therapist 

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Background 

Glenohumeral joint instability (i.e. shoulder subluxation/dislocation) is a relatively common condition in active individuals and athletes, particularly those involved in contact sports. The shoulder joint is somewhat similar to a golfball on a tee and is inherently less stable than the ball and socket joint of the hip, for example. This allows for a very high degree of range of motion multiple planes, which is necessary for daily life and athletic activities, but also lends itself to instability. 

Most commonly the shoulder joint dislocates anteriorly; however, posterior instability can also occur. 

The shoulder labrum acts like a bumper to prevent the humeral head from dislocation and is also closely associated with the shoulder joint capsule. When the shoulder partially or completely dislocates, tearing of the labrum and stretching of the capsule occurs. The more times your shoulder dislocates, the worse the tearing becomes, and the higher likelihood that more dislocations will continue to occur. Eventually recurrent dislocations can lead to not only labral tearing and capsular injury, but also injury and wear to the bone on the humeral head and glenoid surfaces. 

Shoulder instability can also be associated with rotator cuff tears, particularly in patients over the age of 40, as well as fractures and rarely, neurovascular injury. 

Management 

Acute shoulder dislocations should be reduced (put back into place) urgently to prevent damage to cartilage and other anatomic structures. Often the shoulder will self-reduce; however, formal reduction by a trained orthopaedic provider may be necessary. Occasionally this can be done on the field of play after the injury, but often a trip to the emergency department is necessary.

After a first-time dislocation, non-operative treatment may be appropriate. This is determined on a case by case basis and involves a short period of immobilization followed by physical therapy and gradual return to activities and sports.

Patients with multiple instability events are often good candidates for surgical stabilization. This is most commonly an arthroscopic shoulder surgery that involves repairing the labrum/capsule (i.e. Bankart repair) and sometimes repairing a bone defect in the humeral head (Hill-Sachs lesion) by a remplissage (“filling”) procedure.

Patients with numerous dislocation events that have experienced significant bone loss around the shoulder joint may require an open surgical reconstruction with bone grafting to adequately stabilize the shoulder joint. 

Recovery and Prognosis 

Shoulder instability can be a challenging condition to treat, as recurrence of instability is possible with both non-surgical and surgical treatment. In general, younger patients involved in contact sports are at higher risk for recurrence after an instability event.

After a first-time dislocation, nonoperative management involves a short period of immobilization in a sling followed by gradual range of motion and strengthening exercises guided by a physical therapist. Athletes are often able to return to competition in 4-6 months pending functional and sports specific training with physical therapy.

After arthroscopic labral repair surgery, patients will undergo an intensive rehabilitation process that starts with a period of immobilization followed by gradual range of motion and strengthening exercises with physical therapy. Patients typically return to sports between 4 and 6 months post-operatively.

Rehabilitation and recovery after an open shoulder stabilization procedure (such as Latarjet procedure) is longer.