Dr. Budoff's Blog

Acromio-Clavicular (AC) Joint Injuries Subluxation Dislocation Instability

October 31st, 2011

The Acromio-Clavicular (AC) Joint is the small joint on top of the shoulder where the clavicle attaches. If the AC joint is hit head-on, such as when falling off a bike or tackling somebody without shoulder pads, the clavicle may detach, raise up and become noticeably ‘out of joint’. A dislocation occurs when no part of the clavicle remains touching the acromion bone that it normally sets into. A subluxation is a partial dislocation, meaning that the clavicle goes partially out of joint, with part of the clavicle still touching the acromion.

X-rays are necessary to confirm the diagnosis and make sure that a clavicle fracture isn’t present. Unless the AC joint injury occurs in a young manual laborer or an overhead athlete, it’s often best to wait for at least 3 months before considering any surgical reconstruction of the AC joint ligaments that hold the AC joint in place, even in a professional (non-overhead) athlete. The pain will usually subside faster and people usually return to sports quicker without surgery, even to collision sports such as football or rugby. The arm is placed in a sling for a couple of weeks to let the inflammation subside, and then range of motion exercises are begun, either at home or under the direction of a therapist. At 6 weeks, strengthening of the rotator cuff and muscles about the shoulder blade, which may also be affected by the injury, can begin.

The vast majority of people with AC joint injuries can be treated without surgery. The exceptions are when the clavicle is extremely high riding, if the clavicle has been forced backward through its restraining fascia (a sheet of stabilizing tissue), or forced downward under a bone called the coracoid (which is incredibly rare). Although these circumstances are uncommon, they do occur, and are a good reason to have any shoulder injury evaluated by a shoulder or upper extremity specialist.

If non-operative management fails to provide significant pain relief after 3 months, it’s usually because the AC joint ligaments didn’t heal on their own and the end of the clavicle remains unstable. This may lead to persistent pain with shoulder motion. Often, the end of the clavicle is so unstable that it can be moved around with a couple of fingers. In these cases, surgical stabilization may be considered.

There are many surgical stabilizations described to treat AC joint instability. All work fairly well, although some work better than others. However, none of them recreate a totally normal AC joint. I prefer to use a cadaveric hamstring tendon (semi-tendinosis allograft) to recreate the torn ligaments. This is an outpatient procedure. The clavicle is reduced back to its natural place and held there with a ligament reconstruction that includes the cadaveric hamstring tendon to add more strength. However, there is almost always some degree of stretch following surgery. While the clavicle usually raises up a little, it is usually stable enough so that it no longer hurts and full activities can be performed. To prevent the surgical reconstruction from stretching out too much, it is necessary to protect the shoulder until enough scar forms to provide strength. To protect the reconstruction, a sling is worn for 6 weeks with only limited motion allowed until then. Fortunately, despite this immobilization, the shoulder doesn’t usually get very stiff as the surgery is entirely outside of the shoulder joint. Overall, most people do very well following this surgery, and can return to their usual work and sporting activities by 4-6 months.

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Arthroscopic Rotator Cuff Repair

September 12th, 2011

The rotator cuff is made up of the muscles and tendons that help you elevate your shoulder (for details, please see the rotator cuff section in my main website). If the rotator cuff becomes damaged enough, a tear may occur. However, not all rotator cuff tears require surgery.

Rotator cuff tears can occur naturally as part of the aging process and may be normal in people aged 60 years or greater. So people who are 60 years or older who haven’t experienced any trauma and who can raise their arms over the head can be treated nonoperatively, at least initially. A steroid injection with a therapeutic strengthening program will decrease pain and other symptoms in roughly 2/3 of these patients. After 3 months, if the pain is not satisfactorily improved, an arthroscopic rotator cuff repair can be considered.

For those younger than 60 years who have had trauma, and especially for those with shoulder weakness or who are unable to elevate their arm, a rotator cuff repair should be performed. I prefer to perform rotator cuff repairs arthroscopically, which decreases postoperative pain and stiffness. The sooner the repair is performed after the rotator cuff tears, the better. If a traumatic tear is not fixed in a timely manner, which is usually a number of months, it can retract, become stiff and the muscles attached to the torn tendon can atrophy and turn to fat.

Arthroscopic rotator cuff repair is performed as an outpatient procedure. If desired, a nerve block can be performed by the anesthesiologist. This involves a needle stick into the area above the shoulder to block all of the nerves going into the arm so that nothing is felt for 12-24 hours. This is optional, and some have it done and some do not. If you don’t have a high pain tolerance you might want to consider getting the block. For those who don’t get the nerve block, I inject morphine into the shoulder joint and perform a single nerve block, which can ‘take the edge off’ of the pain for 8 to 12 hours. Regardless, arthroscopic rotator cuff repairs performed without subacromial decompression (bone removal), are not very painful. As noted on my website’s main section on rotator cuff repairs, the modern literature, including my own original research papers, has shown that removing bone from the acromion is not only unnecessary, but is painful, leads to stiffness and can cause unwanted biomechanical changes in the shoulder.

While the surgery is not very painful, the postoperative course following a rotator cuff repair is highly inconvenient. An abduction pillow, a sling with a pillow on it that is nearly-universally hated, is worn for 6 weeks. There is no ‘active’ arm elevation (ie. using the operated shoulder to lift the arm) for 6 weeks, and no lifting anything heavier than a telephone for 3 months. Please add a ‘2 week penalty’ to all of those time-periods for very large rotator cuff tears, very old rotator cuff tears and revision (redo) rotator cuff repairs. Physical therapy is used depending on how much the patient can do on their own after surgery. Some need a lot of therapy, some hardly any.

The rotator cuff tendons are very slowly healing tissues. It takes about 1-1.5 years before the shoulder feels ‘as good as it’s going to get’. However, when all is said and done, most patients who obey the restrictions and perform their home exercises are much improved and extremely happy with the improvements in their pain relief, strength and shoulder function.

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Acromioclavicular (AC) Joint Arthritis

May 17th, 2011

Arthritis of the AC joint leads to pain at the top of the shoulder. This happens more frequently in laborers and weight-lifters, but is very common in the general population as well. The diagnosis of AC joint arthritis is best made on physical examination. This is because arthritic changes of the AC joint are extremely common on X-rays and MRI. In fact, 90% of people over the age of 30 have AC joint arthritis on X-ray and/or MRI. However, seeing some arthritis on X-ray or MRI doesn’t mean that the AC joint is actually causing pain; more commonly, it is a ‘red herring’, and not the cause of problems.

If pain is coming from the AC joint, the first treatment is non-operative. Weight-lifters can try widening or narrowing their grip on the bar to see if helps. A steroid injection can be helpful, at least temporarily. If the steroid wears off, then the pain can be lived with or addressed surgically.

The surgery involves removing a small amount, 5-7 mm, of bone from the outside of the clavicle. This creates a space where the AC joint was so that the two bones, the acromion and the clavicle, don’t rub together anymore. Distal clavicle excision can usually be accomplished arthroscopically, except in circumstances where a bone spur has grown so far outside the joint that an open incision is required to remove it.

The distal clavicle excision is usually performed in conjunction with any other necessary arthroscopic shoulder procedures. Arthroscopic distal clavicle excision requires no specific post-operative activity limitations. While the bone may be sore for a few months, this procedure usually provides lasting relief from the pain of AC joint arthritis. Distal clavicle excision is a commonly performed very successful outpatient procedure that has been performed for decades and has “stood the test of time”.

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Biceps Tendon Disorders

March 24th, 2011

The biceps tendon has two muscle ‘heads’ that contribute to it, the long head and the short head. The long head goes through the shoulder, where it often has problems. It can fully tear, partially tear, become painfully degenerative, or sublux/dislocate out of its groove. Any of these conditions can lead to pain in the front of the shoulder.

Sometimes the long head of the biceps tendon completely tears. This may occur after it has been painful for a while due to degeneration, or without any preexisting symptoms. The tear often occurs with a pop, with some pain, swelling and bruising over the front of the shoulder. The biceps muscle usually retracts down the arm a little bit, causing it to look larger and more balled up. This is known as the ‘Popeye sign’. A biceps tear at the shoulder is different than a biceps tendon tear at the elbow. When the biceps tendon tears at the elbow, then both biceps muscle heads are detached, leading to significant weakness it is not repaired. In this case, almost all active patients will want to have it repaired. However, tears of the long biceps tendon at the shoulder still leaves the short biceps tendon intact and leads to only a loss of 5-10% of biceps strength. Consequently, these are usually not repaired. If a young active patient desires to have the long biceps reattached, this can be done through a small outpatient procedure, but it is not necessary to have it repaired. In fact, some well-known NFL quarterbacks had biceps pain until it fully ruptured, had no treatment, and then were finally able to throw pain-free and went on to win super bowls.

Regardless of the specific problem with the biceps, 95% of the time or more, the biceps problem is due to a rotator cuff problem. Therefore, most biceps problems are initially treated similar to how rotator cuff tendinosis /degeneration is treated, with a therapeutic strengthening program and often a steroid injection. If that doesn’t work, then the biceps tendon can be treated arthroscopically at the same time that the underlying rotator cuff problem is addressed. The long biceps tendon is ‘tenodesed’, which means that it is anchored to the top of the humerus bone just outside of the shoulder. It still works the arm, but the diseased portion is removed from the shoulder, relieving the pain. This works very well. In rare cases this can occasionally occur on its own, as happened to my left shoulder, which still works great.

So if your long biceps tendon is causing you shoulder pain and you desire to have it arthroscopically tenodesed (removed from the shoulder and reattached just outside the shoulder), be assured that this is fairly common. Biceps problems are frequently found in association with rotator cuff problems. The biceps tenodesis is not very painful, is still performed as an outpatient, and doesn’t have many additional restictions compared to the rotator cuff surgery alone. In fact, as it’s performed at the same time as any rotator cuff surgery, you probably won’t even notice that it was done.

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Rotator Cuff Problems

September 19th, 2010

The rotator cuff is a structure consisting of four tendons that help you elevate your shoulder. The rotator cuff is the most common source of pain, weakness and dysfunction about the shoulder. While the rotator cuff can be injured in a fall, a motor vehicle accident or by other trauma, most of the time it gets damaged simply by normal wear and tear, especially if overuse is involved.

There are a lot of misconceptions about the rotator cuff. Many surgeons were taught that the rotator cuff gets injured because the bone above it, the acromion, has a hook or a spur that ‘impinges’ against it when the shoulder is raised. This has led to the term ‘impingement syndrome’ being commonly used to describe rotator cuff pain. Because of this, the most common shoulder surgery performed is the ‘subacromial decompression’ or ‘acromioplasty’, where bone from the acromion is removed to relieve this impingement.

However, essentially all of the recent research has shown that this is not true. This ‘hook’ or ‘spur’ is formed within a very important back-up structure, the CA (coracoacromial) ligament. Many MRI and cadaveric studies have shown that this ‘hook’ or ‘spur’ doesn’t cause problems in the vast majority of patients. In fact, surgically removing the CA ligament, that the hook is inside, can cause a significant number of problems including, in some cases, permanently losing the ability to elevate the shoulder.

The real reason that the rotator cuff has problems is because its blood supply is poor, and the rotator cuff has a critical, high-demand job opposing other bigger and stronger muscles to keep the shoulder stable. The rotator cuff develops tendinosis (tendon degeneration) because the stress placed on the shoulder is greater than the rotator cuff’s strength ability to handle this stress. The tendon degenerates and pain occurs. Most people use the term ‘tendinitis’, but that term implies inflammation, which does not actually occur; therefore the term ‘tendinitis’ is inaccurate, although commonly used. Older physicians may use the term ‘bursitis’, but this term is extremely inaccurate. Pain from the rotator cuff can occur over the front or outside of the shoulder, and can radiate to or past the elbow. It’s usually worse at night, when elevating the shoulder, when putting your hand behind your back (as when putting your hand in your back pocket, fastening your bra or reaching into the back seat of a car) and with sudden motion.

The cure for most cases of rotator cuff pain (ie. ‘impingement syndrome’) is specialized strengthening exercises for the rotator cuff and often the shoulder blade muscles. In most cases, this will solve the problem. The exercises are taught by a therapist and performed using elastic resistance (big rubber bands), which work better than dumbbell weights. A steroid injection may also be given. The injection is not a long-term cure, but it can decrease pain and keep the shoulder from hurting at night and allow the rotator cuff strengthening exercises to be performed better, without discomfort. The relief from injections lasts an average of three months, although they don’t help some people at all and others swear the injection cured them.

If three months of strengthening and an injection don’t lead to a decrease in pain, then the choice is to: 1) accept the problem and live with it, 2) continue strengthening, although if exercises haven’t helped after 2-3 months the odds are low that they will in the future, 3) have surgery.

While most surgeons are most familiar with the arthroscopic subacromial decompression, which removes the ‘bone spur’ or ‘hook’, this procedure simply does not work that well. Many times appropriate strengthening exercises are not tried before surgery, so that this surgery is often performed in cases where the strengthening would have cured the problem. After the surgery is done, strengthening is then taught to the patient, who then recovers. But was it the surgery or the therapy that helped?

Good question: Dr. Kirkley conducted an excellent research study where she made sure that all of her patients had appropriate strengthening performed before surgery and then operated only on those patients who didn’t get better from the strengthening. The results? Only 47% (less than half) got better from subacromial decompression (aka. acromioplasty).1 A more recent study by Dr. Ketola showed that patients that had the subacromial decompression surgery plus strengthening did no better than those patients who had strengthening alone without surgery.2

So if subacromial decompression doesn’t work any better than rotator cuff and shoulder blade strengthening alone, what surgery does? There is another arthroscopic procedure where the bad degenerated tendon (ie. the tendinosis) is removed. This is called arthoscopic rotator cuff debridement (ARCD) and is extremely effective. The acromion bone and any ‘hook’ or ‘spur’ is not addressed, unless it is obviously a problem. In two original research studies that I published3,4 ARCD led to excellent or good results in 79- 87% of patients that had already failed 3-6 months of rotator cuff and shoulder blade strengthening. The complication rate was extremely low, and no patient was made worse. This is in contrast to the subacromial decompression, where permanent pain, stiffness, and even permanent loss of shoulder elevation may occur. For a better description of the ARCD procedure, complete with photographs, please see the ‘Rotator Cuff’ section of my website.

In summary, most patients with pain from rotator cuff degeneration (also called ‘tendinitis’, ‘bursitis’ or ‘impingement syndrome’) can be cured with a simple exercise program. For those that don’t get better from exercises alone, ARCD is an extremely effective arthroscopic outpatient (no overnight stay) surgery, with a low complication rate. Following ARCD, the vast majority of patients obtain significant, if not total, pain relief and resume the work and play activities that they enjoy most.

References:
1) Kirkley A, Litchfield RB, Jackowski DM, Lo IK: The use of the impingement test as a predictor of outcome following subacromial decompression for rotator cuff tendinosis. Arthroscopy 18:8-15, 2002.
2) Ketola, S., J. Lehtinen, et al: Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomised controlled trial. J Bone Joint Surg Br 91: 1326-34, 2009.
3) Budoff JE, Nirschl RP, Guidi EJ: Debridement of Partial-Thickness Tears of the Rotator Cuff Without Acromioplasty: Long-Term Follow-up and Review of the Literature. J Bone Joint Surg 80A:733-748, 1998.
4) Arthroscopic Rotator Cuff Debridement (Without Decompression) for Tendinosis, Budoff JE, Rodin DM, Ochiai D, Nirschl RP, Arthroscopy, Vol 21; 1081-9, 2005

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Frozen Shoulder (Adhesive Capsulitis)

August 12th, 2010

Frozen shoulder is a very painful condition in which the shoulder freezes up and becomes stiff. It may or may not be due to trauma. People with diabetes, thyroid dysfunction or gout are more commonly affected. While the reason this happens is unclear (many blame a virus), it is an inflammatory condition and is often due to an underlying rotator cuff problem.

Frozen shoulder may go through phases. The ‘freezing’ phase lasts roughly 3-9 months. The ‘frozen’ phase can lasat for 4-12 months or longer. Some shoulders may then ‘thaw’ over 1-4 years, during which time motion improves, but not necessarily completely. If untreated, the average amount of time for the shoulder to go through this cycle before comfort and some motion returns is 2.5 years. If untreated, 7-42% of patients will have significant permanent stiffness.

In my opinion the best way to treat the frozen shoulder is to ‘hit it early and hit it hard’. The earlier you’re seen, the better. I inject a steroid (cortisone) into the shoulder and prescribe a medrol dose pack (steroids taken by mouth) for 6 days. While long-term steroids can potentially lead to ulcers or arthritis, that is incredibly rare from a 6-day medrol dose pack. The real side effects include increased appetite and water retention, so there may be a slight weight gain. Steroids by mouth may keep some people from sleeping well at night, so I also prescribe a sleeping pill along with it.

The third mainstay of treatment is therapy, which is optimally performed 3 days/week until motion improves. The therapist will use ultrasound on the shoulder and perform stretching exercises. In addition, rotator cuff strengthening exercises with an elastic resistance are prescribed, as the rotator cuff is often involved. It is also extremely important to perform a home stretching and strengthening program. It’s best if the steroid injection, medrol dose pack and therapy all occur at the same time. The vast majority of my patients who follow these instructions improve significantly, and often attain full or near-full motion within 1-2 months. Very few patients require surgery for frozen shoulder.

However, if 3-6 months of nonoperative treatment is unsuccessful, surgery may be considered. If surgery is pursued, a manipulation under anesthesia is usually not enough. In most cases, if a manipulation is all that’s needed, then a good nonoperative management program would have been successful. The most effective surgical treatment for frozen shoulder is an arthroscopic capsular release, in which a small scissor-like instrument is used to cut the joint capsule (balloon) around the shoulder joint. In addition, any inflamed tisssue and pathologic rotator cuff tissue is removed. After the joint capsule has been released the shoulder can then be manipulated, which is less traumatic and more effective. This surgery is not especially painful. Some patients with frozen shoulder due to former surgery or fractures may also need an open incision to release additional scarred tissue planes. Post-operative therapy is critical and begins within 1-3 days. Therapy with a knowledgeable therapist is performed 5 days a week for 4 weeks, and then decreased over the next couple months depending on how motion progresses.

Manipulation following arthroscopic release leads to normal or near normal motion with minimal pain in 75-83%. The prognosis is better for patients who have experienced stiffness for less than 6 months. Patients with frozen shoulders following surgery or a shoulder fracture typically have a more complex and severe problem, with less satisfactory results. That’s one reason why the first surgical procedure performed often sets the tone for that patient’s ultimate outcome and should be done by a specialist.

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Shoulder Instability and Dislocations

July 18th, 2010

The shoulder is the most mobile joint in the body. Consequently, it is also the most commonly dislocated large joint in the body. There are things you should know if you or someone you care about has dislocated his or her shoulder. For example, the first shoulder dislocation leads to a 20% rate of future arthritis, and each subsequent dislocation increases that risk.

Young patients, 20-25 years old or less at the time of the initial dislocation, especially those engaged in contact sports or who use their arms at or above chest level, have a 90-95% risk of recurrent instability (ie. another dislocation or subluxation/partial dislocation). On the other hand, recurrent instability is uncommon in older patients who first dislocate their shoulder at the age of 40 years or older.

Following a single dislocation in young patients <20-25 years old, especially if they are contact athletes, arthroscopic stabilization decreases the rate of recurrent instability. Following arthroscopic stabilization the rate of recurrent instability is 7-10%, compared to 46-58% for those treated without surgery. A government-sponsored review noted a 68-80% reduction in the risk of recurrent instability in those young patients that had surgery compared to those who didn’t. Patients who underwent arthroscopic surgery had significantly better outcomes, better function, less joint damage, were more satisfied, had a better chance to return to sports , had an improved quality of life and even had lower overall treatment costs. Allowing multiple subluxations or dislocations to occur causes additional damage to the shoulder’s ligaments, increases the risk of arthritis, and erodes the bone from the humeral head (the ‘ball’ of the shoulder) and/or the glenoid socket that keeps the shoulder located.

Therefore, arthroscopic stabilization surgery should probably be performed following even a single dislocation in young athletes 25 years old or younger, professional athletes, or in those in whom a recurrent dislocation could be disastrous, such as mountain climbers and construction workers that work at heights. Arthroscopic surgery should also be performed if the shoulder dislocates a 2nd time, or if there is pain due to recurrent subluxations that is not resolved by therapeutic strengthening exercises and acceptable activity limitations. Modern arthroscopic techniques lead to 92-97% good-excellent results, with 91% of high-demand contact athletes returning to sport.

In older patients who have had only a single dislocation and who are not engaged in contact sports, physical therapy to strengthen the muscles about the shoulder may be enough to decrease symptoms and prevent further instability. And while immobilization in a sling or other similar device does not decrease redislocation rates, avoiding bringing the arm up and back (as when throwing a ball) and avoiding sports for six weeks can help decrease re-dislocation rates

The problems created by shoulder dislocations are different for people over 40 years of age. While older patients don’t usually suffer re-dislocations, 54% have their rotator cuffs torn by the dislocation, leading to pain and weakness. Patients over 40 years old who have dislocated their shoulder should have an MRI to diagnose any rotator cuff tear. If the rotator cuff is torn, it should be fixed to maximize function, minimize pain and lower the chance of recurrent instability. This can be done very effectively arthroscopically.

Following multiple dislocations or if a shoulder is left dislocated for a number of hours, bone loss of either the humeral head (ball) or glenoid socket may occur. It should be noted that a CT scan is needed to accurately diagnose bone loss, as MRI notoriously underestimates the degree of bone loss or misses it entirely. If less than approximately 1/5 of the glenoid is eroded, the shoulder may still be treated arthroscopically with good success. However, if >1/5-1/4 of the socket has been eroded away, open surgery with a bone graft taken from another part of the shoulder is needed. While this is open surgery, it is still an outpatient procedure and leads to good or excellent results in 83-95%. If the humeral head (ball) is damaged, unless the bone defect is very large, this can still be treated arthroscopically by repairing part of the rotator cuff into the bony defect.

So, if you or someone you care about has dislocated their shoulder, or has an unstable shoulder, get them evaluated by an orthopaedic shoulder specialist before more damage is done and the risk of future problems increases.

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