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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Clavicle (Collarbone) Fractures

October 11th, 2011

Clavicle (collarbone) fractures are very common injuries. If the clavicle fracture is not significantly displaced (translated) or angulated (bent), then it can be treated in a sling for 6 weeks. For people who do a lot of deskwork, a ‘figure-8’ brace that leaves the arms free is also fine, and may be preferred.
If the clavicle fracture is shortened 1.5 cm or more, or significantly displaced (no bony contact), significantly angulated (bent) or comminuted (many pieces), then it will probably do better if it is surgically repaired, especially in an active individual. If the clavicle fracture is allowed to heal in a shortened or otherwise unsatisfactory situation, pain, stiffness, dysfunction, decreased endurance, and weakness can occur, especially during overhead activities or those requiring shoulder strength. Once a clavicle fracture is healed in a shortened position, the muscles of the shoulder and shoulder blade may become inappropriately shortened or lengthened, which can lead to permanent weakness and loss of endurance, even if treated at a later time. As with most injuries, the best chance to obtain a good result for a clavicle fracture is early after the injury occurs.
Clavicle fixation is performed as an outpatient, same-day, surgery. The best way to fix most serious clavicle fractures is with specially molded plates that conform to the clavicle and locking screws. After surgery, computer use and deskwork can be performed the following day. Showering is fine 3 days after surgery, at which point elbow, wrist and hand motion may also begin. Active shoulder use should be avoided for 4-6 weeks, and a sling should be worn in public for 4-6 weeks for protection. Clavicles often take 3 months to heal. A CT (cat) scan is often ordered 6-12 weeks after surgery to ensure that the bone is healed. Most patients usually do very well following surgical fixation of clavicle fractures.

Smoking greatly increases the risk of clavicle fractures not healing, whether or not surgery is performed, and so quitting smoking is very helpful.

An unhealed fracture, known as a non-union, is a more difficult problem to fix. Clavicle non-unions usually involve some degree of shortening, which may be difficult to fully correct. In order to fix a clavicle non-union, it is often necessary to take bone from the iliac crest (the rim of bone above your hip), which is somewhat painful, although with the small instruments we now have to drill into the bone using a minimally invasive technique, it’s not nearly as bad as it used to be. Again, a specialized plate is used to stabilize the clavicle fracture. Healing is confirmed with a CT scan.

In conclusion, clavicle fractures usually don’t require surgical fixation, but when they do, modern techniques and equipment help produce an excellent result in the vast majority of cases.

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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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SLAP Lesions

December 28th, 2010

SLAP lesions are tears of the superior labrum (meniscus-like tissue around the glenoid socket) that include the attachment of the biceps tendon. These are uncommon injuries, except in throwing athletes and in patients who have had significant trauma (ski accidents, bad falls, motor vehicle accidents, etc). It is rare to see a painful SLAP tear in a patient who is not an overhead athlete and has not sustained a significant trauma.

It should be understood that a history, physical examination and MRI are not reliable for the diagnosis of SLAP lesions. Many times MRIs are ‘overread’, meaning that they think there is a SLAP lesion present when none is. In these cases, the SLAP lesion is a ‘red herring’, and not the cause of the shoulder pain. Sometimes there can actually be a SLAP lesion, but it’s still not the cause of shoulder pain. Because of this, even if a SLAP lesion is suspected, the initial treatment should usually include rest and therapeutic strengthening of the shoulder muscles. In throwers, special stretches can be helpful. If symptoms persist following 3 months of non-operative management, surgery may be considered.

In young athletes, SLAP lesion repair has >95% success rate. Early motion is started after surgery to decrease the chance of stiffness. However, SLAP lesions usually do not cause pain in patients over 40 years old. Pain in patients over the age of 40 is much more commonly due to rotator cuff problems. Repairing SLAP lesions in patients over the age of 45-50 years often leads to painful stiffness. So, if a SLAP lesion is causing problems in patients greater than 45-50 years old, it is usually preferable to leave the SLAP lesion unrepaired, to avoid complications, and take the biceps tendon off of the SLAP lesion and simply repair the biceps tendon to the humeral head; this gets the biceps tendon out of the shoulder joint so that it no longer causes pain, while allowing it to still function to flex the elbow.

All in all, SLAP lesions are injuries that are very treatable by either non-operative or arthroscopic management.

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When is Carpal Tunnel Syndrome Not Carpal Tunnel Syndrome?

September 25th, 2010

Carpal tunnel syndrome is the most common nerve compression in the arm. It causes the fingers of the hand to fall asleep, become numb, burn or tingle. But that doesn’t mean that everything that causes numbness about the hand is carpal tunnel syndrome.

If the small and ring fingers are the only digits involved, then the numbness is probably caused by cubital tunnel syndrome, ie. compression of the ulnar (funny bone) nerve about the elbow.

Sometimes elbow or shoulder pain, from tennis elbow, rotator cuff disease, etc. can cause pain to radiate down the arm as far as the hand. But these referred pains don’t go all the way down to the fingers and make them numb.

The median nerve, the same nerve that is pinched by carpal tunnel syndrome at the wrist, can also be pinched further ‘upstream’ about the elbow. This is known as pronator syndrome. Often times, pronator syndrome can occur at the same time with carpal tunnel syndrome; this is known as a ‘double crush’, because the nerve is compressed in two places at once.

Pinched nerves at the neck can also cause numbness in the fingers. These usually affect the thumb, but any fingers can be involved, depending on the nerve root that is being pinched.

Of course, the opposite also happens. People often think that they have a pinched nerve in their neck when they’ve really got carpal tunnel syndrome. This happens fairly often because carpal tunnel syndrome is so common and nerve studies fail to diagnose carpal tunnel syndrome in approximately 20-33% of patients.

So how do you know where the problem is?

First, you should see a hand surgeon, who should be an expert in diagnosing conditions affecting the hand. General orthopaedic surgeons, plastic surgeons, and other types of physicians may have some knowledge about hand disorders, but don’t have the subspecialty training and experience to predictably diagnose some of the less common conditions, especially when the signs are subtle. You know what they say about jacks of all trades. You want to see a specialist to give you the best chance of getting the correct diagnosis. The physical examination that a specialist does can usually determine the real source of the problem.

For some ‘quick and dirty’ rules, that aren’t 100% accurate, but can point you in the right direction: carpal tunnel syndrome usually bothers people more at night and when gripping things: a book, a steering wheel, etc. It can affect the thumb, index, middle and ring fingers in any combination. It can also affect the small finger, but not the small finger alone; if the small finger (and maybe the ring finger) are the only fingers involved, then it’s not carpal tunnel syndrome. It may be cubital tunnel syndrome, thoracic outlet syndrome or a pinched nerve in the neck.

Numbness that is worse with activities and is associated with an ache in the forearm near the front of the elbow is often pronator syndrome. Numbness that is worse when the neck is moved all the way to one side is often due to a pinched nerve at the neck. Numbness on the back of the hand is often referred from the elbow or shoulder, and not due to carpal tunnel syndrome.

However, for the best chance of an accurate diagnosis, go see a hand surgeon specialist who has the extra training and experience to best diagnose conditions of the hand.

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Rotator Cuff Tears

September 20th, 2010

Rotator cuff tears are a common source of shoulder pain, weakness and dysfunction. However, not all rotator cuff tears need to be fixed surgically. Many rotator cuff tears are a natural part of the aging process. Over time, many of us lose our hair, many lose their bone density, and many of us lose part of our rotator cuff from normal degeneration. These rotator cuff tears are usually painless. In fact, 27% (over 1 in 4) of people 60 years or older with no shoulder pain at all have a full-thickness rotator cuff tear. And it doesn’t bother them.

Should one of these people with a pre-existing tear develop some rotator cuff tendinosis, they may develop pain. But this doesn’t necessarily mean that their rotator cuff needs to be fixed. In patients 60 years or greater with no history of trauma (car crash, falls, etc) and good remaining strength, 50-82% (an average of 2/3) can get better using rotator cuff and shoulder blade strengthening exercises without surgery. These are the same exercises discussed in my last blog and on my website in the ‘Therapy Protocol’ section. Please note you need to be taught the correct form for these exercises by a therapist. An elastic resistance, not a dumbbell weight, works best. Once you know what to do and have the appropriate elastic device, the exercises can be performed at home. If 3 months of therapy, and often a steroid injection, don’t decrease the pain down to a tolerable amount, then arthroscopic rotator cuff repair may be considered. It should also be noted that patients younger than 60 years of age, those who developed the rotator cuff tear from trauma, or those with significant weakness should probably have their rotator cuff tears surgically repaired.

Rotator cuff repair may be performed arthroscopically, which leads to less pain and stiffness than open repairs. For photographs of arthroscopic repair, please see the ‘Rotator Cuff Tear’ section of this website. Arthroscopic rotator cuff repair is performed as outpatient surgery. For the least amount of pain and stiffnes, a subacromial decompression (acromioplasty) is not performed in the vast majority of cases. As noted in my previous blog, removing the bony ‘hook’ or ‘spur’ may increase postoperative pain and stiffness, and can result in the loss of shoulder elevation, which is exactly what we’re trying to improve. A recent research study I published showed that performing a subacromial decompression unfavorably alters the biomechanics of the shoulder, which is not good (1).

Following surgery, rotator cuff repairs need to be protected. Because the rotator cuff is slowly healing tissue, the repair needs to be protected for 6-12 weeks. For 6 weeks following rotator cuff repair an abduction pillow (sling with a pillow in it) is worn around the clock except when showering. It is slept in. Nobody likes it, but it prevents reinjury to the rotator cuff and increases its blood supply to help it heal better. No active shoulder elevation (ie. raising your arm using those shoulder muscles) is allowed for 6 weeks. A home motion program is begun after the first follow-up appointment at 2 weeks. Therapy is used as needed; it’s better if the patient can regain motion on their own at home. No lifting anything heavier than one pound for 3 months. Most people can return to heavy work or sports at 4-6 months, depending on the size of the tear and the stressfulness of the activity.

Most people usually do very well following arthroscopic rotator cuff repair. Those who wait too long often develop atrophy of the rotator cuff muscle that the tendon is attached to, leading to worse results. However, even in these cases it’s usually worth performing the repair to decrease pain and regain whatever function the shoulder can regain.

References:
1: WR Su, Budoff JE, Luo ZP: The Effect of Coraco-Acromial Ligament Excision and Acromioplasty on Superior and Anterosuperior Glenohumeral Stability. The Journal of Arthroscopy 25: 13-18, 2009

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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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