Shoulder Arthritis

By Dr. Brett Greenky                                                                                         The Center for Orthopedic & Spine Care @ St. Joseph's Syracuse Orthopedic Surgeons, PC

                                                                                                             

The shoulder joint is really made up of two Joints: The AC Joint and the Glenohumeral Joint. The AC joint is so named because the Acromion and the Clavicle touch together here. The Acromion is part of the shoulder blade. The AC joint can and does become arthritic. Spurs develop underneath the AC joint and these spurs can agitate the tendons of the rotator cuff. The rotator cuff tendons rub back and forth underneath the AC joint when the shoulder moves. The arthritic spurs of the AC joint can impinge on the rotator cuff tendon during shoulder motion. The resultant rotator cuff tendonitis is the most common cause of shoulder pain in adults over 40.

The Glenohumeral Joint (GHJ) is the main “ball and socket” part of the Shoulder. Arthritis of the ball and socket (GHJ) part of the shoulder is a less common affliction than AC joint arthritis. Many patients with mild to moderate degrees of (GHJ) arthritis can be treated with medications, activity modification and physical therapy or home based exercises. The purpose of these exercises is to that tone the rotator cuff muscles. When toned these muscles can help reduce the amount of rubbing in the GHJ. It is when the GHJ arthritis progresses to the severe stage that these techniques tend to no longer be adequate and total shoulder replacement  (TSR) surgery is considered. Since patients do not need to walk on the shoulder joint, severely symptomatic shoulder arthritis comes late in the disease progression. As a result, most patients who seek treatment for severely symptomatic shoulder arthritis are already at the stage when TSR is the only treatment to afford dramatic relief.

Total Shoulder Replacement (TSR) has a high success rate in reducing or eliminating shoulder arthritis pain. In general the operation is easier to navigate for the patient when compared to Total Hip or Total Knee replacement surgery since the Shoulder is a non-weight bearing joint. The operation is however requires a one to two day hospital stay and some postoperative physical therapy.  A return to near normal function requires a well functioning rotator cuff. Much of the post operative treatment is directed to the strengthening of the rotator cuff muscles which often atrophy during the period of worsening arthritis. Since a functioning and intact rotator cuff is essential for traditional TSR surgery to be successful, the joint replacement specialist may need to do additional preoperative tests (MRI scan) to check the patient’s rotator cuff condition.

A special version of TSR is available for the patient with shoulder joint arthritis who does NOT have a functioning rotator cuff. This operation is called Reverse Shoulder Replacement. The operation reverses the polarity of the ball and socket of the shoulder thus explaining the name. This novel technique allows for pain reduction in the rotator cuff deficient patient but it does not restore the function of the rotator cuff itself. Patients without an intact rotator cuff are usually unable to elevate their arm much above the waist.

Dr. Brett Greenky the Co-director of the Joint Replacement Program at St. Joseph's Hospital. He is
a Board Certified Orthopedic Surgeon specializing in hip, knee, shoulder arthritis, reconstruction/surgery, minimally invasive hip and knee replacement, anterior approach hip surgery and revision hip/knee joint surgery.

Dr. Greenky is an Associate Professor of Orthopedics at SUNY Upstate Medical College and is the founder of Operation Walk Syracuse and Co-Executive Director.

Dr. Greenky completed his undergraduate studies at Northwestern Universityand received his M.D. from SUNY Upstate Medical Center. For more information on Dr. Greenky, visit http://ow.ly/ibztU.

Arthroscopic Rotator Cuff Surgery

By Todd C. Battaglia, MD, MS

The Center for Orthopedic & Spine Care @ St. Joseph's
Syracuse Orthopedic Surgeons, PC

Rotator cuff tears are one of the most common causes of shoulder pain and dysfunction in the adult shoulder, and are one of the most frequent indications for shoulder surgery. Despite its ubiquity, however, there is no such thing as a “standard “rotator cuff repair. In fact, there are two completely different repair techniques used today – the more traditional “open” repair which utilizes a 3-5 cm incision to directly visualize and fix the rotator cuff, and “arthroscopic” repair, which utilizes a camera to repair the tendons through very small incisions. Arthroscopic cuff repair is a relatively new technique, first popularized approximately 15 years ago.

Initially, open repair held one distinct advantage, in that repair strength was better than that achievable with the early available arthroscopic equipment. However, improvements in arthroscopic techniques and technology have progressed to the point that repair strength is at least as good, and with some methods, better, than open techniques. In addition, arthroscopic repair offers a number of distinct benefits. First, for open repair, a portion of the deltoid muscle must be detached for adequate exposure, and then repaired at the conclusion of the surgery. This adds to pain, increases healing requirements, and leads to the potential post-operative complication of deltoid dehiscence (splitting open after repair). Conversely, the small incisions used for arthroscopy do not require any detachment of the deltoid. Second, open techniques allow no visualization of the biceps, labrum, joint surfaces or other structures inside the joint that are commonly abnormal in conjunction with rotator cuff tears. Arthroscopy allows visualization and concurrent treatment of all these structures. Third, only arthroscopy allows assessment and treatment of partial thickness tears without disrupting the whole tendon, particularly those on the deep (joint-side) surface of the tendon. In open repairs, the cuff is viewed only from the superficial (bursal) surface, and undersurface tears will not ever be seen. Fourth, and most critically, arthroscopy provides complete visualization of the entire rotator cuff - this permits a much more thorough assessment of the tear pattern, and allows the surgeon to more accurately determine the best strategy for a complete and tension-free repair.

With each passing year, fewer and fewer rotator cuff tears are repaired using open techniques.  In fact, for today's shoulder specialists, there are almost no rotator cuff tears that cannot be repaired arthroscopically. Interestingly, it is sometimes offered that some tears are “too large” or “too complex” for arthroscopic repair. This is false - such tears are precisely the ones best suited for arthroscopic repair – using the camera, they can be seen better and repaired more accurately and strongly.

Dr. Battaglia is a Board Certified Orthopedic Surgeon. He specializes in sports medicine, arthroscopic & reconstructive surgery of the knee & shoulder, ACL and knee ligament reconstruction, meniscus surgery, cartilage regeneration/restoration, rotator cuff injuries, shoulder instability/dislocations, clavicle and AC joint injuries and shoulder arthritis. Dr. Battaglia received his M.D. from SUNY Buffalo and MS from University of Virginia. For more information on Dr. Battaglia, visit http://ow.ly/hrhhD.

St. Joseph's Health Center's Musculoskeletal Minute

Welcome back to St. Joseph's Health Center's Musculoskeletal Minute! This video blog features doctors from St. Joseph's Hospital Health Center in Syracuse, NY, speaking on orthopedic topics of interest. You will see a new video blog out every few weeks.

In this edition, Dr. Ryan Smart, sports medicine specialist at St. Joseph's Hospital Health Center, discusses shoulder injuries.



Dr. Ryan Smart is board certified in orthopedic surgery.

Education: MD, University of Michigan, BA, Cornell University

Residency: Yale University

Fellowship: Baptist Hospital, Boston

Areas of Expertise: Adult and pediatric sport injuries; fracture care; surgical repair of injuries of the shoulder, hip, knee, including arthoscopic shoulder and knee surgery; total shoulder and knee replacement, arthoscopic management of hip disorders, including labral tears and hip impingment.

Shoulder Injuries in Athletes

Bradley S. Raphael M.D.

RSM Medical Associates

          

As spring sports start up (lacrosse, baseball, tennis) so to can shoulder pain.  Shoulder injuries are common in overhead athletes (swimming, tennis, baseball, football), but can also occur in overhead workers.  This is especially true with heavy laborers or jobs which require repetitive overhead activities at work.

Different shoulder problems from overuse:

                -Impingement

   -Rotator cuff tears

                -Rotator cuff tendinitis

                -Labral tears

                -Instability/dislocation

               

Anatomy:

-The shoulder is essentially a ball in socket with less restriction than any other joint in the body.  This allows the shoulder to be the most mobile joint in the body.

                -Rotator cuff is a series of 4 muscles that center the ball on socket during shoulder motion, maximizing the efficiency of shoulder movement.  These can be inflamed with repetitive motion and can make overhead activity painful.

                -The rotator cuff can also become inflamed as it rubs under the color bone and shoulder blade (often described as a “bone spur”)

                -The labrum is made of a thick tissue that rings the shoulder socket and is susceptible to injury with trauma to the shoulder joint. When a patient sustains a shoulder injury, it is possible for the labrum to tear. Some symptoms are an achy sensation to the shoulder joint, catching of the shoulder with movement and pain with specific activities

Treatment:

                -These injuries are often treated with physical therapy, strengthening, stretching, (especially baseball players and other overhead athletes)

                -It’s important to do appropriate warm up before long pitching outings, lacrosse games, tennis matches and overhead work activity in order to prevent injuries.

                -If physical therapy fails, may need an injection to help decrease pain (steroid).

                - These injuries usually respond to conservative measures, but sometimes it can become refractory and may need arthroscopic procedure to clean out bursitis, remove bone spurs or repair the tendons or labrum.

               

Prevention:

                -Important to follow little league pitching guidelines at young age (littleleague.org)

                -Pre-game, pre-work, and pre-activity stretching

                -Hip and core strengthening to alleviate stress on shoulder with your local therapist or athletic trainer.

                -See your doctor as soon as you start having soreness that doesn’t go right away, because it could be the sign of something more serious

Bradley S. Raphael M.D. completed his sports medicine training in Los Angeles at the Kerlan Jobe Orthopedic Clinic and is in practice at RSM Medical Associates where he specializes in Shoulder and Knee problems. He is also a team physician for Syracuse University Athletics.  For appointments or questions: 315-701-4024 or on the web at raphaelmd.com

Rotator Cuff Tears

By Ryan Smart, MD

Syracuse Orthopedic Specialists

Intro

Rotator cuff tears are among the most commonly encountered disorders of the shoulder.  They can be debilitating and difficult to treat.  Chronic rotator cuff tears are common and with the aging population the incidence of new tears continues to rise.  More than 50% of individuals older than 60 years have at least a partial rotator cuff tear and full thickness tears are found in almost half of individuals older than 80 years. (1)  Approximately two-thirds of all rotator cuff tears in the general population are asymptomatic and factors found to be associated with symptoms when one has a rotator cuff tear are a positive impingement sign, weakness in external rotation, and presence of a tear in the dominant arm. (2)  Procedures done to treat rotator cuff disease are among the most common of all orthopaedic surgeries.

Anatomy

The glenohumeral joint has very little bony support.  The rotator cuff, which is made up of four muscles (subscapularis, supraspinatus, infraspinatus, and teres minor), plays a major role in both the mobility and stability of the shoulder.  Of these two roles, stability appears to be the larger function.  To maintain a ball-and-socket articulation during motion, the humeral head is compressed into the glenoid socket by the rotator cuff.  Without such compression, the humeral head can undergo excessive translation within the socket which disrupts shoulder kinematics.  EMG studies have shown that the rotator cuff muscles fire prior to and then concurrently with the deltoid and pectoralis major muscles.(3)  This preceding and concurrent activation of the rotator cuff muscles maintains the shoulder joint for dynamic stability during larger muscle contractions.

History

Pain is the most frequent complaint.  It can at times radiate down the arm to the level of the elbow.  Many patients will complain of nighttime pain.  Typically, the pain will be worse with certain motions such a forward elevation or abduction.  As the tear progresses, weakness will become a more prevalent symptom.  Rotator cuff pain does not typically radiate down the arm to the level of the wrist or hand.  If such symptoms are present one should suspect the cervical spine as the pain generator.  A history of a trauma or fall will sometimes be present but many times patients cannot recall a specific inciting event.

Physical Exam

A thorough physical exam significantly aids in the diagnosis and management of rotator cuff tears.  A complete shoulder exam should be performed starting with inspection and palpation.  Range of motion is then assessed both passively and actively.  If both passive and active motion is limited one should consider an alternative diagnosis such as adhesive capsulitis (ie frozen shoulder).  Patients with rotator cuff pathology will typically have mid-arc pain.  A positive Neer and Hawkins maneuver is common.  Strength testing is performed for each rotator cuff muscle.  The empty can and drop arm maneuvers test the supraspinatus.  The lift-off, belly press and bear hug all test the subscapularis and external rotation strength tests the infraspinatus and teres minor.  The combination of a positive drop-arm sign, painful arc sign, and infraspinatus muscle strength test was most predictive for full thickness rotator cuff tears.(4)

Treatment

Conservative

Nonsurgical management is typically the first line of treatment for most rotator cuff pathology.  The natural history of rotator cuff tears is thought to be that of tear progression. (5)  It is believed that tear size progression is a factor in the development of symptoms.  Physical therapy and shoulder rehabilitation should focus on restoration of motion, flexibility and strength. (6)  Nonsurgical management may also include pain medication and anti-inflammatory drugs and subacromial cortisone injections.  Although injections are common a recent systematic review suggests that long-term benefits are limited. (7)  Multiple cortisone injection should be avoided in patients who may be best served with surgical intervention.  Successful non-operative management has been correlated with symptom duration of less than 3 months.  Factors that have been found to predict failure of conservative treatment are: 1) full-thickness tear greater than 1cm x 1cm, symptoms present for more than 1 year, and functional impairment and weakness. (8)  Nonsurgical treatment is often attempted for a minimum of 6 to 12 weeks before surgery is considered.

                Surgical

When patients fail conservative treatment surgery is usually indicated.  Tears can be repaired either arthroscopically or by open means.  The clinical results reported with arthroscopic repairs are equivalent to those reported for both open and mini-open. (9,10)  However, the deltoid muscle is undisturbed with arthroscopic repairs thus making it the favored approach by many.  The goal of surgery is to anatomically repair the rotator cuff securely to bone with as little tension as possible.   Reported healing rates, based on ultrasound and MRI, range from 91% in small tears to 10% in massive tears. (11)  With larger tears, the best clinical results are achieved in patients who experience tendon healing postoperatively. (12)

Rehab

The ideal rehabilitation program allows for tendon to bone healing and prevents stiffness.  Most agree the best clinical results occur when the rotator cuff heals to bone in its entirety.  Since the rotator cuff heals very slowly (~5% per week) most have adopted fairly conservative rehab protocols limiting motion the first 6 weeks.

Dr. L. Ryan Smart specializes in sports medicine, arthroscopic surgery, and shoulder surgery.  He completed his fellowship in sports medicine at the New England Baptist Hospital in Boston, MA and completed his orthopaedic surgery residency at Yale in New Haven, CT.   After completing his undergraduate studies at Cornell University, he went on to the University of Michigan for medical school.  He is the team physician for the Christian Brothers Academy football team, Cornell Men’s Ice Hockey, Syracuse Silver Nights soccer club and Fayetteville-Manlius High School. He played 4 years of varsity ice hockey at Cornell and was drafted by the New Jersey Devils in the 1994 NHL entry draft.  His professional memberships include Arthroscopy Association of North America and the American Orthopaedic Society for Sports Medicine.