Arthroscopic Shoulder Surgery: Thermal Capsulorrhaphy

No joint has greater range of motion than the shoulder. But this flexibility is also a liability, because it makes the shoulder prone to dislocation and instability. The upper arm bone (humerus) sits in a saucer-shaped part of the shoulder blade (scapula) called the glenoid. A circle of ligaments, tendons, muscles and cartilage form a capsule around the joint to maintain stability.

Trauma or overuse can cause these soft tissues to stretch or tear. Then they can no longer provide the necessary support. A feeling of "looseness" may develop and the shoulder may "pop out" with some activities. Pain and weakness may interfere with daily activities such as work, sports, or sleep.

An emerging trend

In recent years, arthroscopic techniques that use heat to "shrink" and tighten the tissues have been developed to treat several types of shoulder instability. The new procedure, called thermal capsulorrhaphy (kap-sue-lore'-a-fee), works because the molecular structure of tissue changes in response to heat. Tendons and ligaments are primarily composed of collagen, a type of protein. When collagen is heated to the appropriate temperature, it contracts and "shrinks." The body perceives this as an injury and the tissues rebuild around the shorter collagen fibers, resulting in a tighter, and theoretically more stable, shoulder.

Initially, laser devices that used light to heat the tissues were developed, but the high cost of equipment and other concerns prompted researchers to investigate other methods. Today, radiofrequencies inside the thermal probe can also be used to generate the necessary temperatures. These devices generate vibrations within the intracellular molecules, creating heat.

What to expect

Thermal capsulorrhaphy is an outpatient procedure performed while the patient is under general anesthetic. The surgeon makes two or three small incisions called portals and inserts the pencil-sized arthroscopic instruments. One instrument enables the surgeon to view the joint and another provides the heat source. The surgeon is able to see changes in color and texture in the tissues as the thermal probe is brushed back and forth across them. The entire procedure usually takes less than 30 minutes.

After surgery, patients must wear a sling for at least three weeks. There is little postoperative pain, but the patient must be careful not to raise or turn the arm because this will stretch the tissues before they have healed in their shortened state. The physician will also prescribe a rehabilitation program designed to strengthen the muscles and restore a full range of motion. Patients may be able to safely return to certain sports in as little as four to six months.

Results

Early studies indicate that thermal capsulorrhaphy may be beneficial in treating several kinds of shoulder instability. However, the technique is so new that long-term results are not yet available. Some people may continue to experience shoulder instability and may eventually require open surgery to shorten and tighten the tendons. Others may develop a condition called capsulitis, which is a stiffening or tightness in the joint.

Thermal capsulorrhaphy is not appropriate for every patient. Your doctor will discuss various options with you, based on the underlying cause and the degree of laxity in your shoulder. Traumatic injuries may require surgical repair. If the damage is significant, the orthopaedic surgeon may use an open technique that tightens and reattaches the tissue. A hospital stay is necessary and rehabilitation can take nine to 12 months. Overuse injuries can often be treated with an aggressive rehabilitation program, but if nonoperative treatment fails, surgery may be recommended.

Broken Collarbone

A broken collarbone (fractured clavicle) is a common injury among two very different groups of people: children and athletes. Many babies are born with collarbones that broke during the passage down the birth canal. A child’s collarbone can easily crack from a direct blow or fall because the collarbone doesn’t completely harden until a person is about 20 years old. An athlete who falls may break the collarbone because the force of the fall is transmitted from the elbow and shoulder to the collarbone.

The collarbone is considered part of the shoulder and helps connect the arm to the body. It lies above several important nerves and blood vessels. However, these vital structures are rarely injured when the collarbone breaks. The collarbone is a long bone, and most breaks occur in the middle section.

Signs of a break

• Sagging shoulder (down and forward).
• Inability to lift the arm because of pain.
• A grinding sensation if an attempt is made to raise the arm.
• A deformity or "bump" over the fracture site.
• Although a fragment of bone rarely breaks through the skin, it may push the skin into a "tent" formation.
• Diagnosis

Although a broken collarbone is usually obvious, your orthopaedist will do a careful examination to make sure that no nerves or blood vessels were damaged. An X-ray is often recommended to pinpoint the location and severity of the break.

Treatment

• Most broken collarbones heal well with conservative treatment and surgery is rarely necessary.
• A simple arm sling can usually be used to immobilize the arm. A child may have to wear the sling for 3 to 4 weeks; an adult may have to wear it for 6 to 8 weeks.
• Depending on the location of the break, your physician may apply a figure-of-eight strap to help maintain shoulder position.
• Analgesics such as acetaminophen or nonsteroidal anti-inflammatory medications such as aspirin or ibuprofen will help reduce pain.
• A large bump will develop as part of the healing process. This usually disappears over time, but a small bump may remain.
• Range of motion and strengthening exercises can begin as soon as the pain subsides. However, you should not return to sports activities until full shoulder strength returns.
• In rare cases, depending on the location of the break and the involvement of shoulder ligaments, surgery is needed. Surgery usually gives good results.

Dislocated Shoulder

The shoulder joint is your body’s most mobile joint. It can turn in many directions, but this advantage also makes your shoulder joint easy to dislocate. A partial dislocation (subluxation) means the head of the upper arm bone (humerus) is partially out of the socket (glenoid). A complete dislocation means it’s all the way out. Both partial and complete dislocation cause pain and unsteadiness in your shoulder. Your muscles may have spasms from the disruption, and this can make it hurt more. When your shoulder dislocates time and again, you have shoulder instability.

Symptoms to look for include swelling, numbness, weakness and bruising. Sometimes dislocation may tear ligaments or tendons in your shoulder. Once in awhile, the dislocation may damage your nerves.

Your shoulder joint can dislocate forward, backward or downward. A common type of shoulder dislocation is when your shoulder slips forward (anterior instability). This means your upper arm bone moved forward and down out of its joint. It may happen when you put your arm in a throwing position.

Your doctor will examine your shoulder and may order an X-ray. It’s important for you to tell your doctor how it happened. Was it an injury? Have you ever dislocated your shoulder before? Your doctor will place the ball of the upper arm bone (humerus) back into the joint socket. This process is called closed reduction. Your severe pain stops almost immediately once your shoulder joint is back in place.

Rest and rehabilitation

Your doctor may immobilize your shoulder in a sling or other device for several weeks following treatment. You should get plenty of rest and ice the sore area 3-4 times a day. After the pain and swelling go down, your doctor will prescribe rehabilitation exercises for you. These help restore your shoulder’s range of motion and strengthen your muscles. Rehab may also help you prevent dislocating your shoulder again in the future. You begin by doing gentle muscle toning exercises. Later, you can work up to using weights.

If your shoulder dislocation becomes a chronic condition, a brace can sometimes help. However, if therapy and bracing fail, then you may need surgery to repair or tighten torn or stretched ligaments, which help hold the joint in place.

Frozen Shoulder

If you’re having trouble lifting your arm above your head, reaching across your body or behind your back, you may have a problem with the range of motion in your shoulder. Limited motion is an early symptom of a frozen shoulder, which is a general term denoting all causes of motion loss in the shoulder.

Who’s at risk?

• Affects more women than men.
• Usual onset begins between ages 40 and 65.
• Affects approximately 10% to 20% of diabetics.
• Other predisposing factors include: - A period of enforced immobility, resulting from trauma, overuse injuries or surgery. - Hyperthyroidism. - Cardiovascular disease - Clinical depression. - Parkinson’s disease.

Causes of frozen shoulder

The cause of frozen shoulder is unknown, but it probably involves an underlying inflammatory process. The capsule surrounding the shoulder joint thickens and contracts. This leaves less space for the upper arm bone (humerus) to move around. Frozen shoulder can also develop after a prolonged immobilization because of trauma or surgery to the joint. Usually only one shoulder is affected, although in about one-third of cases, motion may be limited in both arms.

Three stages of development

Frozen shoulder develops slowly, and in three stages.

• Stage One: Pain increases with movement and is often worse at night. There is a progressive loss of motion with increasing pain. This stage lasts approximately 2 to 9 months.
• Stage Two: Pain begins to diminish, and moving the arm is more comfortable. However, the range of motion is now much more limited, as much as 50 percent less than in the other arm. This stage may last 4 to 12 months.
• Stage Three: The condition begins to resolve. Most patients experience a gradual restoration of motion over the next 12 to 42 months; surgery may be required to restore motion for some patients.

Diagnosis and treatment

Your physician will test the range of motion in your arm and may ask for an X-ray to rule out any underlying condition. Treatment is geared to relieving the discomfort and restoring motion and function to the shoulder.

Nonoperative treatment includes:

• Medications (such as aspirin or ibuprofen) to reduce the inflammation and relieve the pain.
• Muscle relaxers.
• A program of physical therapy, often combined with home exercises and other therapies, to stretch and help restore motion and function.
• Heat or ice therapies.
• Corticosteroid injections.
• Stretching exercises, such as those described below, done several times a day.
• Surgery is an option, but only if there is no improvement after several months. Arthroscopic surgery can successfully release and repair the shoulder, but it must be followed by an exercise program to maintain motion and restore function.

If you have a stiff shoulder, see your physician to make sure you do not have any internal injury before starting any exercise program. It is important that you follow your physician’s instructions carefully, especially regarding an exercise program. With your doctor’s approval, you can do these simple exercises to help stretch and keep your shoulder mobile:

1. Overhead stretch: Lie on your back with your arms at your sides. Lift one arm straight up and over your head. Grab your elbow with your other arm and exert gentle pressure to stretch the arm as far as you can.
2. Cross-body reach: Stand and lift one arm straight out to the side. Keeping the arm at the same height, bring it to the front and across your body. As it passes the front of your body, grab the elbow with your other arm and exert gentle pressure to stretch the shoulder.
3. Towel stretch: Drape a towel over the opposite shoulder, and grab it with your hand behind your back. Gently pull the towel upward with your other hand. You should feel the stretch in your shoulder and upper arm.
   
   

Rotator Cuff Tears

We "shoulder" responsibility, put our "shoulders to the grindstone" and occasionally "carry the weight of the world on our shoulders." Perhaps that’s why more than 4 million people in the U.S. seek medical care each year for shoulder problems.

Although there are many reasons for shoulder pain, a common problem for people over 40 years of age is a rotator cuff tear. The rotator cuff is comprised of the muscles and tendons that surround the top of the upper arm bone (humerus) and hold it in the shoulder joint. A tear may result suddenly from a single traumatic event or develop gradually because of repetitive overhead activities.

Signs and symptoms

• Recurrent, constant pain, particularly with overhead activities.
• Pain at night that prevents you from sleeping on the affected side.
• Muscle weakness, especially when attempting to lift the arm.
• Catching and grating or cracking sounds when the arm is moved.
• Limited motion.
• Usually occurs in the dominant arm (right shoulder for right-handed people; left shoulder for left-handed people).
• May be triggered by a specific incident.

Risk factors

• Repetitive overhead motion, such as pitching or painting a ceiling.
• Heavy lifting.
• Excessive force, such as a fall.
• Degeneration due to aging, including a reduction in the blood supply to the tendon.
• Narrowing of the space (acromioclavicular arch) between the collarbone (clavicle) and the top portion (acromion) of the shoulder bone (scapula).
• Abrasion (rubbing) of the cuff surface by the top portion of the shoulder bone.

Diagnosing a tear

When your consult your physician, he or she will ask you about your symptoms and any recent trauma or injuries. Your doctor will carefully examine the top and back of your shoulder to see if the muscles have begun to shrink (atrophy). You may be asked to move your arm in several directions, or to hold it in various positions. X-rays can help the doctor see any problems with the bones, although other imaging tests may be required to confirm a rotator cuff tear. One such test is an arthrogram, in which a dye is injected into the joint before the X-ray is taken. Other imaging tests include magnetic resonance imaging (MRI) and ultrasound.

Rotator cuff tears may be partial- or full-thickness. Partial-thickness tears do not completely sever the tendon and may respond well to nonoperative treatments. Full-thickness tears require surgery to correct. Surgery may also be used to treat partial-thickness tears that do not respond to nonoperative treatment.

Treatment options

Your doctor will prescribe a treatment regimen based on your injury and your need for pain relief, movement and function. In most cases, the initial treatment is nonsurgical and involves several modalities.

• Rest. If the tear is due in part to overuse, resting the shoulder may help.
• Nonsteroidal anti-inflammatory medications will help control pain.
• Strengthening and stretching exercises, as part of a physical therapy program, are recommended.
• Corticosteroid injections can help reduce pain but cannot be repeated frequently because they can also weaken the tendon.
• Ultrasound can enhance the delivery of topically applied drugs and has thermal effects that may also help in the healing process.
• There are several surgical options to treat rotator cuff tears, depending on the size, depth, and location of the tear. If other problems with the shoulder are discovered during the surgery, they will be corrected as well.
• Arthroscopy, in which miniature instruments are inserted into small incisions, can be used to remove bone spurs or inflammatory portions of muscle and to repair lesser tears.
• A mini-open repair that combines arthroscopy and a small incision can be used to treat full-thickness tears.
• In more severe cases, open surgery is required to repair the injured tendon. Sometimes a tissue transfer or a tendon graft is used. Joint replacement is also an option.

Rehabilitation

It takes some time to recover from shoulder surgery. Full functioning may not return for six months or more. Your orthopaedic surgeon will recommend a program of exercises to strengthen and restore motion. Your commitment to following the program outlined will make a difference in the ultimate results. Although every case is unique, surgery can relieve pain for most people and rehabilitation can restore functional range of motion.

Separated Shoulder

A separated shoulder is a common injury among football quarterbacks, but it can happen to anyone who falls and lands on the tip of their shoulder. The result can be an injury to the muscles, tendons and ligaments that hold the bones in your shoulder together.

Evaluation

You may have a partial or complete tear of one or both of the main ligaments that connect your collarbone (clavicle) to your shoulder blade (scapula). These ligaments are the acromioclavicular (AC) and coracoclavicular (CC). Your doctor will probably X-ray both your injured and uninjured shoulders to help correctly diagnose the extent of your problem. You may be asked to hold a 10-pound weight while you’re X-rayed to make your injury more noticeable on the film.

Your shoulder separation is classified by the extent or magnitude of your injuries.

• A mild shoulder separation involves a sprain of your AC ligament that does not move your clavicle and looks normal on X-rays.
• A more serious injury tears the AC ligament and sprains or slightly tears the CC ligament, putting your clavicle out of alignment to some extent.
• The most severe shoulder separation completely tears both your AC and CC ligaments and puts your shoulder joint noticeably out of position.

Treatment

Since the severity of your injuries may vary greatly, your doctor treats separated shoulders on a case-by-case basis. Generally, if your injury is mild, you’ll probably wear a sling for a few days until the pain subsides. Use ice during the first 48 hours. You may also use anti-inflammatory medications and pain relievers. When the pain in your shoulder eases, you may resume your normal activities. The same nonsurgical treatment is also possible for other shoulder injuries, however, if both ligaments are torn or your injury is severe, you may need surgery. After surgery, expect to immobilize your shoulder in a sling for up to a month.

Whether treated conservatively or with surgery, your shoulder will require rehabilitation to restore and rebuild motion, strength and flexibility.

Shoulder Impingement (Bursitis, Tendinitis)

Athletes, industrial workers and home maintenance buffs often suffer shoulder pain caused by excessive rubbing or squeezing (impingement) of the rotator cuff and shoulder blade.

Shoulder impingement syndrome involves one or a combination of problems, including inflammation of the lubricating sac (bursa) located just over the rotator cuff, a condition called bursitis; inflammation of the rotator cuff tendons, called tendinitis; and calcium deposits in tendons caused by wear and tear or injury. A torn rotator cuff is a potential outcome of shoulder impingement.

What is it?

Bursitis: Frequent extension of the arm at high speed under high load (i.e., pitching a baseball) can cause bursitis. Nonsports activities such as painting, hanging wallpaper or drapes or washing windows also can cause it. Medical research shows that the older you get, the more likely you are to develop bursitis.

Tendinitis: Tendinitis develops over time and is likely to occur when a person whose muscles are not in good condition starts an overly aggressive training program. In younger athletes, the causes of tendinitis are similar to those of bursitis.

What are the signs and symptoms?

Patients frequently try to ignore the first signs of shoulder problems. There is usually no single episode of the shoulder giving way and, at first, a person may notice only minor pain and a slight loss of strength. Loss of range of motion, especially the ability to lift the arm overhead, may be ignored for awhile.

Bursitis: Symptoms of shoulder bursitis include mild to severe pain and limited movement.

Tendinitis: Inability to hold the arm in certain positions indicates tendinitis is present. Recurrent episodes of tendinitis may indicate a rotator cuff tear.

What is initial treatment?

Bursitis: Once bursitis is diagnosed, rest is the recommended treatment. If necessary, icepacks can also be prescribed, as well as anti-inflammatory drugs, steroid injections and ultrasound therapy. Some patients require temporary use of a sling. After inflammation subsides, the patient should do shoulder strengthening exercises.

Tendinitis: Acute tendinitis usually passes if the activity which caused it is avoided long enough to give the shoulder sufficient rest. Later, a patient can gradually resume the activity incorporating gentle heat and prescribed stretching beforehand and icepacks afterward. More severe cases may require anti-inflammatory drugs or a cortisone injection.

If initial treatment doesn’t work, what’s next?

Bursitis: Severe bursitis can require surgery.

Tendinitis: A physician may perform additional diagnostic tests to rule out other conditions before surgery is advised.

How can further injury be prevented?

Overuse injuries require attention. However in many cases, people do not seek medical care for their shoulder inflammation and think they can "work through the pain."

Don’t play tennis or golf in an attempt to "loosen up" tightness. When a shoulder injury is ignored, it can become the source of chronic problems.

If your shoulder is sore after you use it actively, especially at the limits of your reach, give it some rest. If pain persists or worsens, consult your orthopaedist.

The Shoulder

Nearly six million people a year go to the doctor’s office for a shoulder sprain, strain, dislocation or other shoulder problem.

Shoulder injuries can be caused by sports activities that involve excessive overhead motion like swimming, tennis, pitching and weightlifting. People involved in everyday activities like washing walls, hanging curtains, and gardening also can get shoulder injuries due to excessive overhead arm motion.

Athletes are especially susceptible to shoulder problems. A shoulder problem can develop slowly in athletes through repetitive, intensive training routines.

Here are some facts about the shoulder from the American Academy of Orthopaedic Surgeons.

What are the warning signs of a shoulder injury?

If you are experiencing pain in your shoulder ask yourself these questions:

Is the shoulder stiff? Can you rotate your arm in all the normal positions?

Does it feel like your shoulder could pop out or slide out of the socket?

Do you lack the strength in your shoulder to carry out your daily activities?

If you answer "yes" to any one of these questions, you should consult an orthopaedic surgeon for help in determining the severity of the problem.

What types of shoulder injuries are most prevalent?

Most problems in the shoulder involve the muscles, ligaments, and tendons rather than bones. Orthopaedic surgeons group shoulder problems into the following categories.

Instability

Sometimes, one of the shoulder joints moves or is forced out of its normal position. This condition is called instability, and can result in a dislocation of one of the joints in the shoulder. Individuals suffering from an instability problem will experience pain when they raise their arm. They also may feel as if their shoulder is slipping out of place.

Impingement

Impingement is caused by excessive rubbing of the rotator cuff and the top part of your shoulder blade called the acromion. Impingement problems can be sustained when participating in a sports activity that requires excessive overhead motion. If you do not seek medical care for the inflammation in your shoulder, it could eventually lead to a more serious injury.

Why is the rotator cuff so important?

The rotator cuff is one of the most important components of the shoulder. It is comprised of a group of muscles and tendons that hold the shoulder joint in place. The rotator cuff provides individuals with the ability to lift their arm and reach overhead. If injured, it can become difficult for people to recover the full shoulder function needed to properly participate in the sports activity.

What causes a shoulder injury to become worse?

Some people will have a tendency to ignore the pain, and "play through" shoulder injuries which only aggravates the condition, and possibly causes more problems. People also may underestimate the extent of the injury because steady pain, weakness in the arm, or limitation of joint motion will become almost second nature to them.

How are shoulder injuries treated?

Early detection is the key to preventing serious shoulder injuries. Many times, orthopaedic surgeons will prescribe a series of exercises aimed at strengthening shoulder muscles. Anti-inflammatory medication also may be prescribed to reduce pain and swelling.

Here is a series of shoulder exercises aimed at helping individuals strengthen their shoulder muscles and prevent injuries.

Basic Shoulder Strengthening Exercise: Attach elastic tubing to a doorknob at home. Gently pull the elastic tubing toward your body. Hold for a count of 5. Repeat 5 times with each arm. Perform twice a day.

Wall Push-Up Exercise: Stand facing a wall with your hands on the wall and your feet shoulder-width apart. Slowly perform a push-up. Repeat 5 times. Hold for a count of 5. Perform twice a day.

Shoulder Press-Up Exercise: Sit upright on a chair with armrests; your feet should be touching the floor. Use your arms to slowly rise off the chair. Hold for a count of 5. Repeat 5 times. Perform twice a day.

For more information on "Prevent Injuries America!," call the American Academy of Orthopaedic Surgeons’ public service telephone number 1-800-824-BONES (2663).

Thoracic outlet syndrome

A syndrome is a combination of signs and symptoms that characterizes an abnormal condition. A physician must review all of these signs and symptoms in order to make a diagnosis. That’s certainly the case with thoracic outlet syndrome, or TOS.

TOS gets its name from the space (the thoracic outlet) between your collarbone (clavicle) and your first rib. This narrow passageway is crowded with blood vessels, muscles, and nerves. If the shoulder muscles in your chest are not strong enough to hold the collarbone in place, it can slip down and forward, putting pressure on the nerves and blood vessels that lie under it. Symptoms vary, depending on which structures (nerves or blood vessels) are being compressed. Pressure on the blood vessels can reduce the flow of blood to your arms and hands, making them feel cool and tire easily. Pressure on the nerves can leave you with a vague, aching pain in your neck, shoulder, arm or hand. Overhead activities are particularly difficult.

TOS can result from injury, disease, or a congenital abnormality. Poor posture and obesity can obesity can aggravate the condition, which is more common in women than in men. Psychological changes are often seen in patients with thoracic outlet syndrome. It is not clear whether these precede the onset of the syndrome or are the result of dealing with the pain and frustration of diagnosing and treating this condition.

Diagnosis

When you visit your doctor, he or she will ask you about the history of your symptoms, give you a physical examination and try to reproduce your symptoms through a series of tests to diagnose TOS. There may be a depression in the shoulder, or a swelling or discoloration in the arm. Range of motion may also be limited. X-rays may be recommended; an MRI (magnetic resonance imaging), nerve conduction tests, or ultrasound may be used to rule out other possible causes for your symptoms. Your doctor may order special blood circulation tests and elecrodiagnostic tests to aid in making the diagnosis of TOS.

Treatment

The treatment for TOS is conservative, and does not usually involve surgery.

• Physical therapy can help strengthen the muscles surrounding the shoulder so that they are better able to support the collarbone.
• Postural exercises can help you stand and sit straighter, which lessens the pressure on the nerves and blood vessels.
• Nonsteroidal anti-inflammatory drugs, like aspirin or ibuprofen, can ease the pain.
• If you are overweight, your physician may recommend that you go on a diet.
• You may need to change your workstation and avoid strenuous activities.
• In rare cases, surgery may be recommended if conservative treatment fails. The surgery involves dividing a muscle in the neck and removing a portion of the first rib.

Avoiding TOS

If you have symptoms of TOS, avoid carrying heavy bags over your shoulder because this depresses the collarbone and increases pressure on the thoracic outlet. You could also do some simple exercises to keep your shoulder muscles strong. Here are four that you can try; do 10 repetitions of each exercise twice daily.

1. Corner Stretch: Stand in a corner (about one foot away from the corner) with your hands at shoulder height, one on each wall. Lean into the corner until you feel a gentle stretch across your chest. Hold for 5 seconds.
2. Neck Stretch: Put your left hand on your head, and your right hand behind your back. Pull your head toward your left shoulder until you feel a gentle stretch on the right side of your neck. Hold for 5 seconds. Switch hand positions and repeat the exercise in the opposite direction.
3. Shoulder Rolls: Shrug your shoulders up, back, and then down in a circular motion.
4. Neck Retraction: Pull your head straight back, keeping your jaw level. Hold for 5 seconds.

As with any exercise program, if you start to hurt…stop!