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About Jonathan Franklin

Jonathan Franklin, MD (Retired) Dr. Franklin is a board-certified orthopedic surgeon with a clinical focus in arthroscopic and reconstructive knee surgery, arthroscopic shoulder surgery, as well as knee replacement surgery. Dr. Franklin has a strong background in sports medicine, and treats many high school, as well as recreational and professional athletes for a wide variety of sports injuries.

Frozen Shoulder Causes and Treatment

Frozen shoulder, or adhesive capsulitis, is a disorder characterized by pain and stiffness in the shoulder joint. The symptoms generally begin gradually but worsen over time. As more time passes, the shoulder becomes very difficult to move. Around 2% of the general population is affected with this condition, and it typically occurs more often in women between the ages of 40 and 60.

The shoulder is a ball-and-socket joint that consists of the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). With frozen shoulder, the shoulder capsule thickens and gets tight due to stiff bands of tissue called adhesions.

To diagnose this condition, the orthopedic specialist will perform a complete physical examination and take an extensive medical history. Tests that will help the doctor rule out other shoulder disorders include X-rays, MRI, and ultrasound.

What are the stages of frozen shoulder?

Frozen shoulder develops in three stages: freezing, frozen, and thawing. The “freezing” stage occurs slowly and pain worsens gradually. With this stage, you lose range of motion of the shoulder joint, and it typically lasts from 6 weeks to 9 months. In the “frozen” stage, the painful symptoms actually improve – only the stiffness remains. This stage lasts around 4 to 6 months, and daily activities are troublesome during this time. The “thawing” stage is where shoulder motion slowly returns to normal. This stage lasts around 6 months to 2 years.

What are the symptoms of frozen shoulder?

During the “freezing” stage, the shoulder joint becomes quite painful. Any movement of the shoulder leads to discomfort during this time. Stiffness occurs in the “frozen” stage and there is decreased range of motion. These symptoms improve during the “thawing” stage.

What causes frozen shoulder?

Experts do not fully understand the causes of frozen shoulder. There is no distinct connection to arm dominance or occupation. With this condition, the capsule that encases the shoulder joint becomes thickened and tightens, restricting movement. There are some factors that can put you at risk for developing this condition. These include:

  • Age and Sex: People over the age of 40 are more likely to experience frozen shoulder, and it is more common among women.
  • Diabetes: Frozen shoulder has been found to occur more commonly in the diabetic patient, affecting around 15% of the diabetic population.
  • Other Diseases: There are some additional medical problems associated with frozen shoulder like hyperthyroidism, hypothyroidism, tuberculosis, cardiac disease, and Parkinsons disease.
  • Immobilization: When the shoulder is immobilized for an extended period of time, frozen shoulder can develop. Possible conditions requiring immobilization include a broken arm, a rotator cuff injury, a stroke, or recovery from surgery.

How is frozen shoulder treated?

Frozen shoulder typically resolves with time, although it can take as long as three years. The focus of treatment is to control pain and to restore strength and motion of the shoulder joint. Nonsurgical measures include non-steroidal anti-inflammatory medications (NSAIDS), steroid injections, and physical therapy. The orthopedic specialist can also inject sterile water into the joint capsule to stretch the tissue and enhance movement. This is called “joint distension.”

If these conservative measures do not improve the symptoms, the orthopedic specialist may find it necessary to operate on the shoulder. The surgeon can perform manipulation under anesthesia or shoulder arthroscopy. During the manipulation procedure, the doctor will force your shoulder to move under an anesthetic so it will not be painful to you, making the capsule and scar tissue stretch.

This is done to release the tightening and increase the range of motion. With shoulder arthroscopy, the doctor cuts through tight portions of the joint capsule to increase motion of the shoulder. This can be done with tiny instruments and a small camera.

Common Sports Shoulder Injuries

Most injuries to the shoulder occur during athletic activities that involve repetitive, excessive overhead motion. These include pitching, weightlifting, tennis, and swimming.  Some sports related shoulder injuries include shoulder instability, shoulder impingement, shoulder separation, shoulder dislocation, rotator cuff tears, acromioclavicular joint sprains, and SLAP lesions.

Shoulder Instability

When the shoulder joint is forced out of normal position, the condition is known as instability. Shoulder instability can result in a dislocation, which is quite painful. Most people who suffer with shoulder instability have pain when raising the arm and the shoulder feels as if it is slipping out of place. If this instability becomes a chronic, recurring problem, the surgeon may find it necessary to perform an arthroscopy. This procedure allows for the orthopedic specialist to look inside the shoulder with a tiny camera to assess the extent of the injury and perform surgery on the area to repair the soft tissues.

Shoulder Impingement

Impingement of the shoulder is caused by excessive rubbing of the tendons against the upper portion of the shoulder blade (the acromion). When there is repeated use of the arm overhead, shoulder impingement is likely. Injections and physiotherapy can improve this syndrome, but surgery is often necessary to remove bony spurs that trap the rotator cuff tendons and worsen the condition.

Shoulder Separation

With a separated shoulder, the acromioclavicular (AC) joint is injured. The AC joint is located where the collarbone (clavicle) meets the upper area of the shoulder blade (acromion). Most of these injuries are the result of a fall where the ligaments attaching to the underside of the clavicle become torn. A separated shoulder causes pain and deformity of the shoulder region. A mild separation involves AC ligament sprain and will appear normal on X-rays. With a more serious injury, the AC ligament could tear, putting the collarbone out of alignment.  Most minor shoulder separations can be treated conservatively with the use of slings, cold packs, and medications for pain.

For more severe injuries, the orthopedic specialist may need to surgically trim back part of the end of the collarbone to prevent rubbing against the acromion. Also, the torn ligaments may need to be addressed by attaching them back to the underside of the collarbone to restore stability of the AC joint therefore allowing motion, flexibility, and strength to return.

Shoulder Dislocation

The shoulder joint is the most mobile joint of the body, making it potentially unstable and at risk for dislocation. Repeated dislocations result in instability and stretching of the shoulder joint, which can lead to poor sports performance and long periods out of the game. In order to reduce a shoulder dislocation, the surgeon will position the ball of the upper arm bone back into the joint socket by means of a closed reduction. For severely dislocated shoulders, however, surgery is often necessary to repair the torn or stretched tissues around the shoulder that normally support the joint.

Rotator Cuff Tears

The rotator cuff is a group of tendons and muscles that allow for movement and stability of the shoulder. The rotator cuff allows an individual to lift the arm and reach overhead. When this structure is injured, pain and weakness occurs. If tearing is significant, the surgeon may need to perform a rotator cuff repair through small incisions (arthroscopy) or by an open method.

Acromioclavicular Joint Sprain

The AC joint is important for athletes who throw and put their arms overhead. It is often sprained from repeated falls and can dislocate easily. When this joint is sprained, there will be pain and loss of normal movement of the shoulder. The orthopedic specialist can provide injections and physiotherapy to improve an AC sprain. Occasionally, with more significant AC sprains, an operation may be necessary to help alleviate persistent, long-term pain.

SLAP Lesions

Tears of the Superior Labral Antero-Posterior (SLAP) region of the shoulder occur with overhead throwing, tackling sports, and heavy lifting. Because the biceps anchors the shoulder, it is easily pulled off the bone by force. The symptoms of this type of injury include pain within the shoulder with lifting and sports. Many complain of a clicking sensation that extends down the upper arm. If the SLAP tears are not serious, the orthopedic specialist will prescribe non-steroidal anti-inflammatory medications and physical therapy. Some tears, however, will require surgical repair via arthroscopy or open techniques. This way, the surgeon can determine the extent of your injury and repair it at the same time.

Shoulder Arthroscopy

Arthroscopy is the medical term for a procedure that our orthopedic specialists use to examine, diagnose, and repair problems inside your shoulder joint. This word comes from two separate Greek words, “arthro” meaning “joint” and “skopein” meaning “to look.” This term means “to look within the joint.”

How do I plan for a shoulder arthroscopy?

Your orthopedic specialist may ask you to see your family doctor to make sure that you do not have any health concerns that should be addressed before your procedure. You may need to have an electrocardiogram, blood tests, and a chest X-ray before your surgery. If you have any health risks, you should discuss this with the surgeon and advise him of any medications or supplements that you are currently taking.

If you are in fairly good health, your shoulder arthroscopy will most likely be performed on an outpatient basis. The surgical center will contact you before the procedure to discuss the specific details. Make sure you follow their instructions regarding arrival time and when to stop eating or drinking prior to your operation.

Before your shoulder arthroscopy, a member of the anesthesia team will discuss your anesthesia options. Most shoulder arthroscopic procedures are performed using regional nerve blocks, which numb your arm and shoulder. The numbing medicine will be injected in the base of your neck or high upon your shoulder. The nerves that control feeling in your shoulder and arm will be targeted so you do not feel anything during the operation and for several hours after your surgery to help with post-operative discomfort.

Many of our orthopedic specialists combine nerve blocks with sedation or a general anesthetic in order to make you comfortable while lying on the operating table. Most shoulder arthroscopies take less than one hour; however, the length of your surgery will depend on what the doctor finds and what repairs are necessary.

Before you undergo a shoulder arthroscopy, plan to wear comfortable clothing that is easy to put on and take off. You should also leave all watches, jewelry, and valuables at your residence. You will also have to arrange to have someone drive you home after your procedure. Plan for assistance for at least two weeks following your shoulder arthroscopy, as tasks at home may be a little difficult.

What happens during a shoulder arthroscopy?

Once you have arrived and are positioned in the surgical room, you will be placed in the beach chair position. This is a semi-seated position to allow you to be essentially reclining in a chair. The surgical team will remove the hair from the operative site if necessary, and then spread an antiseptic solution on your shoulder to properly cleanse and sterilize the surgical site. The shoulder and arm will be covered with sterile drapes, and your arm will be placed in a holding device to keep it safe and stable.

The orthopedic specialist will first inject fluid into one of the small incisions he makes on your shoulder. This makes it easier for him to insert the instruments that will be used to visualize the structures with the arthroscope. Images from this scope are projected on a TV monitor so the surgeon can see inside your shoulder clearly.

Fluid flows through the arthroscope as he guides it around the joint space of the shoulder. Once your problem is identified, the orthopedic specialist can insert tiny instruments through the buttonhole-sized incisions for the purpose of removal or repair. These specialized instruments are necessary for tasks such as cutting, suture passing, knot tying, or shaving. Once the procedure is complete, the surgeon will close these incisions with stitches or Steri-strips and cover that will a large, soft bandage.

What should I expect after my shoulder arthroscopy?

During the recovery period, you will stay in a recovery room for a couple of hours before being discharged home. The orthopedic specialist and his team will monitor your condition to make sure you are ready to travel. At home, you can expect some pain and discomfort for a least a week following the procedure. Ice is recommended to help with this and your doctor may prescribe you some medication. You are allowed to shower once your wounds are no longer draining, but should avoid prolonged soaking or scrubbing of the incisions. A special immobilizer will be issued for the purpose of protecting your shoulder. The doctor will advise you on how long this will be needed.

Rehabilitation will allow you to get back to your daily activities. This is an exercise program to help you regain your range of motion and strength in your shoulder. It is important for you to follow doctor’s orders and make a noble effort at your rehabilitation in order for full recovery to occur.

Shoulder Replacement Surgery

The upper portion of your arm bone is shaped like a ball. Muscles and ligaments hold this ball against the cup-shaped part of the shoulder bone. Orthopedic specialists perform a shoulder replacement when this area is damaged from arthritis or trauma.

Before the Procedure

During surgery the anesthesiologist will use general anesthesia which means you will be unconscious. Occasionally, your orthopedic specialist prefers to use regional anesthesia, meaning you won’t be able to feel the area he is working on and you will be sleepy but awake during the surgery.

The choice of which kind of anesthesia will depend on your overall health status, what you prefer, and what your anesthesiologist chooses. Also, you will be given antibiotics during and after your surgery to reduce the risk of infection. Many times our orthopedic surgeons want you to get your dental work completed before you have shoulder replacement surgery.

During the Procedure

A total shoulder replacement is done to replace the ends of bones in a damaged shoulder joint. This procedure creates new joint surfaces. During surgery, the orthopedic specialist will replace the ends of the damaged upper arm bone (called the humerus) and the socket (called the glenoid). The surgeon will cap these areas with artificial surfaces made plastic and metal. Shoulder joint components that are placed into the joint must be held in place with cement or they may be made out of a special material that allows new bone to grow into the joint components over time and hold them in position.

Basically, for shoulder joint replacement, your orthopedic specialist will make an incision over the front of your shoulder joint to open up the area he will be working on. Then he will remove the top of your upper arm bone, cement the new prosthetic head and stem in place, and smooth or replace the surface of the old socket. He will then close the incision with staples or sutures and place a bandage over your wound. This surgery usually takes anywhere from one to two hours to complete.

After the Procedure

Right after surgery you will have an intravenous (IV) and antibiotics going through this for one or two days. You will also receive medications that will prevent blood clots and relieve pain. Keep in mind that you will not feel yourself for a few days after surgery due to the effects of anesthesia. You may be constipated, have an upset stomach, and feel groggy or tired.

When you wake up from the procedure you will have a bandage on your shoulder and possibly a drain to collect fluid and prevent it from building up in the joint area. A physical therapist will begin to work with you to perform gentle exercises on your shoulder on the day of surgery or the day after. The sooner you work your shoulder, the better.

Shoulder Conditions and Shoulder Surgery

Your shoulder allows you to move and rotate your arm in a variety of positions. The shoulder, in fact, is the most flexible joint your body has. This type of flexibility also makes your shoulder susceptible to injury. If you do injure your shoulder, there are some nonsurgical methods of treatment that sometimes are recommended before surgery is considered.

However, in some cases, delaying surgical repair could increase the likelihood that your condition will be more difficult to treat later on.

If you have injured your shoulder, consult one of our orthopedic specialists for correct diagnosis and treatment of the problem, as this can make a big difference in the long run.

How does the shoulder work?

Your shoulder is made up of a ball-and-socket joint that has three bones: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). The top end of the humerus has a ball on the end that fits into a small socket of the shoulder blade. This is what forms the shoulder joint. The socket of the shoulder is surrounded by soft-tissue and the head of the arm bone has a smooth, durable surface. There is a thin inner lining of the joint called the synovium, and this allows for the smooth motion of the joint.

The upper portion of the scapula protects the shoulder joint. Your collarbone is attached to the shoulder blade by the acromioclavicular joint, often called the ‘AC joint’. The inner portion of the collarbone joins with the breastbone (sternum). Your rotator cuff is the group of tendons and muscles that attach your upper arm to your shoulder, and this structure covers the shoulder joint. You have many muscles that attach to the three upper arm bones and these enable you to lift your arm, throw a ball, swim, and reach over your head.

What are some common shoulder conditions?

Bursitis or Tendinitis
Bursitis or tendinitis occurs with overuse from repetitive activities like weight lifting, swimming, and throwing. These types of activities lead to a pinching and rubbing of the rotator cuff under the AC joint. The biceps tendon and rotator cuff will get irritated and inflamed with tendinitis and can lead to impingement syndrome and biceps tendon tears and/or rotator cuff tears. Sometimes, this condition can be treated by limiting the activity, but oftentimes, the pain starts after the damage has been done. If you have this condition and it is associated with isolated biceps tendon damage and pain, a procedure called ‘biceps tendoesis’ can be performed by our surgeons. This procedure relieves symptoms and prevents further damage to the joint.

Partial Rotator Cuff Tears
If the rotator cuff is partially torn, it is called a ‘partial thickness tear’. These are associated with chronic inflammation of the shoulder joint and the development of spurring under the AC joint. Sometimes, our orthopedic specialists treat these with modification of activity, light exercise, as steroid injections. If these methods fail, surgery will be necessary to repair the rotator cuff and remove the spurs that have developed.

Full-Thickness Rotator Cuff Tears
When the rotator cuff is torn completely in two pieces, it is known as a full-thickness rotator cuff tear. This can occur from heavy lifting, a fall, or a car accident. Most of the time, surgery of the shoulder is necessary for full-thickness tears. Arthroscopic techniques allow our expert surgeons to shave the spurs, evaluate the rotator cuff, and repair the tear. If the tear is larger or significantly retracted or associated with other structural problems, the surgeon may have to perform open surgery on the shoulder.

Impingement Syndrome
Impingement syndrome develops when the bursa of the joint is inflamed and the bone and tendons are irritated from rubbing on the undersurface of the acromion or AC joint. Our orthopedic surgeons can treat this with an ‘arthroscopic subacromial decompression’ procedure. With this procedure, the doctor removes some of the bony prominence or spurs and the inflamed bursa to allow for more space for the shoulder structures.

Instability
When the head of the upper portion of the arm bone is forced out of the shoulder socket, instability occurs. This usually is the result of a sudden injury, but can occur from excessive laxity of the shoulder ligaments. The two forms of instability are subluxations and dislocations. Basically, a subluxation is an incomplete dislocation. With subluxation, the shoulder is partially out of the socket. A dislocation occurs when the head of the upper arm bone slips completely out of the socket and may result in chronic instability of the joint. If you have repeated dislocations, our orthopedic specialists can operate by means of arthroscopic or open surgical repair.

Frozen Shoulder
A frozen shoulder occurs when the structures of the shoulder joint become immobile and lose flexibility. This occurs from injury or ‘wear-and-tear’ or may develop spontaneously with no specific cause. Our orthopedic specialists can treat frozen shoulder with many modalities including physical therapy, anti-inflammatories, injections and on rare occasions with manipulation under anesthesia or surgery to release the tight structures.

Fractured Collarbone and Acromioclavicular Joint Separation
Two common injuries for children and young adults who fall are a fractured collarbone and acromioclavicular separation. Most of these types of injures can be treated with splinting and arm slings, but often a serious displaced fracture or separation requires open surgical repair.

Fractures of the Upper Humerus or the Humeral Head
If you fall on an outstretched arm, you could suffer a fracture of the upper arm or humeral head. This type of fall is common in older people with osteoporosis. Open surgical repair is needed if the fracture is fragmented or displaced. Sometimes, our orthopedic specialists must put in an artificial joint called a prosthesis.

Osteoarthritis and Rheumatoid Arthritis
Arthritis can completely destroy the shoulder joint and its surrounding structures. Two forms of arthritis that do this are osteoarthritis (the most common type) and rheumatoid arthritis. These conditions may also cause deterioration and degeneration of the rotator cuff. If this happens, our orthopedic surgeons can surgically replace the shoulder joint with a metal and plastic joint to aid mobility and eliminate pain.

What are the types of shoulder surgeries?

Arthroscopy
Arthroscopy is a type of shoulder surgery that allows the surgeon to insert a small device inside the joint structure through a small incision to look inside. The images inside the shoulder joint can be viewed on a TV monitor that allows our orthopedic specialists to make a correct diagnosis. The surgeon can also insert small instruments inside the joint to make necessary repairs. Arthroscopy can usually be performed on an outpatient basis. The American Orthopedic Society for Sports Medicine reports that there are around 1.4 million shoulder arthroscopies done worldwide every year.

Open Surgery
Open shoulder surgery may be needed for some cases where there is an extensive injury or if the structures inside the joint are severely damaged. Open surgery can be done with a few small incisions. For some injuries, open surgery is associated with better results than arthroscopy. Open surgery technique uses larger incisions than arthroscopy to allow the surgeon to mobilize retracted tissues. Our orthopedic specialists will recommend the procedure that is best for you.

What are the possible complications of shoulder surgery?

After your shoulder surgery, some pain, stiffness, and tenderness are to be expected. There are some possible risks that could occur, however. These include infection, blood clots, and nerve damage.

How can I prevent future shoulder problems?

Once you have undergone a shoulder procedure, it is vital that you continue a shoulder exercise program that includes daily stretching and strengthening. Patients who follow their doctor’s therapies and instructions have the best medical outcome after shoulder surgery.

What can I expect during the recovery from shoulder surgery?

Your recovery really depends on the type of surgery that was performed. Most of the time, you will receive physical therapy for several weeks following surgery. It is critical that you only perform the activities your orthopedic specialist recommends.