Shoulder Ligament Injuries

Things tend to wear out and break at the moving parts. It’s just one of those principles of engineering that we cannot shake. It is one of the reasons that we see so many people with shoulder injuries.

The shoulder is the most mobile joint in the body and we ask it to do a lot for us. Every day, we reach forward, overhead and behind the back, sometimes repetitively or with heavy loads.

Other times, the shoulder absorbs more force than it should as we use the arm to break a fall in sports. This activity can lead to either traumatic or repetitive use injury. Today, we will focus on those injuries specific to the ligaments of the shoulder complex.

Ligaments hold one bone to another bone and limit the amount of motion available in the joint. This prevents excess movement or motion in directions not intended for a particular joint.

The tighter the ligaments are, the less motion available. Because the shoulder is a highly mobile joint, the ligaments must be loose to allow motion in all directions. This creates some inherent instability in the joint, and an avenue to potential injury.

Anterior Ligament Sprain/Dislocation

This injury usually occurs when we raise the arm overhead or out to the side and apply a force, such as with retrieving a heavy object from an overhead shelf. If the load is too great, then the ligaments in the front of the shoulder become overloaded and can tear, causing a sprain. If the ligaments tear enough, then the bones can separate and cause a dislocated shoulder.

Dislocations should get immediate medical attention in the emergency room. Treatment involves applying traction to the joint, which allows the shoulder to return to its normal position and then a period of immobilization to allow the ligaments to heal.

Unfortunately, the ligaments do not heal quite as tightly as they once were. The shoulder becomes increasingly unstable, disposing it to another dislocation. Conservative treatment following a dislocation involves strengthening of the rotator cuff, a group of four muscles that provide additional stability to the shoulder.

As you move your arm through space, the rotator cuff sucks the head of the arm bone, medically termed the humerus, into the socket. After a dislocation, it is even more important to keep the rotator cuff working properly. You may be referred to a physical therapist, who can provide instruction in the proper exercises.

Should the shoulder continue to dislocate, surgical intervention may be required. This entails tightening the shoulder capsule by “pulling up the slack” in the loose ligaments and stitching them back in place. This surgery is highly successful at stopping future dislocations, but there is a period of immobilization and rehabilitation for several weeks following the surgery.

Shoulder Separation

This is a common traumatic injury caused by falling on an outstretched hand. With this injury, the force of landing on the hand is transmitted through the shoulder, causing a tear in the ligament that holds the collarbone in place. The result is a dislocation of the joint where the collarbone meets the shoulder blade, located at the bony area on top of the shoulder.

This joint is called your acromioclavicular, or AC joint, and because this is the pivot point where the shoulder blade rotates, an injury here can cause significant loss of function in the arm, especially in the overhead range of motion.

Minor sprains in the ligament may heal, but active individuals who have difficulty or pain with arm use may need to undergo surgical correction, as conservative treatment usually will not restore proper mechanics and movement patterns.

Surgery involves harvesting a tendon from elsewhere in the body and using is as a replacement for the broken ligament. This effectively anchors the collarbone back in its correct position.

Frozen Shoulder

Medically termed adhesive capsulitis, this condition may be a result of injury to the shoulder, but just as often occurs without any type of trauma. It is an inflammation of the shoulder joint capsule, which contains the shoulder ligaments.

As the capsule becomes inflamed and thickened, the shoulder becomes painful and loses significant mobility. Frozen shoulder may persist from several months to a year or longer and usually follows a predictable pattern of presentation that includes three stages.

  1. The acute stage is marked by sharp pain in the shoulder throughout the range of motion, but especially with reaching overhead and out to the side. Shoulder mobility becomes limited.
  2. During the frozen stage, acute pain starts to subside, but mobility of the shoulder continues to be limited.
  3. The final phase is the thawing phase, where the joint mobility of the shoulder begins to improve, and functional use returns.

Although frozen shoulder can afflict a wide range of people, there are certain risk factors that may dispose someone to getting this condition including diabetes, cardiac disease, and hypo or hyperthyroid issues. Treatment is usually non surgical, as the condition usually gets better with time.

During the acute and frozen phases, anti-inflammatory medications may be prescribed, as well as a steroid injection directly into the joint capsule, which significantly limits the degree of inflammation.

Physical therapy may be ordered in order to learn some gentle mobility exercises, followed by more aggressive stretching and mobilization of the shoulder as the condition progresses into the thawing phase.

Treatment of Cavus Foot Deformity

Cavus Foot Deformity

Now that it’s summer, we spend more time at the beach or swimming pool enjoying the warm weather. As an orthopedic surgeon that specializes in conditions of the foot and ankle, I tend to notice wet footprints across the pool deck or in the sand and cannot help but analyze the health of the individual’s feet. One of the conditions that I notice is the high arched foot, medically termed pes cavus. This is noticeable by a footprint that is pronounced in the heel and forefoot, with very minimal or even absent impression in the middle part of the foot.

Causes of Cavus Foot Deformity

Pes Cavus is caused by muscle imbalances in the lower leg and foot that draws the front of the foot, or sometimes draws the heel downward, making the arch higher than normal. It usually begins during childhood and may be associated with neurological conditions such as muscular dystrophy or spina bifida, but not always. In many cases the muscles of the feet become tighter or weaker for unknown reasons. As with many medical conditions, genetics play a role in who will become afflicted with high arches.

Symptoms of Cavus Foot Deformity

High arches can cause a number of symptoms, ranging from mild to severe. Pain in the forefoot is a common occurrence due to increased weight bearing in this area. Excessive callus buildup at the ball of the foot behind the great toe as well as just behind the fifth toe is common, as these become high-pressure areas during standing and walking. Tightness in the calf muscles is often present, and the individual may also suffer from recurring ankle sprains due to the inwardly rolled ankles associated with the deformity.

Diagnosis of Cavus Foot Deformity

Identifying pes cavus is a straightforward process. The high arched foot is noticeable to anyone, but an orthopedic surgeon should evaluate the individual in order to identify some of the nuances of the condition. Diagnosing which muscles are tight or weak and assessing their potential to be stretched or strengthened is important for initiating an effective treatment plan.

Also, the cavus foot causes increased body weight to be distributed through areas of the foot that are not designed for this purpose. Evaluation by the surgeon will aid in a proper prescription of orthotics, if deemed necessary.

Treatment of Cavus Foot Deformity

Conservative intervention is generally the rule when starting to treat high arches. Often times if the feet have become painful, orthotic inserts are prescribed. As opposed to pes planus (flat feet), which is often a flexible disorder of the foot that we try to correct with orthotics (i.e., push back into the correct position), pes cavus is usually a rigid deformity,meaning that the shape of the foot cannot be changed.

In this case, the goal of orthotics is to accommodate the shape of the foot and to redistribute body weight over a larger area. Because of the rigidity, the cavus foot is not able to flex and absorb impact as the individual walks. For this reason, orthotics are usually constructed of softer materials to act as a shock absorber.

Physical therapy may also be prescribed to stretch and strengthen the muscles of the lower leg. Tight calf muscles and weak muscles along the outside of the lower leg (peroneal muscles) are often present in pes cavus. While therapy cannot change the shape of the foot, it may be able to help with pain control and function. Because the foot is usually rolled inward along with the high arch, the individual is susceptible to chronic ankle sprains and some reactive muscle strengthening may be beneficial, along with ankle bracing.

If conservative treatment fails to achieve the desired result, then surgical correction maybe necessary. There are many types or surgeries that the physician can perform based on individual need:

  • Tendon lengthening: This procedure involves making precision cuts in the tight tendons of the lower leg to allow better alignment of the foot. Following surgery,there is a period of immobilization for several weeks to allow the tendons to heal.
  • Osteotomy (bone cut/realignment): If the condition has been present since childhood and the bony structure of the foot has grown abnormally, then small sections of bone may need to be removed in order to restore proper position of the foot. The first metatarsal, located in the midfoot behind the great toe, is often treated with an osteotomy. The metatarsal often is positioned at a downward angle that is greater than normal, which in turn rolls the ankle toward the outside of the foot as the person bears weight.

    The osteotomy procedure seeks to normalize that angle and place the foot in a neutral position that is perpendicular to the ground. Many times, this osteotomy is performed in conjunction with soft tissue surgery such as tendon lengthening. Also, the calcaneus (heel bone) tends to be oriented toward the midline in pes cavus, as opposed to away from the midline in the normal foot, and sometimes an osteotomy is required to correct this.

  • Arthrodesis: Also known as a joint fusion, this procedure permanently locks the affected joint into a fixed position. It is a last resort option, but sometimes necessary when the cavus foot deformity is severe or when arthritis is present.

The FAQ’s on Thumb Arthritis

Try this experiment. On your dominant arm, take a piece of masking tape and strap your thumb to the side of your hand. Then leave it in place for a few hours as you try to go about your normal activities. You will soon find out just how integral this appendage is to getting through the day. Answering your cell phone, grabbing the coffee creamer from the refrigerator, turning the key to unlock the front door, are all activities that depend on proper functioning of your thumb.

Recreational activities such as golf or tennis – forget it. Now, if you have arthritis in the thumb joints, then this experiment does not end after only a few hours. It keeps going until treated medically by a qualified hand surgeon.

Degenerative arthritis of the thumb is one of the most common types of hand arthritis. It usually strikes at the base of the thumb where it meets the wrist. This joint, known as the carpometacarpal (CMC) joint, is a highly mobile joint that allows motion in all directions. It is also the joint that allows for a strong pinching motion.

However, because of its wide range of mobility, the bones that comprise the CMC joint must give up some stability, similar to the shoulder joint. Because of this, the ligaments around the joint are forced to bear most of the burden of stabilizing the thumb during hand use, and if they are unable to do it effectively then the aberrant motion in the joint over time can contribute to arthritis.

Diagnosis

The bones of the body at the joint surfaces are covered with cartilage, a slippery coating that allows smooth motion at the joints. Arthritis is an inflammation and eventual wearing away of the cartilage, creating rougher surfaces and painful motion. In my practice, arthritis of the thumb is a common occurrence with a straightforward diagnosis. Palpation of the joint as the patient moves the thumb will often reveal the typical grinding sensation as if the joint surfaces were lined with sandpaper. There also may be an audible grinding sound known as crepitus. I may also order an X-ray to confirm the extent of the arthritis and determine the most effective treatment options. Other tests such as the CT scan or MRI are most often unnecessary.

Treatment

In the earlier stages of the disease process, this type of arthritis is usually treated with anti-inflammatory medication. This is often successful for months to years, allowing the individual to fully use the hand at home and work. Thumb splinting may also be advantageous as it allows the thumb to rest in a neutral position where mechanical stress is at its least, which in turn may settle the inflammation.

However, arthritis is a generally a progressive condition and because the thumb is used so frequently and strenuously, the disease often progresses despite these measures. As more conservative treatments fail to provide adequate relief, I will attempt to reduce the joint inflammation with one or more cortisone injections to the affected joint.

In the later stages of arthritis, as more and more hand function is lost, surgical reconstruction is often the best course of action. Part of the diseased joint is removed and reconstructed using a tendon graft from another part of your body. Following surgery, you will have to wear a splint for several weeks to allow the surgical repair to strengthen. If your occupation depends upon heavy use of your hands, then you may need to be out of work during this time if you are not able to find restricted duty work.

It is important to factor this into your overall planning prior to surgery. After removal of the splint, occupational or physical therapy with a therapist who specializes in rehabilitation of the hand will be prescribed. This will help you regain strength and motion and allow you to fully utilize the thumb and hand.

If you believe you are suffering from degenerative arthritis of the thumb and need specialized orthopedic care, Orthopedic Specialists of Seattle has excellent treatment options available for you.

Enjoy the Fruits of Your Labor with these Summer Gardening Tips

Have you ever noticed how a tomato plucked from a garden tastes so much better than store bought? It’s near impossible to purchase that amount of flavor. Anybody that has ever planted a vegetable garden is sure to agree. Enjoying a salad or sandwich made with fresh vegetables from your own backyard is one of summer’s many benefits.

Flower gardening is also enjoyable for many people, and often those who like to be outside in the warm weather will spend considerable time planting, weeding, and harvesting the fruits of their labor. For those with chronic hand pain due to arthritis, this once pleasurable activity could now become a chore due to the aggressive hand movements that are involved, and the anticipated discomfort that it may cause. Luckily, there are some ergonomically designed tools on the market that will help those with hand pain continue with their hobby, and also some self-treatment strategies to minimize pain. So take heart, you can still get out there and enjoy one of your favorite activities with a little planning and strategy.

Pace yourself

You may be used to planting an entire garden or pruning an entire yard full of bushes in a day, but working with arthritis means that you should often work slower to minimize the cumulative stress on your hands. Whether you have osteoarthritis or rheumatoid arthritis, this is a good idea. Plan your activity so that you spread the work out over a few days. This will help keep the arthritis from flaring and causing increased pain.

Use arthritis friendly gardening tools

Gripping is one of the major movements in gardening work. Repetitive clamping of pruning tools can put excessive pressure on the joints of the fingers and thumb. Some tool manufacturers such as Fiskars® have designed garden tools specifically for those with limited hand and arm strength. Many of these tools have been commended by the Arthritis Foundation due to their ease of use.  These tools include spring opened scissors and pruners which maximize leverage with the use of gears and longer handles.

Keep tools sharpened

Having a dull blade on your tools means that you will have to exert more pressure in order to cut branches and stems. Have your pruning tools sharpened annually to maximize their effectiveness. Many local hardware stores offer a sharpening service, and pricing is usually very reasonable compared with the cost of new tools.

Wrap tool handles in foam

Wrapping the handle of a trowel or hand rake in foam tubing increases the handle’s diameter and reduces the muscle pressure needed to keep the tool steady within your hand. Some tools made specifically for the arthritis sufferer already have a wider handle, but otherwise this is a great technique to alleviate hand stress. You can use water pipe insulation found at the same hardware store where you get your tools sharpened.

Wear gloves

Gardening gloves do more than just keep dirt from getting under your fingernails. They also absorb perspiration. This is important because as your hands get sweaty, they also get slippery. That means you must grip your tools harder to keep them from sliding in your hand. Wearing gloves mitigates this and results in less force needed to handle your tools.

Use a lightweight coiled hose

Managing a standard garden hose can be aggravating for anyone. The kinks that develop and cut off the water supply often lead the gardener to vigorously shaking the hose to untangle it. Of course, this adds to the cumulative strain on the arthritic hand and wrist. Today’s pre-coiled garden hoses are made of a lighter weight material than standard hoses, and they resist tangling. When you are finished, the hose automatically recoils, making clean up easier.

Stay ahead of the pain

Taking ibuprofen or naproxen based medications 30 minutes prior to gardening can reduce the inflammation associated with heavy use of the hands. If you know that working in the yard will produce some soreness, then you may wish to employ this strategy prior to starting.
So get out there and enjoy the nice weather. You don’t have to give up your gardening hobby because of arthritis. Try these tips, but if pain persists you should feel free to contact my office so we can discuss effective treatment options if further detail.

Shoulder Arthroscopy FAQ

What is arthroscopic surgery?

Arthroscopic surgery is a technique that orthopedic surgeons use to diagnose and repair structural damage within a joint.  The surgeon makes 3 or 4 small incisions around the joint, about ½ inch each. Here, a fiberoptic camera is used to see within the joint and miniature surgical tools are used to perform the repair.

Arthroscopic surgery of the shoulder is an outpatient surgery, which means that you will not have to be admitted to the hospital. You will return home shortly after the surgery is over.

Arthroscopy of the shoulder joint has been a major advancement in surgical technique. This procedure allows less cutting of intact tissue to perform repairs, allowing for faster recovery times than with open surgery.

What types of shoulder surgeries can be performed using arthroscopic technique?

Dr. Shapiro performs many types of shoulder arthroscopy. Among those are:

  • Rotator cuff repair
  • Subacromial decompression (removal of bone spurs)
  • Glenoid labrum repairs (SLAP tears)
  • Repair of shoulder instability (dislocation)
  • Biceps tendon repair
  • Bursitis
  • Debridement due to arthritis
  • Frozen shoulder release

How long will my surgery take?

Most surgeries will take 45 minutes to 1 hour. You will then be required to stay in the recovery room for about another hour. You will then be discharged home. Please be sure to make arrangements for a ride home, as you will not be able to drive the day of surgery.

How long is the rehabilitation process after shoulder arthroscopy?
This depends on the type of procedure you had performed. It is important to understand that physical therapy is an important piece of recovery. You must be committed to the post-operative rehab if you wish to achieve the best outcome.

General rehab guidelines for specific surgical procedures are as follows:

Rotator Cuff Repair, SLAP Repair, & Shoulder Dislocation Repair: Physical therapy is grouped into several phases, beginning with gentle mobility and progressing to strengthening through the full range of motion. The process generally takes 4-6 weeks. Dr. Shapiro will provide both you and your physical therapist with specific instructions following your surgery.

Bone Spur Removal: Because the shoulder is left structurally intact, the rehab process flows quicker, about 6-8 weeks.

How much pain will I have following my shoulder surgery?
This varies greatly from patient to patient. You will be prescribed pain medication following surgery, along with instructions for icing the shoulder, which will help control excessive swelling. During physical therapy sessions, you will be asked to move the shoulder joint in order to restore full arm motion.

This may cause an increase in your pain level, and for this reason it is recommended that you take your pain medication 45 minutes prior to the start of therapy sessions. In time, you will need to take less pain medication.

Will I have to wear a sling following surgery?
This depends on the type of surgery that you had performed. For rotator cuff repairs, SLAP repairs, and dislocation repairs, you will be required to wear the sling for 2 weeks after surgery. For subacromial decompression surgery, a sling may be worn for comfort measures following surgery, and discontinued as pain decreases.

Can I take a shower following surgery?
Showering is permitted 72 hours following surgery.

When do I follow up with Dr. Shapiro following my arthroscopic surgery?
Dr. Shapiro or his physician assistant will follow up with you 1 week following your surgery. The goal of this visit is to make sure that your pain is under control, and the incision is free of infection and healing well.

Physical therapy is also prescribed at this time. This visit is designed to give the patient an opportunity to ask any new questions that may have arisen following your surgery.

When can I return to work?
Of course, this is highly dependent upon your occupation. You will be unable to actively use your arm following rotator cuff repair, SLAP repair, or dislocation repair. This is important in order to allow for proper healing and to not disrupt the surgical area.

If you have a sedentary job or are able to secure restricted duty where use of the arm is not required, then you should anticipate being out of work for 5-7 days. If you are required to use your involved arm, then time away from work is greater. You should discuss your situation with Dr. Shapiro prior to surgery so that you can make appropriate arrangements with your employer.