Colin Porter, a starting guard for the Washington football team the last two seasons, knew the nagging pain in his shoulders was only getting worse. In the Arizona game last year, his left shoulder popped out five times.

But the Bothell High grad figured that offseason surgery would fix the problem.

Instead, surgery on each shoulder in recent months revealed degenerative arthritis and a recommendation from his doctor that Porter give up football. This week, Porter — who would have been a junior next season — made the decision to stop playing.

Porter said he first began having shoulder problems in the ninth grade, but never had a surgery until January.

“I was always able to play with them and able to play with the pain,” he said Wednesday. “But it got to a point this year that I needed to get them done, and I didn’t know it would be that bad. Thought it would just be a little repaired labrum on each shoulder. But it turned out to be a lot, lot worse.

“… I’m 20 years old with these problems and I’ve got a lot of life ahead of me and with these problems already, it could be a hard road ahead of me with my shoulders as is, and if I kept playing it would be even worse.”

Porter’s departure is a significant blow for the Huskies as he was expected to help anchor the line and be one of four projected returning starters. Instead, UW has been hard hit up front with Porter gone and fellow starting guard Colin Tanigawa recovering from a knee injury suffered against Oregon State with no return date set.

Porter will stay in school on a medical scholarship and finish a degree in political science and international security.

While some talked of Porter having an NFL future, he said that was never a specific goal and that he had always hoped to pursue a career in the military or intelligence. He said that’s where he will now turn his focus instead of looking back on what might have been.

“I consider myself lucky to even get the chance to play Division I football, let alone be able to start and be a contributor and a contributor to team success,” he said. “Not everyone gets two years, or even gets any chance to do that. So I consider myself lucky. My career was stopped short of the four years it would have been, but not everyone gets the chance that I got, and I’m thankful for that.”

http://seattletimes.nwsource.com/html/huskyfootball/2017961024_porter12.html

The second issue is that surgery by itself at an earlier stage isn’t necessarily a solution.  As we have come to learn more and more about how the shoulder works, it has become increasingly clear that the shoulder functions in a circular or global manner, meaning that most often a problem on one side of the globe will most often have some associated or complementary effect on the opposite side of the globe.  So although many surgical procedures have been succesful at reducing dislocations, because they created an imbalance in the circle, also contributed to developing instability in the opposite direction or increasing the risk of developing arthritis by not fully restoring global balance.  This is similar to replacing worn tires on your car without addressing the core problem of alignment, which will ultimately result in premature wear of the new tires.  So to avoid a failed shoulder surgery and reduce the risk of further damage,  it is not only important to get early treatment, but to make sure and get comprehensive treatment and pick a shoulder specialist that understands the global balance of the shoulder.

The last issue is one of competing priorities.  Colin Porter knew he had hurt his shoulder as early as the ninth grade, but because he could play with the pain, he felt that he could just wait to address the issue later.  No one wants to miss time because of an injury-most coaches, trainers, parents, and athletes believe that “no pain, no gain” builds stronger athletes and ultimately stronger people.  Unfortunately, as this case illustrates, the challenge in life is to try and use as much real and meaningful information as possible to guide our decisions and be able to tell the difference between the pain of growth and building from the pain of injury and destruction.

Playing Can Worsen Already Damaged Shoulders is a post from: Shoulder Pain

Along with the other stretches and exercises recommended in the Cressey post, we recommend the one arm row as an excellent scapular stabilizing exercise that just about everyone can do:

Shoulder Pain-Multiple Reasons for Pain and Strategies for Optimal Function is a post from: Shoulder Pain

We still don’t know what the final course of action will be for Orioles 2009 top draft pick Matt Hobgood and his ailing right shoulder. After seeing an Orioles team doctor last night, the 21-year-old pitcher remains shut down and will soon seek a second opinion.

At this point, the Orioles are not recommending surgery for the player the O’s selected with the fifth overall pick in the draft.

The right-hander saw Orioles orthopedist Dr. John Wilckens in Florida last night and is expected to meet with Delaware-based Dr. Craig Morgan, possibly later this week, to get another opinion on what is causing the pain in his shoulder. A specialist in this area, Dr. Morgan has worked with and helped pro pitchers with similar injuries before.

“No one (Dr. Wilckens, etc) knows 100 percent for sure what’s wrong with it at this point, myself included,” Hobgood wrote to me today via text message. “Lots of opinions from multiple people close to me, players, trainers, doctors, coaches and physical therapists. But nothing is concrete yet on why the shoulder is still giving me problems.”

Last year, Hobgood went 0-6 with an ERA of 8.76 between the Gulf Coast League O’s and the short-season Single-A Aberdeen IronBirds as he tried to work his way back from the injury. He didn’t get into an affiliated game until June 20 and pitched just 37 innings, allowing 51 hits with 26 walks and 22 strikeouts.

Hobgood also wrote that he had praise for those that are trying to figure out just exactly what is wrong his shoulder.

“All the doctors and trainers who I have seen have done their best to continue to help me get back to being healthy. Everyone involved has done a great job in helping me try to figure out what exactly is wrong. Everyone has been great, especially John Stockstill, in doing whatever it takes to figure out what is best for me going forward,” he wrote.

About a week ago, Hobgood was shut down after feeling soreness when throwing a live batting practice session. He is 4-15 with an ERA of 5.48 over 157 2/3 innings in his O’s minor league career.

No one can project yet whether this latest development will keep Hobgood from missing some, a portion of or all of the 2012 season.

http://www.masnsports.com/steve_melewski/2012/03/os-and-hobgood-seek-second-opinion-for-shoulder-injury.html

Remember, failed shoulder surgery is far more time consuming, frustrating, and expensive than taking the time to establish the best treatment plan for you personally.

The Correct Diagnosis is Paramount-Get a Second, Third, or Fourth Opinion if Needed is a post from: Shoulder Pain

DORAL, Fla. — Paul Casey already has missed five tournaments this year after dislocating his shoulder while snowboarding over the holidays. It’s a bad time for an injury, especially in a Ryder Cup year, though Casey has a good reason to feel optimistic.

It could have been worse.

One of the doctors he saw in the aftermath of his injury said that surgery was a possibility, and he would be out four to six months.

“That was a little bit worrying,” Casey said Wednesday.

After getting more opinions, he was convinced that surgery was not needed. It was the first time he had dislocated the shoulder, the labrum was in good shape and there was every reason to believe he could return to 100 percent health.

Casey figures he’s at about 90 percent at the Cadillac Championship at Doral, which has a 74-man field with no cut.

“It’s feeling strong,” he said. “All that work I’ve been putting into the shoulder, now I have to do a lot of work on the golf game.”

Casey said he heard a sound coming from his shoulder when he fell, felt pain and within minutes could not move his arm. When he got down the mountain and had an X-ray, he was told it was dislocated. Then, the shoulder was put back in the socket and the pain went away.

“I thought it was great,” Casey said. “I thought maybe I can be ready for Abu Dhabi or Qatar or something like that. I had absolutely no clue how long a dislocation takes to repair. Finding out that I didn’t need surgery was a relief because the surgery … basically would have wiped out the whole season.”

Now, he has some catching up to do.

Casey is at No. 41 in the European points list (based on European Tour earnings) and No. 19 in the European ranking list. The top five players are taken from each list.

At least it didn’t cost him any of the four majors, which offer the most ranking points. Casey is playing the next two weeks in Florida, taking a week off, then playing Houston and the Masters.

“I think I’ll throw in some events as the golf game gets stronger and as the year goes on,” he said.

http://www.washingtonpost.com/sports/casey-returns-from-shoulder-injury-early-reviews-on-augusta-national/2012/03/07/gIQAVc0exR_story.html

Of course, the decision for surgery isn’t simple either.  Some of the worse shoulder problems we see are patients that have had poorly conceived or executed shoulder surgery for an unstable shoulder.  Here is more information about shoulder surgery complications.  Here are some tips on how to choose a shoulder specialist.  Another tip is to make sure the surgeon you choose is able to comfortably tie arthroscopic knots and uses only surgical techniques that require knot tying.  Although the vast majority of surgeons that perform shoulder surgery do not tie knots routinely and use so call knotless implants, the failure rates with these types of implants has been reported to be as much as five times greater.  So do your homework, and like Paul Casey, don’t be afraid to get a second, third, fourth, or even fifth opinion until you have a clear understanding of your unique circumstances and the best treatment option for you personally.

Shoulder Dislocation- Is Surgery the Better Option? is a post from: Shoulder Pain

All bones in the human body start out as cartilage. In fact, most bones have not even begun to turn into bone (or ossify) at the time that a baby is born. But, the first bone to ossify in the womb is the collarbone or clavicle.

The clavicle is the only contact between our entire (axial) skeleton and the arm. It connects the breastbone (sternum) to the shoulder blade (scapula). There are no other bony contacts, as the shoulder blade is otherwise suspended in space by muscle. This makes the collarbone one of the most common bones to fracture or break in the human body. Some research suggests that it happens 20 percent of the time. It can happen while landing on an outstretched hand or by direct force to the shoulder. It can also happen during the birth of your child.

Nonsurgical management has been the mainstay of treatment for centuries. This can be done by using either a sling or a figure-of-eight brace. Many will advocate the latter because it draws the shoulder backward potentially lining up the broken bone ends better. However, research has demonstrated that most children do not tolerate the figure-of-eight device and ultimately stop using it early in the treatment course. Similar studies have shown equal outcomes when comparing the sling to the figure-of-eight.

Traditionally, if the fracture punctures the skin, or pushes on vital structures, then surgery is considered a better treatment. In general, surgery approximates the two ends of the collarbone and secures it in place with either screws or a plate-and-screw construct. Recently, there has been some good research in adults suggesting a change to the indications for surgical treatment. Data suggests that nearly 15 percent of adult clavicle fractures do not heal properly without surgery. New indications suggest that if the fracture is short by an inch in length, then surgery should be considered.

In children, and perhaps even adolescents, there is no research to support this change in indication to perform surgery. In fact, for children under the age of 10, most studies suggest that surgery is rarely necessary. The age group of 10 to 18 is a gray area (not quite a child and not quite an adult – since the clavicle does not stop growing until the mid-20s). Many surgeons will translate the adult literature to kids in this age group, especially if the injury is on the dominant arm, or if the child is an overhead athlete.

You should see your doctor if there is an obvious deformity of the collarbone or, without deformity, if the pain is not improving after two weeks of rest, or the pain is associated with a fever.

http://www.utsandiego.com/news/2012/mar/06/collarbone-a-common-casualty/

If you are unsure of the best available options for treatment, or for particularly complex and difficult shoulder girdle injuries, you and/or your physician may consider getting a second opinion with a shoulder specialist .

Shoulder Injuries-Broken Bones is a post from: Shoulder Pain

VIERA, Fla.—The former ace of the Yankees arrived here a broken pitcher. This was two years ago, when Chien-Ming Wang was just six months removed from shoulder surgery.

The Washington Nationals had signed him for $2 million, and already, it seemed like a wasted investment. His shoulder was untenably weak. He threw as if he had never thrown before, lobbing the ball as if it were a hand grenade

“The first few weeks I was working with him, I saw a guy that I didn’t think would make it back,” Nationals pitching coordinator Spin Williams said.

But Wang did make it back, eventually. He made it back last summer from the same shoulder injury—a torn anterior capsule —that Johan Santana is trying to recover from, which makes him something of a case study for the Mets.

As Wang vies for the last spot in Washington’s deep starting rotation, he offers both reason for optimism and reason for tempered expectations for Santana, whose recovery is essential to the Mets’ quest for relevance in 2012.

Santana said he has not followed Wang’s progress. He believes he can come back faster and stronger than Wang, who took a full two years to return. But Wang was curious about Santana, who is 18 months removed from his last major-league game.

“He’s not back yet?” Wang asked. If Santana asked for advice, Wang said he would offer this: “Be patient.”

Dr. Craig Levitz, the chief of orthopedic surgery at South Nassau Community Hospital on Long Island, likened the anterior capsule to a piece of saran wrap that protects the shoulder. It is what allows a pitcher to cock his arm back without his arm sliding out of the shoulder socket.

Wang tore his in 2009, his fifth season with the Yankees. Santana tore his in September 2010. At the time, the only other known major leaguer to undergo surgery for such an injury was Mark Prior, who has yet to make it back to the majors.

There is no road map to recovery, but Wang’s journey is the closest thing to it. It was a path marked by numerous setbacks and revised timetables, of inklings of progress erased by sudden pain.

One year ago, Wang was roughly where Santana is now. A year and a half after his surgery, the end of his rehab was seemingly in sight. He threw off a mound without incident. But he made it through only 16 pitches in an intrasquad game before leaving with tightness in the shoulder. So it went for a while.

“Sometimes, in the rehab, you have pain, then you shut it down, then you go back on the field, throw, feel pain,” Wang said. “Sometimes you feel like you’re not going to make it back.”

Santana can relate. After his first minor-league rehab game last summer, he reported fatigue in his shoulder. The Mets shut him down for a few weeks, effectively eliminating any chance he had of pitching in the majors in 2011.

The setbacks are indicative of the challenge the Mets still face with their ace: building up his shoulder strength without giving him a heavier workload than he can handle. The ideal balance is difficult to find.

“It’s hard for doctors, hard for trainers and hard for patients,” Levitz said. “There’s no green or red light that goes on when you try to do too much.”

What makes Santana’s recovery especially difficult to forecast—and what sets him apart from Wang more than anything else—is that his injury required open surgery. Most shoulder surgeries, including the one performed on Wang, can be done with a minimally invasive arthroscope. But doctors couldn’t reach Santana’s injury with a scope, so they had to make an incision in the area of the tear. As a result, he has also had to rehab the tissues and muscles that were cut in order to reach the tear.

“It’s an area of unknown,” Levitz said. “There has not been a pitcher of his level that has had open surgery since 1970.”

So far, Santana’s spring training has been encouraging. He plans to face hitters in live batting practice for the first time Thursday and is scheduled to make his first Grapefruit League start Tuesday.

Even if he is ready for Opening Day, Wang’s experience suggests Santana will still need time to regain his velocity. Wang said he throws his signature sinker in the low 90s now, down a few miles per hour from before surgery.

But Wang continues to get stronger and more effective. That should give the Mets hope that even if Santana is a shell of himself when he returns, he will get better over the course of the season.

“They used to say in two years, you really knew what you had in a guy after surgery,” Williams said. “But I think it’s even longer than that, especially with major shoulder surgery. You get a feel for what you have in two years, but if they continue to make progress, you’re still going to see a better product down the road.”

http://online.wsj.com/article/SB10001424052970203986604577253800375357334.html?mod=googlenews_wsj

Along with a greater understanding of the kinetic chain and each athletes unique patterns of coordinating the body for compound movements like throwing, shoulder surgery has also advanced significantly.  As the most mobile joint in the human body, it took great advances in medicine and arthroscopy to understand that the shoulder is a circle and that a tear or injury in one part of the joint means there is obligate injury in other areas of the joint as well, see unstable shoulder. In practice, this means developing a surgical technique that allows comprehensive evaluation and treatment of the entire shoulder joint and not just focusing on a small area of the labrum or rotator cuff , see shoulder dislocation.  The materials used to perform the repairs have also improved greatly see video below:

Along with your own resolution to succeed, a shoulder specialist  can help swing the odds of making a successful recovery in your favor.

Sports Shoulder Injuries- The Long Road Home. is a post from: Shoulder Pain

Shoulders are the third most commonly replaced joints in the United States, and are he fastest growing joint replacement, in part due to the US approval of the Reverse Total Shoulder in 2004.  Depuy and Tornier share nearly half of the global shoulder repair market.  This rapid rate of growth and success has attracted the attention of many other orthopedic manufacturers and the market is quickly expanding to include offerings from many others.

Although the Reverse Total Shoulder is the result of over 20 years of research and development culminating with the current design by Professor Paul Grammont in France in 1991, its rapid success has garnered a lot of attention and tweaking, which may or may not result in improved results.

The Reverse Total Shoulder grew out of the frustration and limitations observed with the more traditional options (anatomical total shoulder and partial shoulder replacement) for the treatment of patients with rotator cuff arthropathy (massive rotator cuff tear and arthritis).  To gain a better understanding of this we have to remember that the shoulder, like a golf ball on a tee, has a very shallow bony socket and relies almost entirely on its surrounding tissues and muscles to maintain a stable center of rotation.  A stable center of rotation is important because in order for muscles to work optimally, they must be maintained at an optimal level of stretch, so when they contract, they are able to provide the most efficient level of power and function.  Conversely, when an unstable center of rotation exists the risk of adversely promoting wear, tear and arthritis of the shoulder joint greatly increases, like driving your car out of alignment significantly speeds up the wear on your tires from too much stress on just one part of the tire.

Although there are many possible ways to end up with an unstable center of rotation and arthritis, resulting in debilitating shoulder pain, the most commonly observed indication is because of a large or massive rotator cuff tear resulting in so called rotator cuff arthropathy.  In these patients, because the rotator cuff can no longer help provide a stable center of rotation, surgeries like partial replacements or the standard anatomical total shoulder replacements have little hope of providing a durable solution, because they do not address the unstable center of rotation, similar to just replacing the tires on your car without correcting the alignment problem.

The Reverse Total Shoulder Replacement as conceived by Professor Grammont, addressed these shortcomings, by defining three principles for success:

1.      Move the center of rotation down and medial in order to provide a better lever (moment arm) for the deltoid (large muscle on outside of shoulder) to help lift the arm.

2.      Use a large ball (hemisphere) without a neck so the center of rotation remains within the bone.  All previous designs with a center of rotation that was not in bone eventually failed. Keeping the center of rotation in bone prevents destructive shear forces at the glenoid (cup).

3.      Use a higher angle for the shaft (humerus) component from 135 degrees to 155 degrees, so the shaft would be lower on the ball component (glenosphere), resulting in better tensioning of the deltoid and a greater available range-of-motion.

Reverse Total Shoulder replacement systems produced that honor these three original principles have, in experienced hands, resulted in remarkable results for patients that did not previously have any other solution.

As more experience has been gained with the original design, we learned that there are some new challenges and complications.  One of the most talked about problems that emerged with this Reverse Total Shoulder design has been the problem of scapular notching.  Because the Reverse Total Shoulder design does not have a neck, as the arm moves around the ball (glenosphere) it abuts or impinges onto the scapular neck, especially at the bottom when the arm is at the side.  This results in an erosion of the bone below the ball creating a notch.  As you can imagine, a small notch is not a problem, but as the notch becomes larger, and the bone erodes to the point that the stability and fixation of the glenosphere is placed at risk, failure or loosening of this component may occur.  As you can imagine, a lot of intense research and work has been done to avoid scapular notching.  Several research papers have elegantly demonstrated that simply altering the placement of the glenosphere to produce a small inferior overhang, can avoid the scapular notching problem.  Others have chosen to take a different approach-move the center of rotation outside the bone by placing more than a hemisphere for the glenosphere component.  Unfortunately, by placing the center of rotation outside bone, the stresses placed on the glenoid component are again greater as seen in historically similar designs with higher failures.  Having had the benefit of learning from the experience of our colleagues in Europe, for years our preferred method is to maintain the center of rotation within bone and place the glenoid component more inferiorly to avoid the problem of scapular notching.

The second potential issue that has been recognized as a result of moving the center of rotation medial is that while it helps the deltoid work easier, it does remove some of the tension on the remaining rotator cuff possibly weakening the remaining rotational strength and increasing the risk for dislocation and instability.

Along with others, we conceived a unique solution to this problem while still honoring the three original principles of the Reverse Total Shoulder.  The Biologic Reverse Total Shoulder concept involves utilizing bone from the humerus (ball) that would typically be sacrificed during the procedure and creating a custom graft to correct any bony deformity on the glenoid, as well as move the center of rotation slightly back out towards its anatomic position, while still maintaining it in bone.  This technique creates a bony neck for the glenosphere that helps tension the remaining rotator cuff and provides a more anatomic contour to the shoulder.  For those patients with severe rotator cuff loss, we have also been pleased with the results of combining tendon transfers with the Revere Total Shoulder Replacement to help provide more rotational ability.

Written by Vivek Agrawal

Biologic Reverse Total Shoulder Replacement: Improving Results by Honoring Original Principles. is a post from: Shoulder Pain

Biceps tendon pain treatment

Biceps tendon pain, particularly the long head of the biceps at the shoulder, is a very popular diagnosis these days.  This diagnosis is also followed by an increasingly common recommendation to perform a surgical procedure called a biceps tenodesis, where the portion of the biceps tendon inside the shoulder joint is removed while stabilizing the origin of the biceps tendon elsewhere, along its anatomic course in the bicipital groove (proximal or distal) or moving it to another location like the coracoid process adjacent to the short head biceps origin.  Although we have treated thousands of patients with biceps tendon pain (pathology), the incidence of patients with isolated pathology of the biceps tendon in my practice is exceedingly rare.  In this article, we hope to help sort through the controversy of not only the diagnosis of isolated biceps pathology, but also the best method of treatment, finally reviewing our preferred technique for addressing biceps tendon pathology.

DIAGNOSIS

Often the diagnosis of biceps tendon pain is made based on tenderness to palpation at the anterior shoulder or at the bicipital groove.  As we reported previously, palpation can be highly accurate for rotator cuff tears, but while the RENT test has been independently cited as having a high quality of diagnostic accuracy for rotator cuff tears (Br J Sports Med 2008; 42:80–92.), no such physical examination maneuver or test has been supported for the diagnosis of biceps tendon pathology.  In Physical Examination for Partial Biceps Tendon Tears, AJSM. Vol. 35, No. 8, 2007, Gill et al. evaluated 847 patients with a variety of shoulder pathologies who underwent arthroscopy for the accuracy of physical examination techniques to predict the presence of biceps tendon pathology.  Overall, tenderness on palpation in the region of the biceps had a sensitivity of 53%, a specificity of 54%, and an accuracy of 54%.  The authors concluded, “Our study shows that no single physical examination test can accurately predict the presence of a partial tear of the long head of the biceps tendon and highlights the difficulty of assessing the role of the biceps tendon in pain syndromes of the shoulder. One confounding factor is that there is no known pain pattern specific for the biceps tendon. Although biceps tendon pain can radiate down the front of the shoulder, pain into the front of the shoulder can be secondary to a variety of causes, including rotator cuff injury.”  Of further interest, as in our own experience, all patients with partial biceps tendon tears also had other lesions.

ANATOMY, PATHOLOGY, AND FUNCTION

The biceps tendon long head has several unique features.  Along with being part of a two joint muscle (the biceps spans the shoulder and elbow joints), the biceps long head tendon is intra-articular (within the joint) but extrasynovial, meaning it is contained within a sheath formed by the continuation of the synovial lining of the joint capsule.  This means that the segment of the tendon within the joint from approximately 1-3cm distal to its origin is a relatively hypovascular region. As with other tendons that are part of two joint muscles (Achilles tendon, Iliotibial band, quadriceps tendon, etc.) the biceps tendon is subject to potentially greater stresses.  The elastic range of strain for tendons is less than 4% and microscopic failure occurs beyond 4% strain.  Beyond 8-10% strain, macroscopic failure occurs and complete failure can occur rapidly thereafter.  Both the amount and rate of loading can play a role in tendon injury.  The highest risk of rupture occurs when tension is applied quickly and obliquely, and the highest forces are seen during eccentric muscle contraction.

The biceps tendon itself, like other tendons, does not have many nerve fibers within the main body of the tendon. The majority of the nerve supply forms a sheath around the tendon as well as supplying specialized mechanoreceptors (Golgi Tendon Organs) to the muscle tendon junction.  Along with helping coordinated muscle activity, position sense, protective inhibition and stress relaxation, these fibers also help transmit biceps tendon pain (glutamate, substance P, etc.).

The oxygen consumption of tendons and ligaments is also 7.5 times lower than that of skeletal muscles.  Although these adaptations are essential to carry loads and maintain tension for long periods without ischemia and necrosis, the low metabolic rate also means a very slow rate of healing after injury.

All of these factors help us better understand that the biceps tendon, along with other tendons as well, can be injured by multiple mechanisms-acute, chronic, intrinsic, extrinsic, micro trauma, and macro trauma-and commonly a combination of mechanisms, acute on chronic for example.   With any injury, the intrinsic ability of the tendon to heal is tested.  Although the term biceps “tendonitis” and “tendinitis” are often used, inflammation of the biceps tendon itself is rarely seen, as the inflammatory changes typically occur at the biceps tendon sheath.  As with other tendons, the more correct term for biceps tendon injury should be biceps tendinopathy, meaning pathologic change of the biceps tendon.  The exact mechanism and process for biceps tendinopathy still remains unclear, with many possible-contributing factors.  Often, degenerative changes of the rotator cuff also accompany biceps tendon degeneration with mucoid degeneration, fibrocartilaginous metaplasia accompanied by calcium deposition, and amyloid degeneration all observed.

Unfortunately, the degenerative tissue that forms in response to injury does not have the same biomechanical profile of normal tendons, and more than likely a downward spiral of increasing stress and strain on the remaining normal tendon fibers results in propagation of injury with progressive deterioration leading to tendon failure.

The function of the biceps tendon long head is still highly debated and not entirely understood.  Shoulder function and movement requires a highly complex and coordinated chain of events, which also means that with so many steps involved in the process, the causes for injury and pain can be many and varied.  For instance, one study, comparing professional to amateur pitchers, found that amateurs required considerably more biceps activity to accelerate and decelerate the arm, while professionals were able to selectively recruit the subscapularis portion of the rotator cuff for this purpose.  Possibly, those with the greatest inherent skill or control in the throwing motion are able to lessen the demands on the biceps tendon (AJSM 1987 Nov-Dec;15(6):586-90).

Along with biceps tendon pain and tendinopathy, a lot of work has also been done on the origin of the biceps tendon long head.  There is considerable variability in the origin of the biceps tendon long head, with reported origins from the supraglenoid tubercle, superior labrum, posterior labrum, and rotator cuff, have been reported.  Combinations of these have also been reported.  More information about superior labrum anterior posterior (SLAP) lesions is available here (http://www.theshouldercenter.com/labrum-tear-slap-lesion.htm).

Consistent with the “circle concept” of the shoulder, we find biceps tendon long head pathology to often coexist with all the other maladies and diagnoses that afflict the shoulder.

TREATMENT

Treatment of biceps tendinopathy is also controversial.  For the biceps tendon long head, itself, recommendations include biceps tenotomy and biceps tenodesis.  There is also considerable controversy regarding the need to evaluate and address concurrent shoulder pathology at the same time.  This recent article from USA Today helps highlight the debate at this shoulder surgery article at USA Today. Based on our belief that the shoulder function is indeed complex and not entirely understood, we focus on anatomic restoration and repair of all concurrent pathology.  To provide some historical basis and support for the anatomic approach, a long-term review performed at the Mayo Clinic (Becker et al. JBJS. 1989; 71: 376-381) found that isolated biceps tenodesis although advocated for more than fifty years, resulted in disappointing results with longer follow-up.

A biceps tenotomy involves releasing the biceps tendon long head from its origin inside the shoulder joint.  The tendon then retracts for a variable distance and heals at this variable distal location.

A biceps tenodesis involves releasing the biceps tendon long head from its origin inside the shoulder joint, followed by fixation of the tendon.  The fixation method and location can be highly variable and are of significant debate.  Several popular options include-soft tissue tenodesis (suturing the biceps tendon long head to the rotator cuff or biceps pulley), suture anchor fixation and interference screw fixation.  Biceps tenodesis has also been promoted proximally within the bicipital groove, distally at the exit of the bicipital groove, more distally at the pectoralis major insertion, and at the coracoid process next to the biceps short head origin.

A recent study by Wittstein et al. (AJSM. 2010) compared biceps tenotomy with biceps tenodesis, and found that the patients with a biceps tenotomy had a higher incidence of a “Popeye deformity” and reduced supination strength with all other parameters including patient satisfaction similar between the two groups.

OUR APPROACH

The “Popeye deformity” has been reported with both biceps tenodesis and tenotomy and most agree that this is likely more reflective of the level of core degeneration and fraying of the biceps tendon long head rather than the strength of fixation.  It is important to honor the biologic time required for tendon healing before initiating stressful activities.  With this in mind, we attempt to preserve the anatomic course of the biceps tendon long head in the hopes of helping to preserve as much of the neuromuscular and proprioceptive feedback role of the biceps tendon long head while removing the diseased and hypovascular portion of the tendon from within the shoulder joint.  For highly diseased and frayed tendons with little remaining structural capacity, we perform a biceps tenotomy at its origin, which typically results in the migration of the tendon to the level of the bicipital groove.

For tendons with residual structural capacity, we perform a soft tissue biceps tenodesis.  Our technique for soft tissue biceps tenodesis is termed the arthroscopic locking lasso rack hitch biceps tenodesis technique.  The biceps tendon is sutured to the rotator cuff (subscapularis, supraspinatus) and/or the biceps reflection pulley based on the unique circumstances involved in each case.

As noted at the beginning of our discussion, in our hands, biceps tendon pathology is most often incidental to other treatable pathology within the shoulder so it is important to have a reliable, minimally invasive, and anatomic technique that does not require a considerable amount of operative time and additional implants.  Our technique also avoids the possible complications related to open surgery, avoids the cost of additional implants, and does not interfere with MRI or CT scans.

In summary, biceps tendon pain is often the harbinger of additional pathology and we recommend a thoughtful, detailed, and comprehensive approach to the evaluation of patients with anterior shoulder pain and biceps tendon pain.

Biceps Tendon Pain: A Popular Diagnosis Loaded with Decades of Controversy is a post from: Shoulder Pain

Predicting the likelihood of shoulder surgery complications

Shoulder surgery complications occur all too commonly.  The choices we make as patients both before and after surgery can play a significant role in predicting the likelihood of a complication after shoulder surgery.  A common saying in shoulder surgery is, “The surgeon is the method,” meaning that any innovative technique, tool, or procedure is really only as good as the person using it.  While this makes intuitive sense to us when we think about other fields of endeavor, it is harder to remember when faced with the prospect of finding a solution to persistent shoulder pain and debility.  More information on how to go about the decision making process of finding the best shoulder surgeon for your personally is available at our pages shoulder specialist and shoulder pain.

The choices we make as patients after surgery can also play a major role in predicting a shoulder surgery complication and we plan a more in depth review of this topic in an upcoming article. Please watch the video below:

A more subtle and sometimes difficult to evaluate factor in predicting shoulder surgery complications is the choice of technique or implant by the surgeon.  While this is true for implants related to shoulder replacement and other reconstruction procedures as well, we focus presently on the ever-expanding area of tissue repair in shoulder surgery.  Shoulder tissue (capsule, ligaments, labrum, cartilage, rotator cuff, etc.) can become stiff, stretched, or completely torn and with the emergence of technology and more minimally invasive techniques, the methods to mend these tissues have also evolved.

When many of the shoulder tissue repair techniques and implants were originally conceived, the goal was to reproduce the same methods the surgeon would perform in a fully open surgery, meaning using needle and thread to mend the tear, or if the tissue needed to be repaired back to bone, the thread (suture) would be passed through bone tunnels and then tied.  With the recognition that the quality of the bone varies significantly in different areas of the shoulder as well as among different patients due to multiple factors and the risk to surrounding nerves and vessels with certain suture passing techniques recognized, a leap forward was the invention of the suture anchor, designed to provide a way to mend the tissue back to bone in a more reliable, safe and strong fashion.  These suture anchors were originally made of metal with the suture threaded through them.  As we gained more experience with these devices and the techniques evolved, it became clearer that despite the use of reliable and reproducible delivery systems, technical difficulties and complications with these devices did occur.

Shoulder surgery complications reported with these devices include: incorrect placement, migration after placement, loosening, breakage, and tissue damage from the implant being significantly harder than the surrounding tissue.  Catastrophic grinding down of joint cartilage is a potentially devastating complication from a prominent or displaced metal anchor.  Because the metal can often interfere with further imaging studies, it can also be difficult to fully assess the quality of the tissue healing with metal anchors.  Particularly for shoulder dislocation or unstable shoulder, in the event of the patient requiring a repeat or revision surgery, the amount of bone real estate available for mending the tissue back to bone can be severely limited and the need to remove the prior anchor and graft the bone void may arise, potentially meaning the patient may have to have yet another surgery once the bone void heals.

In response to these concerns, the next generation of devices to mend tissue back to bone included suture anchors and tacks made of non-metallic and absorbable polymers.  The hope and idea behind the absorbable polymers was that they would provide the needed stability during the critical healing phase of the tissue back to bone and then the body will gradually dissolve or resorb these away, hopefully, leaving no trace behind.  While in the vast majority of cases these implants have been used with great facility and success, there have been problems in a handful of reported cases.  Initial implants made with polymers such as polyglycolic acid and polyglycolic acid-trimethylene carbonate copolymer had problems with draining sinuses and lytic bony change (meaning the bone dissolved around them).  This led to poly-L-lactic acid (PLLA) becoming the polymer of choice for most absorbable or degradable implants because it degraded much more slowly (up to 5 years).  Over time this has been further refined to include different recipes to achieve a more favorable biologic reaction, including the admixture more recently of calcium compounds to promote bony replacement/ingrowth of these implants.

Based on multiple factors including the local stresses placed on the implant, the number of implants, design of the implant, and rate of degradation, one portion of the implant can conceivably resorb or break more easily leaving some portion as a loose or free body in the shoulder joint.  These can lead to shoulder surgery complications, as well as inflammation, joint damage, grinding, and failure of the repair.

Improved imaging characteristics, potentially fewer problems with revision surgery, and eventual resorption are advantages biodegradable anchors have over metal anchors.  Because of their strength and reduced risk of inflammatory response and osteolysis, metal anchors also continue to command a prominent role in shoulder repair.

Particularly for shoulder dislocation, labrum tear, and unstable shoulder surgery, bone loss and the amount of bone available are significant variables to consider.  The next generation of anchors for tissue repair to bone has taken a novel approach to fixation using 100% suture for fixation. Recognizing the inherent limitations of both metal and absorbable anchors in this challenging application, these purely suture anchor devices offer the advantage of avoiding the risks of osteolysis and inflammatory resorption response, while also greatly reducing the risk of subsequent fracture propagation because the anchor is tiny (1.4mm) -creating a tunnel that is nearly two-thirds smaller than other available anchors. Another advantage we have already seen in patients that have suffered an unfortunate injury after shoulder surgery with these implants is that revision surgery is significantly easier for the patient and surgeon.

Regardless of the type of fixation device used, surgeons and patients should be aware of the type of implant used for their operation and that any unexpected event that occurs after a shoulder repair surgery may result in compromise of the repair with a broken suture or implant.  If you experience an unexpected event and start to have grinding, squeaking, or other catching type symptom, keep this possibility in mind and discuss it with your shoulder surgeon.  Knowledge of the mechanisms of failure, recognizing the possibility and vigilance are “an ounce of prevention” to avoid more serious shoulder surgery complications.

Shoulder Surgery Complications: An Ounce of Prevention is a post from: Shoulder Pain

So, what exactly is an AC separated shoulder?

Shoulder Separation also referred to as AC (acromioclavicular) dislocation or AC separation is a very common injury typically as a result of a direct force on the top of the acromion (shoulder blade) or fall on an outstretched hand.  To better understand this injury, we have to take a step back and review the anatomy of the shoulder girdle.

The shoulder girdle (clavicle and scapula) is only truly connected to the rest of the body at the joint formed between the clavicle and sternum (breastbone).  The shoulder therefore is suspended and supported by many muscles that originate or insert on the bones making up the shoulder.  The shoulder is really suspended from the clavicle (collarbone), being held in place by the ligaments between the coracoid (shoulder blade) and clavicle, along with the AC joint capsule, as well as the multiple muscles surrounding the shoulder.

So if just the AC joint capsule is injured but the ligaments are preserved, this is considered a mild separated shoulder and does not result in a big bump or prominence of the clavicle.  As the severity of the separated shoulder injury increases and more damage is done-the ligaments suspending the shoulder blade are torn-the shoulder now drops down, leaving the clavicle elevated, resulting in a bump.  With even more injury, the clavicle can also be displaced or moved higher up, further back, or even pushed down as well.

The mild levels of injury are typically treated like any other sprain (think mild ankle sprain, for instance) and usually do not require any sort of surgical treatment to regain normal use.  The really severe levels of injury are typically treated with surgery.  The most controversial type of injury is the Type III Shoulder Separation, where the ligaments and AC capsule are disrupted.  This is the same injury suffered by NFL quarterback Sam Bradford during his last year of collegiate play at Oklahoma.  In some patients with a lot of muscle tone or bulk, the muscles are sometimes able to compensate for the injury by holding the shoulder girdle reduced while the injuries heal.  Unfortunately, for many patients with this injury, the amount of shoulder drop that occurs cannot be fully compensated and they experience significant pain and dysfunction.

Literally hundreds of surgical procedures have been described to repair and/or reconstruct high-grade shoulder separations.  The vast majority of these procedures are based on a modification of a surgery called the Weaver-Dunn surgery.  This surgery and all the subsequent modifications involve transferring another ligament [the CA (coracoacromial) ligament] to take the place of the torn CC ligaments (coraco-clavicular).  Unfortunately, these procedures have been limited by highly variable success rates.  The CA (coracoacromial) ligament is also increasingly recognized as important for shoulder function.  Although the incidence of a separated shoulder is relatively high, the number of surgeons performing more than 5 shoulder separation surgeries annually is very small-meaning that most orthopedic surgeons perform these procedures only rarely.  Especially for technically advanced procedures, it is very difficult for the surgeon only performing the procedure rarely to develop any sort of reliable expertise.  Add to this the vast array of procedures available and it is not uncommon to see surgeons trying a different type of reconstruction procedure for each separated shoulder subsequent case.

Also see AC dislocation and AC reconstruction

Separated Shoulder; Shoulder Separation is a Common Injury is a post from: Shoulder Pain