A Brief Look at Shoulder Surgery
SHOULDER ANATOMY
The shoulder is a complex joint, involving the gleno-humeral joint (ball and socket joint), and the acromio-clavicular joint (AC joint) on top of the shoulder. Three bones make up the shoulder – the clavicle, scapula and the humerus. The humeral head articulates with the glenoid portion of the scapula to make the ball and socket type joint, and the clavicle (collarbone) meets the acromion of the scapula on top of the shoulder to create the AC joint.
The shoulder offers a great degree of range of motion to allow us the greatest degree of function. The trade-off is the potential instability. The large ball, and shallow socket of the shoulder is reinforced by the labrum – a fibrocartilage ring that is around the periphery of the socket. This effectively makes the socket ‘deeper’, and contributes to more stability. The capsule of the shoulder joint, also contributes to static and dynamic stability. There are several ligaments within the capsule for added support. Finally, the rotator cuff offers dynamic stability to the gleno-humeral joint during motion. . The rotator cuff is a group of 4 relatively small muscles deep in the shoulder that become tendinous attachments to the humeral head. Its primary function is to keep the humeral head centered on the glenoid, while the larger, more powerful muscles move the shoulder and arm in space.
SHOULDER SURGERIES
Surgery of the acromio-clavicular joint is relatively common. The AC joint is frequently injured during a fall on to the side of the shoulder. This is particularly common in skiing, football and wrestling. Many of these lesser sprain injuries go on to healing without any surgical intervention. Only the severely displaced or painful shoulder separations need consideration for surgery. The AC joint can also become painful due to early degenerative arthritis, sometimes related to repetitive overhead lifting. ‘Weight-lifters shoulder’ involves degeneration on the end of the clavicle at the AC joint. This pain can usually be relieved with anti-inflammatories, or a local injection of cortisone, at least temporarily. The duration of pain relief following an injection is very difficult to predict. Often times a distal clavicle excision is needed to relieve recurrent, persistent, or chronic pain. This involves removing 5-10 millimeters of the end of the collarbone, so it no longer articulates with the acromion.
Rotator cuff tears come in various degrees. They can range from small partial thickness tears, to large full thickness tears with retraction. The decision to surgically fix these tears is based on many factors, including size of tear, age of the patient, overall health of patient, patient’s work and function, chronicity of the tear and secondary changes. The prevalence of rotator cuff tears increases with age, and can be as high as 20% in the age group 60-69 and greater than 50% in those over 80, who are without symptoms. But decisions of repair are based on the above factors, and not simply on radiology findings. Rotator cuff repairs can be performed arthroscopic ally, through several small incisions about the shoulder. This procedure offers less pain and morbidity (harm) than a large open incisional procedure which had been necessary in years past. Nonetheless, a period of 16 weeks of relative protection is needed to allow adequate healing of the repair, before a return to athletics, and higher level activities. Within this protective time frame, the patient starts physical therapy between 2 – 4 weeks post-operatively, and weans from a sling by 6 weeks. A gradual return to activity follows, and the need for physical therapy varies in the individual between 2-3 times per week.
A labral tear within the shoulder is a tear of the fibrocartilage ring around the glenoid, that supplementally provides stability to the gleno-humeral joint. This often occurs with a dislocation or subluxation of the ball and socket joint. The shoulder is particularly susceptible to this type of injury when the arm is extended or abducted out to the side. Tears of the labrum may also be degenerative in nature, related to repetitive activity. These injuries may also be repaired arthroscopically with tiny anchors in the glenoid, that are pre-loaded with sutures, that pull the labrum back down to the bone. Relative protection is necessary for up to 16 weeks, to allow adequate healing before a return to higher level activities. Depending on the physician’s protocol, Physical Therapy begins between 1 - 4 weeks,and averages 2-3 time per week. There is a trade-off between restoring range of motion in an appropriate time frame and protecting the surgical repair. Experienced Physical Therapists are critical in this portion of the patient’s overall return to normal function without pain.
There are many more shoulder surgeries that go beyond the scope of this article. Evaluation by a well trained Orthopaedic specialist is obviously needed before surgery is considered. However, most of the above problems have potential to be treated adequately by Physical Therapy, and without surgery. Many times Physical Therapy can get a patient back into an equilibrium, where they were prior to experiencing pain or problems. Again, the decision for shoulder surgery is based on many factors, and not simply the findings on MRI or x-rays. The key is for the patient to be confident and comfortable with their Physical Therapist and Orthopaedic specialist.
Scott Mehlos, PA-C Biography
Scott received his Bachelors of Science degree in Sports Medicine from the University of Wisconsin – Stevens Point in 1993. His career in orthopaedics began thereafter, as an Athletic Trainer for a period of 4 years. He was the Head Athletic Trainer for the Milwaukee Mustangs Arena Football team, an Athletic Trainer for the Milwaukee Ballet, as well as several high schools and a small college.
Scott was accepted into the first class of the Marquette University Physician Assistant Program. He earned his Masters Degree in Physician Assistant Studies in 1999. The following seven years were spent at the Milwaukee Orthopaedic Group, working with several of the sports medicine surgeons. After a brief two and a half year period away from the group, he has returned to work with Dr. Michael Gordon, and his sports medicine practice. He is a member of the medical staff of the Milwaukee Bucks, and Marquette University Athletics.
In addition to his clinical duties, Scott is also a Clinical Associate Professor for the Marquette University Physician Assistant program, and Clinical Lab Instructor for Arthrex Sports Medicine in Florida.
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