- So it gives me great pleasure
to introduce your speaker tonight.
So Dr. Rob Rupp has been
probably, what, 20 years?
A little more?
Yeah, I'm mean, he's been
in Tahoe for a long time.
He's one of our best orthopedic surgeons
for the Tahoe Orthopedics
& Sports Medicine group.
He's also known, what he's know for
being a hip arthroscopist,
which he's not talking
about that tonight, but I
just think it's important
to know that, before he
became a hip arthroscopist,
your options for hip
surgery were pretty small,
and they weren't great.
So the fact that he's not
only a hip arthroscopist,
a shoulder specialist, a
sports medicine professional,
I mean, you're getting
an expert here tonight
to talk about shoulders.
So I'm going to stop talking,
I'm going to bring Dr. Rupp up,
and please welcome him
with a warm applause.
(audience applauding)
- Thanks, Chris.
Can you guys hear me okay back there?
(audience murmuring)
Okay.
- [Chris] You're good.
- Maybe.
Okay, so I'd like this
to be very informal.
If anybody has a question,
they don't understand
what I'm saying or what
I'm trying to get at,
go ahead, raise your hand.
We have time after also
to cover any questions,
but like I said, I'd rather just,
if someone's confused or has anything
that needs clarified, just ask me, okay?
So I'm going to do a broad
presentation of shoulder issues.
It's summertime and everybody's able to do
a little bit more than
what we do in the winter,
which is ski and snowboard.
Those definitely cause
some shoulder injuries,
but when we start adding
events where we're using
overhead activities with our shoulders,
other thing come into play.
So again, this is going to
be a broad presentation.
I'll hit on some treatment options also,
and if anybody needs clarification,
especially afterwards if you don't want to
introduce yourself to ask a question,
I'll be around here
afterwards if anybody wants
to ask me any questions.
So we could also label this
talk why does my shoulder hurt,
or what can I do to avoid shoulder injury.
So again, my goals are to
review some of the anatomy
of the shoulder so you guys
know what we're talking about.
In general, there's going
to be a lot of orthopedic
and bony terms, but that's
just the descriptive nature
of shoulder anatomy.
Then we're going to look at
some of the common causes
of shoulder pain, I'll
try to break them up
into just different
locations of the shoulder.
And then outline some
of the treatment options
that you can go through.
So again, starting with the anatomy,
we're going to go with the bone structure.
So if we look at some
of the bone structures,
the main ones of the
shoulder are the humerus,
and at the end of the humerus
is the head or the ball.
There's the clavicle, there's the scapula.
If we look a little bit
closer at the shoulder blade,
which is the scapula, it comes together
to form some bony prominences such as
the acromion, the
coracoid and the glenoid.
So the glenoid is the
socket of the shoulder.
So we have a ball and socket joint
that is formed, and if
we look at all the joints
of the shoulder, again, joints are where
bones come together and have movement.
So if we look at the shoulder,
there's the acromioclavicular joint,
there's the glenohumeral joint,
there's the scapulothoracic joint,
and part of the shoulder girdle
is the sternoclavicular joint,
which is a little bit away
from the edge of the shoulder.
So the main shoulder joint is actually
the glenohumeral joint.
So again, all these names
are anatomic descriptions.
So we're looking at the
glenoid anda the humeral head,
So we're looking at the
glenoid and the humeral head,
And again, a joint is
where bones move together,
so around the ends of the
bone is a protective layer
of cartilage called articular cartilage.
So both the ball and the socket
have an articular cartilage layer.
The other interesting thing
about the glenohumeral joint
is it has a muscle tendon
that goes right through it.
So our biceps is two muscles.
It's the long head and the short head,
and one of those tendons goes right next
to the humeral head and attaches
at the top of the shoulder joint.
So if we take away the ball
and we look into the
socket of the shoulder,
we have the glenoid, and
it's a pair-shaped bone.
we have the glenoid, and
it's a pear-shaped bone.
with a labrum, which is a
cartilage structure around it.
And into that labrum,
there's multiple ligaments,
and there's, again, the long
head of the biceps tendon
that inserts on that.
These are all important
structures that we'll go over
in a little bit more detail later.
The shoulder joint's interesting because,
unlike the hip joint
which is very constrained,
a ball and a socket, and
there's a lot of bony stability,
the glenohumeral joint is often compared
to a golf ball on a tee.
So this is an X-ray of a shoulder.
And you can see the ball much larger
than the small socket.
So again, that's the comparison,
and that's what gives us so much motion
with our shoulder joint.
If our joint was constrained,
it would be very hard to
have this kind of motion
that our shoulder does enjoy.
So what makes it stay together?
And it's kind of a
combination of muscle control
and ligaments, which
are soft tissue bands,
to hold this unstable construct together.
Another joint in the
shoulder is the AC joint,
or the acromioclavicular joint.
So again, we're going to name things
based on what bones come together.
The acromion and the clavicle,
so it's the acromioclavicular joint.
If you just rub your hand
on the top of your shoulder,
kind of the ridge or the bump you feel,
that's the AC joint.
The scapulothoracic joint
is the shoulder blade
and it moves on the ribcage,
so it's very coordinated.
and it moves on the rib cage,
so it's very coordinated.
as someone moves their arm,
their ball and socket
through range of motion,
it requires your shoulder blade
to rotate on the ribcage.
to rotate on the rib cage.
but it's so complex, it's
very much like a seal
trying to balance a ball;
it has to move its head,
it's nose to balance that.
its nose to balance that.
it's not just the ball and socket moving,
but the shoulder blade has to rotate
in a way to balance the ball and socket.
If that doesn't happen,
then we have something
like this part of the diagram,
where maybe the ball wants
to come out of the socket.
Why all this is coming
up is because this is
how complex our shoulder is.
Just to bring my arm up is over 20 muscles
that come into play
involving the ball and socket
and the scapulothoracic joint.
Sternoclavicular joint
is the bump we feel here.
This is the medial border of the clavicle,
and it has some articulation
with the sternum.
And some people come into the office,
and they have questions about this part
of their shoulder also that we'll get to.
So we've discussed the
bones, now the muscles.
So the main muscles deep in the shoulder
that kind of are the
weak link of the shoulder
and cause so many people problems
are collectively known
as the rotator cuff.
So along the shoulder blade,
whether it's deep in the
front or along the back,
there's four muscles: the
subscapularis is in front,
and then in the back
there's the supraspinatus,
infraspinatus and teres minor,
and they all come together from red muscle
that turns into white tendon that inserts
at the edge of the ball,
and it forms a cuff.
And so that's why it's
called the rotator cuff.
And the rotator cuff is very important
for how our shoulder works.
If the rotator cuff doesn't work well,
there's not a lot of
stability to how the ball
stays on the socket.
So part of the function
of the rotator cuff
is to just center the ball on the socket
while some of the bigger
muscles that are more powerful,
like the deltoid, the pectoralis
move our shoulder safely.
If my rotator cuff isn't working well,
and I try to lift my shoulder up,
sometimes it looks like this.
So sometimes we see people
with rotator cuff problems,
and you can tell just by
seeing what their shoulder does
when they try to lift it.
The ball just comes
directly out of the joint
because the rotator
cuff doesn't control it.
So this is a back view
of the shoulder blade,
and you can see the majority
of the rotator cuff muscles
and how they would pull the ball
and hold it centered on the socket
while we're using our
shoulder through motion.
The other major muscle
in the shoulder joint,
again, the long head of the biceps tendon
which comes from one of
the biceps muscle bellies.
Why this is important,
because a lot of people
can have pain and injury in
the part of the shoulder,
and sometimes they wonder
why is my biceps ache,
why is the muscle ache down here?
And it can be related to
something in the shoulder
with this relationship.
So we've discussed the bones, the muscles,
the major muscles in the
shoulder; then there's ligaments.
So ligaments are bands of tissue
that go from bone to bone.
So as we see here, the ball and socket,
again, the glenohumeral
joint is held together
with multiple bands of soft
tissue, these are ligaments.
And the other major
relationship is the AC joint,
and it's got multiple ligaments
that hold it together also.
Another structure that's
very a common source of pain
but it's a normal structure is the bursa.
So a bursa is a cushion or a pad
that our shoulder has under the acromion
and above the rotator cuff.
So on this diagram, it's
this blue structure here.
The shoulder blade also has some bursa.
So when our shoulder blade
is rotating over the ribcage,
So when our shoulder blade is
rotating over the rib cage,
So many parts of our body have bursa:
the tip of our elbow,
the edge of our hip here,
the front of our knee.
Sometimes you see someone
that impacts their elbow,
they get a big swollen area;
that's the bursitis.
So if we take a normal bursa,
which is a very thin layer of tissue,
and often you can't feel it,
but if it gets inflamed, it's a bursitis,
so it becomes boggy and swollen.
And when that happens in the shoulder,
it gets even harder to move
our shoulder up without pain
because it's larger and things get pinched
in the shoulder.
So this is another
potential source of injury
or source of pain in the shoulder.
So putting all this together,
so for my shoulder to
work normal and not hurt
and to allow me to move
and use it how I want,
we've got to have these criteria.
So we need full motion, and again,
it's not just the ball and socket,
but it's the shoulder blade
rotating on the ribcage.
We need joint stability
from the ligaments.
We need strong and
balanced muscle control.
And one thing that's kind of
on its own is inflammation.
So we need to have a
shoulder that isn't inflamed,
because sometimes all the
anatomy can be normal,
but we have inflammation in the shoulder,
and that can cause pain.
So now I'd like to just
review some of the things
that can make a shoulder hurt.
And if anybody's shoulder
in the audience hurts,
you kind of listen to what I'm describing.
And if you need more information about it,
just ask me at the end with questions.
So we're going to hit a
lot of different areas
because a lot of different things can be
a source of pain in the shoulder.
So we'll start with the
glenohumeral joint again,
and one of the things that
can happen is arthritis.
So osteoarthritis is
when that smooth layer
of white cartilage that
coats the ball and the socket
starts to break down.
And the problem is our body
doesn't make new cartilage.
That cartilage is a protective
cover over the bone,
and if it breaks down, then
we have bone rubbing on bone,
and that causes pain.
Why do people get arthritis?
Well sometimes it's genetic,
there's a component.
Maybe the parents had wear
and tear issues in the joints,
so you might be prone.
Sometimes we don't always
know why it happens
to some people more than other people.
Sometimes a bad impact to a shoulder,
the cartilage will take an impact
and it will set of a process that leads
to post-traumatic arthritis.
This is an X-ray of a
normal-looking shoulder,
so we see the ball, we see the socket,
and there's a nice space
between those structures.
That space is the cartilage that coats
the end of the bone and protects it.
This is a shoulder X-ray
that looks like arthritis.
So we have bone-on-bone appearance.
And the other thing you might notice
is we don't really have
a ball shape anymore.
The bone that is getting
overloaded by pressure,
because it doesn't have cartilage,
starts to form extra bone,
and these are bone spurs.
As that happens, a shoulder not only hurts
when you try to use it,
but you can't move it as much.
So we can't rotate, we can't
get our hand behind our back,
and partly because these bone spurs
start capturing the
motion of the shoulder.
The other thing that can happen
in the glenohumeral joint
a lot of times to throwers;
say you take your dog
out, you've been waiting
to play with your dog until the summer,
it's been a long winter, and
you start throwing the ball,
and you throw really hard
and you feel something
give in the shoulder.
Well sometimes people tear the attachment
of the labrum or where the
long head of the biceps
attaches to that structure.
So that can be called a SLAP tear.
This stands for superior labrum,
which is the top of the
glenoid where the labrum is.
A-P, or anterior to posterior.
So the tear goes from
the front to the back.
And again, a lot of
times people just can't
throw anymore after that type of injury.
So a lot of time, people that do overhand
or throwing sports or tennis,
they might be affected
by that type of injury.
But by far and away, the most common thing
that causes pain in the shoulder in terms
of the muscle structures, again,
maybe a weak link in how we're built,
is the rotator cuff muscles.
So this is a rotator cuff tear.
And again, the structure is such
that we have red muscles fibers
that we have red muscle fibers
and origin on the shoulder blade.
They turn into white tendon
fibers that insert on the bone.
So usually even though
we kind of interchange
muscle tear and rotator cuff tear,
it's usually the white tendon
that actually pulls off the bone.
The problem is, once
it pulls off the bone,
there's nothing the body
can do to get it reattached,
because the muscle's
over here contracting,
so once it comes off the
bone, it really can't heal.
One of the hallmarks of
the rotator cuff injury
is night pain.
So a lot of people go, "Well
my shoulder's not great,
"but during the day it
feels okay, I can use it.
"But at night time, I
lay down to try to sleep,
"and my shoulder starts hurting."
And again, it just seems to be a hallmark
of rotator cuff injuries.
So this is something
to consider if you have
a lot of night pain with
your shoulder injury.
Another type of glenohumeral joint injury
is the dislocation.
So this is typically where ligaments
that hold the ball and the
socket together get torn.
So now the ball can move
away from the socket.
And this is kind of interesting in that
young people, if I'm a
20-year-old snowboarder,
and I fall, and I dislocate my shoulder,
999 times out of 1,000,
I've just torn ligaments.
But as we get older, and if
we dislocate our shoulder,
so someone over the age of 50,
if they dislocate their shoulder,
they might've also torn
their rotator cuff.
So we have to start
worrying about other types
of injury based on someone's
age and what happened.
So if someone is a snowboarder or skier,
maybe they're 60-some years old,
they fall, they dislocate their shoulder,
gets put back into place.
Story's not over because we
have to check the muscles,
because what if your
shoulder's back in place
but I can't get my arm up?
Maybe the rotator cuff tore.
So we have to be real careful when someone
dislocates their shoulder.
And if they're a little bit older,
maybe they hurt some muscle
and not just the ligament attachments.
Another thing that can
happen in the shoulder
is sometimes people have no injury,
and maybe they just notice
over about a week span,
they just start losing motion.
And a term for that is a frozen shoulder.
And what can happen is the
normally loose ligaments,
or capsule of the shoulder,
which should be very loose so
that we have all this motion,
they sometimes undergo a
process of inflammation
and they tighten.
So we can use the term
adhesive capsulitis,
or we can talk about a frozen shoulder.
And I'd say the vast majority
of these are idiopathic,
meaning it just can come on.
Sometimes people that
have had heart surgery,
there's a little bit of an
association like months later.
They go, "Oh yeah, I had heart procedure,
"and couple months have
gone by, and now I can't,
"I can't move my shoulder that well."
Or somebody that has diabetes,
another association with people that
sometimes develop a frozen shoulder.
We're not really sure why that is,
but again, it's something that can limit
how the shoulder works.
Another thing, again, is back
to the subacromial space,
so under the arch of the acromion bone.
Again, that bursa.
A bursa's normal, but if
it gets inflamed and boggy,
it's a bursitis.
And one thing that can
cause the whole thing
is something that we refer
to as shoulder impingement.
So if I end up with some
bone spurs under my acromion
or from my AC joint,
and if maybe my muscles
aren't controlling the ball,
keeping it centered on the socket
when I bring my arm up,
things might start pinching
the bursa and then we get the bursitis.
Go ahead.
- [Audience Member] Is
there a difference between
a bursa and a tuberosity?
- Yeah, so if we go into
a little bit more detail
of the anatomy of the humerus,
the prominences are the tuberosities.
So the greater tuberosity
is a little bump here
that's normal on the humerus bone,
and that's where three of the
rotator cuff muscles insert.
The lesser tuberosity is deep in front,
and that's where the
subscapularis inserts.
So anytime our bones have a bump,
there's a name for it, and there's usually
a muscle or tendon insertion.
So that's what the tuberosities are.
Different than just a
fluid-filled sack of bursa.
The other issue that sometimes happens
in the subacromial space is what is called
a calcific tendonitis.
So this is an X-ray of a shoulder,
and everything that this arrow
is pointing at shouldn't be there.
It's because the body, for some reason,
has deposited calcium in part
of the rotator cuff tendon.
And it looks like that on an X-ray.
We think maybe there's some injury
in the rotator cuff tendon,
but we're not really sure
why the body decides to put calcium there.
But this can be a source
of significant pain.
Someone just after, maybe they overdid it
playing tennis or throwing a ball;
couple days later, their
shoulder starts hurting,
then it gets severely painful.
And we might get an X-ray and see
that the body has deposited calcium.
Again, just another interesting
thing that can happen.
The AC joint, so the
acromioclavicular joint,
the term shoulder separation:
someone takes a bad fall and the ligaments
that hold the clavicle to
the acromion, they tear.
And so sometimes you see people
and their clavicle's sticking up.
and their clavicle's sticking up.
everything together tore when they fell.
Different than a shoulder dislocation
of the glenohumeral joint.
Almost everybody over the age of 40 gets
some arthritis of their AC joint.
It's just the nature of how it's built.
It just tends to break down.
But for most people, luckily,
it doesn't cause pain.
But in some people, the arthritic process
causes bone spurs to form,
and especially, on the
undersurface if they form,
sometimes they contribute
to that impingement.
So this is another issue of
potential pain in the shoulder.
Some people move their arm
around, they feel crunching,
in pain under the shoulder blade.
This can be referred to
as a snapping scapula.
And again, just like the bursitis deeper
in the glenohumeral joint,
under the shoulder blade
we have some bursa,
and sometimes that gets inflamed
and can cause catching and
grinding of the shoulder blade.
Some people come in, they say,
"How come I got some swelling here?
"It doesn't really hurt,
but I've got a bump."
Well again, this is another joint,
and if there's any
process of wear and tear,
sometimes our bones form
a little prominence.
So if this bump doesn't
bother you, it's okay.
It's just a little wear and tear.
Some people take a hard
fall and can actually
dislocate the clavicle there.
Not as common as the AC joint separation,
but it can happen here too.
So if you take a hard
fall, and, all of a sudden,
you notice things look different,
that could've happened.
So part of restoring shoulder function
is looking at all those
conditions I just outlined
and seeing how the affect the normal
function of the shoulder.
So we if we want to get back
to our shoulder working,
again, we have to restore the motion,
the stability, have strong
and balanced muscle control
and limit inflammation.
So a lot of people ask me, they go,
"Well when should I come see the doctor?
"You know, my shoulder's been hurting,
"do I need to come see you or can it heal?
"Does it have a chance
to heal on its own?"
So say you go out, you're doing something,
you're kayaking and you
notice the next few days,
your shoulder starts to hurt.
Well maybe you just overdid it.
So maybe a period of rest,
let things try to calm down.
Over-the-counter
anti-inflammatory medicines,
if you're stomach's okay
with Ibuprofen or Aleve,
or Tylenol is a pain medication.
A period of cold or heat,
that can really help.
And then if you feel like
you're getting better,
maybe you do gradual return,
you don't go back 100%.
I think if you give
things two, three weeks
to calm down, that's reasonable.
But you got to be making progress,
and if you're not able
to move your shoulder,
you got to be worried
about something worse
than just a strain or an overuse injury.
So it's okay to give things some time,
but if you have an
injury and you can't lift
your shoulder up, or it does
something funny like this,
you should come in sooner
rather than later, okay?
So what are other treatment options
besides you doing things on your own?
Well injections are great way to treat
a lot of shoulder issues.
So one option is a steroid injection.
Now people hear steroids in the news,
and they think they're
going to build muscles;
that's one type of steroid.
But cortisone and the
steroids for injections
are just anti-inflammatory medicines.
So if someone has an inflamed bursa,
sometimes a steroid
injection into that boggy,
swollen tissue will
shrink it down to normal
so it quits pinching.
So that sometimes is curative
for a bursitis in the shoulder.
This diagram shows ultrasound.
Sometimes we use ultrasound to help guide
the needle placement in the shoulder.
We can also inject around the long head
of the biceps tendon.
Sometimes it's inflamed
and that will calm down.
If someone has a little
arthritis in the shoulder,
we can actually direct it
into the shoulder joint,
and it can make it feel better.
Some other types of injections:
we use viscosupplementation
or lubricant shots
a lot for knee wear and tear issues,
but we can also use them in other joints,
including the shoulder.
And sometimes people ask about
PRP, platelet-rich plasma.
It's kind of an interesting concept.
If we take someone's blood,
a certain number of ccs,
we centrifuge it, we
get a layer of platelets
and other growth and healing factors.
And if we inject that back to where
maybe someone has an injury
to their biceps tendon
or their rotator cuff, if it's
a partial-thickness injury,
maybe it will help it heal.
So these get kind of exotic,
but it's really based on what's
going on in the shoulder.
Physical therapy, so to get here,
you passed on of the best
therapy facilities in town.
It's amazing what's going on downstairs.
A lot of people ask, "Well
can I do things on my own?"
But I would just say, in general, you can,
but anytime you have guidance,
it's going to help with the therapist.
Yeah?
- [Audience Member]
Isn't the cortisone shot
that you get just masking the problem?
If it's not going to fix it,
then isn't it just masking it?
- So the question is, again,
is the cortisone going to help
or just mask things?
It depends on what the problem is.
So if it's just an inflamed bursitis,
it may be a little bit of overuse.
Sometimes we can take a
swollen tissue and shrink it,
and if it doesn't get swollen again,
that solves the problem.
But other things like arthritis or a tear,
those won't get better
with the steroid injection
in terms of long term, so you're right.
So certain conditions
are, I guess, curative.
Other ones are just trying to help someone
with their pain.
So physical therapy, like I said,
best if a therapist is involved,
because again, you can look at YouTube,
you can look at some of the
slides I'm going to show,
but until someone works with you
and really shows you the
correct way to do things
and try to accomplish the goals of getting
things balanced and loose,
best for therapy involvement.
But what can people do?
So say I hurt my shoulder,
I was playing baseball.
Next day, I wake up, it's really sore.
And again, I had that
slide restoring function,
we want to let things calm
down, we want to regain motion.
So before we work on
restrengthening the shoulder,
we want to get some motion.
And one of the things we want to do
is try to avoid aggravating the shoulder,
which usually hurts
when your arm comes up.
So if I can do things
when I'm leaning forward
and gravity pulls my arm away from my body
and I start moving it, that's a safe way
to get some movement going.
If I put it on the table in front of me
and stretch a little
bit, or if I use the wall
and walk my fingers up the wall,
I can start getting a little bit of motion
without just taking the tender muscle
and making it do all the work.
As we get a little bit more complex
with helping one shoulder work,
we have options like using a rod or a wand
or a stick, and one arm
can help move the other arm
into flexion, rotation.
There's a variety of things that,
like I said, therapy can help show people
how to use another body part to help
the injured area to regain motion.
And then after you get a certain amount
of motion that's comfortable,
that's when you start
worrying about restrengthening
or rebalancing the muscles.
And in general, it's
safest to work, again,
on these muscles that involve
no overhead activity or no
shoulder-level activity yet,
but down here.
So I can still work
most of my rotator cuff
with both internal and external rotation.
There's a variety of
ways to use a TheraBand,
whether I'm internally
or externally rotating
and stretching, or say,
a weight or a dumbbell
on my side, I'm going
to go against gravity,
and then some other maneuvers
to work on my shoulder blades.
Once I'm comfortable down
here, that's when it's
a little bit safer to
try to do things overhead
such as, now I'm going
to start progressing
my arm above the shoulder
level if I'm comfortable.
So these are some things
that you can do on your own
if you're just trying to
keep your shoulder function
as optimal as possible.
Say your shoulder doesn't even hurt
but you want to avoid having an injury,
you working on the rotation
maneuvers to the rotator cuff
and the strengthening
in the supraspinatus,
'cause again, they're going to help center
the ball in the socket when we're doing
all these other activities
with different sports
or different shoulder movements.
So where does orthopedics come in?
We do some injections, obviously.
But if there's a major problem
that our body can't heal,
and sometimes you've tried
therapy, medications,
that's where we come in
for definitive treatment.
So our procedures are either arthroscopic,
which is looking in the
shoulder or any joint
through little openings,
including a camera
and then special instruments.
But occasionally, we still
have to do open procedures
like a shoulder replacement,
which is kind of a bigger exposure.
So what can we treat in
the glenohumeral joint?
So say someone has developed arthritis.
Their shoulders, it just
hurts them all the time.
They can't really move,
it's hard to sleep,
their motion is really restricted.
The underlying problem is
that the ball and the socket
no longer have protection.
Once that cartilage wears
away, it's bone on bone.
So we don't really have the technology
to put new cartilage
on the end of the bone,
but we can put artificial surfaces
on the ends of the bone.
So if the ball and socket's arthritic,
we can put a metal ball,
we can put a polyethylene socket.
So then when you move
your shoulder around,
it's no longer bone on bone.
This is an X-ray example.
Again, we've got joint space narrowing,
we've got bone spur formation.
And here's the X-ray solution.
We've resurfaced the ball with metal,
so now it's got a smooth
covering over the bone.
And we have a polyethylene,
which you can't see on the X-ray,
but it makes that space, it's
like that, over the socket.
Interesting, if someone has
a really bad rotator cuff
injury, like it's torn,
it doesn't work anymore,
we can still do a shoulder replacement.
This is a standard shoulder replacement
that works with the normal rotator cuff,
so my arm can still come up.
But if someone has no rotator cuff,
their shoulder's arthritic,
we still have options.
This is called a reverse
shoulder replacement.
It's interesting, if we put a ball
where the socket used to be,
and a socket where the ball used to be,
it changes the dynamics
of how the shoulder works.
And if I need to lift my arm
with the reverse shoulder replacement,
all I need is my deltoid muscle.
So I don't need a rotator
cuff muscle anymore.
So this is really kind of revolutionized
shoulder replacement surgery over the past
10, 15 years in orthopedics.
Now what if my shoulder,
acromioclavicular joint gets arthritis?
Do I have to put a joint
replacement in there?
No, it's a small area.
The interesting thing is we
can get rid of the bone on bone
by just removing about a centimeter
of the end of the collar bone.
And that decompresses the arthritis,
there's no more bone on bone,
and the pain goes away; easy solution.
Inflammatory conditions, I've
already talked about bursitis.
We can look in the shoulder,
we can clean out the bursitis.
Ideally, if we clean out bone spurs
or other things that
are causing the bursitis
to have formed initially,
bursa comes back which
is normal small cushion,
but not the thickened bursitis.
My scapula, my shoulder blade is grinding,
I can't get relief with that; same thing.
It's kind of interesting,
we can put someone
prone on their stomach, but their arm
in this chicken bone position
and actually do arthroscopy
under the shoulder blade
to clean out that bursitis.
Calcific tendonitis,
again, we don't always know
why this happens, but
someone's shoulder hurts a lot,
they've got this big calcium deposit.
We can look in the shoulder
and direct a needle
into that mass of calcium.
And what's called a barbotage is
inserting fluid, sucking it out;
inserting fluid like washing
it over and over again,
and you can suck out the calcium,
and you can actually
collect it in the syringe.
If that doesn't seem to work,
then we can always do
shoulder arthroscopy.
And when you look down
at the rotator cuff,
which is this picture, you
can see a bulge typically,
and if you make a little opening in it,
out comes the calcium.
It's interesting, the calcium
isn't like a stone in there.
It's like the consistency of toothpaste.
So it kind of, you can press the edges
and out come the calcium.
And the pain is then
improved dramatically.
What if my shoulder won't move?
The doctor says I've
got a frozen shoulder,
and I've gone to therapy
and they've worked hard,
but I just can't, it hurts too much
to have them push on it.
We've tried steroid shots,
we've done other things.
Sometimes we do a manipulation.
So if we have someone go to
sleep briefly under anesthesia,
we can move the shoulder
through full range of motion,
and we're actually
stretching out the ligaments.
So if I'm doing that manipulation,
I can feel the ligaments stretch and tear.
We actually have to stretch them out
so that they loosen up.
If that doesn't work,
we can do arthroscopy.
This is the ball, this is the socket.
There's tight ligaments that don't allow
any movement in the shoulder.
We can release those, and
it kind of looks like that.
And then, again, the ligaments heal back,
but they heal back a little bit lengthened
so we have movement.
What if I dislocate my shoulder?
So again, this is the
glenoid, this is the socket,
all the ligaments attach that hold
the shoulder joint together.
The most common area
the ligaments tear off
is at the bottom part of the glenoid,
and that's called a Bankart lesion.
So we just look in the shoulder,
we find the ligaments that pulled off,
and we reattach them with
stitches back to the bone.
The AC joint, and I'm
sure everybody has seen
someone that their collar
bone is sticking out there.
Some people, dramatically or amazingly,
have a shoulder that looks like that,
and it works just fine.
So you don't need surgery
just because it looks funny.
But there are some people
that have this injury,
and when they try to use
their shoulder, it hurts.
It hurts right there.
So in those cases, if it hurts,
we can reconstruct, like
we can take a ligament
that normally goes from the
coracoid to the acromion
and transfer it to the clavicle
and back it up with some stitches.
That's how we fix those.
What if my biceps tendon is hurt?
What if I have one of those SLAP tears?
My biceps itself may look funny,
sometimes you see people,
their biceps is wadded up,
part of it here looks different.
They have that, so one of
their biceps tendons gave,
the long head biceps, and
it wadded up down here.
And a lot of people, just
like the AC separation,
they may do okay.
Their arm looks kind of funny,
but if it works, that's fine.
Some people, though, it doesn't work well,
and one of our options is to attach it
to a different place.
Where our normal anatomy
attache the biceps tendon
Where our normal anatomy
attaches the biceps tendon
It doesn't have a good blood supply,
so we don't try to repair
it here if it's torn.
We make a little opening in the humerus,
we insert the biceps tendon,
that's called a biceps
tenodesis, and it heals there.
And people do really well with that
if they have biceps injury.
So rotator cuff, again, this
is kind of the biggest problem
we see overall that ends up
needing surgery, I would say,
because when the rotator cuff tears,
the tendon pulls away from its attachment.
And again, the body can't
get it back out there.
So what do we do as orthopedic surgeon?
Well we insert an anchor where
the tendon should be attached.
that anchor can be all stitches,
or it can a composite
material that turns into bone.
We used to use metal, but we don't tend
to use metal these days.
But out of that little
anchor comes stitches,
and we can weave those stitches
through the torn tendon
and attach that tendon back to
where it was before it tore.
And that's the only way it can get back
to where it needs to to heal.
So that's the solution
for a rotator cuff tear.
So lot of different
things I've talked about,
So, lot of different
things I've talked about,
of the shoulder that can hurt,
from bones to muscles to the joints.
Some of the activities I discussed,
trying to keep your rotator cuff strong,
trying to keep your motion full,
these are preventative and
kind of treatment options
for a lot of these shoulder conditions.
But if your shoulder
just doesn't get better,
if you can't move it especially,
you should probably come
in sooner rather than later
to see for sure what's going on.
