Wednesday, 27 March 2013

Shoulder | Acromioclavicular Joint Degeneration | A/C Joint | ACJ

Shoulder | Acromioclavicular Joint Degeneration | A/C Joint | ACJ

The acromio-clavicular joint is the anatomical part of the shoulder where the collarbone joins the shoulder. It is commonly called the A/C joint or ACJ.

Acromioclavicular Joint Degeneration

Pain and inflammation may occur as part of a sudden (acute) injury, or a recurrent overload (overuse) injury.
When overload and degeneration occurs, the ACJ often develops osteoarthritis. It may also develop osteolysis, where the end of the collarbone disintegrates as the bone starts to die.


ACJ degeneration is a progressive problem where there is localised pain in the ACJ area. Tenderness is localised to the tip of the shoulder and a swelling may develop. It is usually painful to lie on the shoulder or perform activities which compress the ACJ. These commonly include push-ups, bench press, overhead activities. Some people complain of clicking or grinding in the shoulder.  
Management of ACJ degeneration is a step-by-step process:
  1. Diagnosis. An X-ray is essential to confirm existence of degeneration
  2. Reduce the load and reduce the inflammation. Changing work and exercise habits where possible. For pain relief the regular use of ice for the ACJ; the use of anti-inflammatory tablets or cortisone injections.
  3. Over a period of 2-3 months if there is no progress, surgery is an option. This is an excision of the distal (outer) clavicle and is now mainly performed through keyhole/arthroscopic surgery. The operation is known as an arthroscopic excision of the distal clavicle.

Injections to the Acromiclavicular Joint (AC Joint)

The ACJ may be approached from different directions. Many favour an anterior approach (see below left), although the ACJ may be approached posterior or superiorly.

Standard hygienic precautions must be followed, and then a combination of 1 ml corticosteroid (cortisone) with 1 ml of local anaesthetic may be introduced.

Osteoarthritis of the Acromioclavicular Joint |

Osteoarthritis of the Acromioclavicular Joint |

A Patient's Guide to Osteoarthritis of the Acromioclavicular Joint


Some joints in the body are more likely to develop problems from normal wear and tear. Degeneration causes the cartilage that cushions the joint to wear out. This type of arthritis is called osteoarthritis. Doctors sometimes refer to this type of arthritis as arthrosis.
The acromioclavicular (AC) joint in the shoulder is a common spot for osteoarthritis to develop in middle age. Degeneration of the AC joint can be painful and can cause difficulty using the shoulder for everyday activities.
This guide will help you understand
  • what the AC joint is and how it works
  • the causes of pain and problems in the AC joint
  • the treatments used for this condition


What exactly is the AC joint?
The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).
The part of the scapula that makes up the roof of the shoulder and connects with the clavicle is called the acromion. The joint where the acromion and the clavicle join is the AC joint.
In some ways, the AC joint is like any other joint. It has two bones that need to connect but be flexible as well. The ends of the bones are covered with articular cartilage. Articular cartilage provides a slick, rubbery surface that allows the bones to glide over each other as you move. Cartilage also functions as sort of a shock absorber.
However, the AC joint is different from joints like the knee or ankle, because it doesn't need to move very much. The AC joint only needs to be flexible enough for the shoulder to move freely. The AC joint just shifts a bit as the shoulder moves.
View animation of shoulder movement
Related Document: A Patient's Guide to Shoulder Anatomy


Why does degeneration of the AC joint occur?
We use our shoulder constantly. The resulting strain makes AC joint osteoarthritis a common disorder. The AC joint is under constant stress as the arm is used overhead. Weightlifters and others who repeatedly lift heavy amounts of weight overhead tend to have an increased incidence of the condition, and often at a younger age.
AC joint osteoarthritis may also develop following an injury to the joint, such as an AC joint separation. This injury is fairly common. A separation usually results from falling on the shoulder. The shoulder does heal, but many years later degeneration causes the AC joint to become painful.
Related Document: A Patient's Guide to Acromioclavicular Joint Separation


What are the symptoms of this condition?
In its early stages, AC joint osteoarthritis usually causes pain and tenderness in the front of the shoulder around the joint. The pain is often worse when the arm is brought across the chest, since this motion compresses the joint. The pain is vague and may spread to include the shoulder, the front of the chest, and the neck. If the joint has been injured in the past, there may be a bigger bump over the joint on the affected shoulder than on the unaffected shoulder. The joint may also click or snap as it moves.


What tests will my doctor do?
Your doctor will want to get a detailed medical history, including questions about your condition and how it is affecting you. You will need to answer questions about past injuries to your shoulder. You may be asked to rate your pain on a scale of one to ten. Your doctor will also want to know how much your pain affects your daily tasks.
Diagnosis of AC joint osteoarthritis is usually made by physical examination. The AC joint is usually tender. A key finding is pain as the joint is compressed. To test for this, your arm is pulled gently across your chest. Your doctor may inject a local anesthetic such as lidocaine into the joint. If the AC joint is the problem, the injection will temporarily reduce the pain.
Your doctor may want to take X-rays of the AC joint. X-rays can show narrowing of the joint and bone spurs around the joint, which are signs of degeneration.


What treatment options are available?

Nonsurgical Treatment

Initial treatment for AC joint osteoarthritis usually consists of rest and anti-inflammatory medications such as aspirin or ibuprofen. A rehabilitation program may be directed by a physical or occupational therapist. If the pain doesn't go away, an injection of cortisone into the joint may help. Cortisone is a strong medication that decreases inflammation and reduces pain. Cortisone's effects are often temporary, but it can give very effective relief in the short term.
Related Document: A Patient's Guide to Joint Injections for Arthritis


If nonsurgical measures fail to relieve your pain, your doctor may recommend surgery.
The most common procedure for AC joint osteoarthritis is resection arthroplasty. A resection arthroplasty involves removing a small portion of the end of the clavicle. This leaves a space between the acromion (the piece of the scapula that meets your shoulder) and the cut end of the clavicle, where the joint used to be. Your surgeon will take care not to remove too much of the end of the clavicle to prevent any damage to the ligaments holding the joint together. Usually only a small portion is removed, less than one cm (about three-eighths of an inch). As your body heals, the joint is replaced by scar tissue. Remember, the AC joint doesn't move much, but it does need to be flexible. The scar tissue allows movement but stops the bone ends from rubbing together.
This procedure can be done in two ways. Today, it is more common to do this procedure using the arthroscope. An arthroscope is a slender tool with a tiny TV camera on the end. It lets the surgeon work in the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery.
The older open method of performing this operation is done by making a small incision, less than two inches long, over the AC joint. The AC joint is very close to the surface of the skin and can be easily reached through a small incision. The surgeon can then use a special saw or other instrument to shave off a small portion of the end of the clavicle.


What should I expect after treatment?

Nonsurgical Rehabilitation

If you don't need surgery, range-of-motion exercises should be started as pain eases, followed by a program of strengthening. At first, exercises are done with the arm kept below shoulder level. The program advances to include strength exercises for the rotator cuff and shoulder blade muscles. The goal is to get your shoulder moving smoothly and to learn how to control your symptoms. You will probably progress to a home program within four to six weeks.

After Surgery

Your surgeon may have you wear a sling to support and protect the shoulder for a few days. A physical or occupational therapist will probably direct your recovery program. The first few therapy treatments will focus on controlling the pain and swelling from surgery. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.
Therapy can progress safely and quickly after a simple arthroscopic resection. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You need to avoid doing too much, too quickly.
Therapy goes slower after surgeries where an incision is made through the shoulder muscles. Therapists usually wait up to two weeks before starting range-of-motion exercises. You will begin with passive exercises. In passive exercises, the shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.
Active therapy starts after four to six weeks. Active range-of-motion exercises help you regain shoulder movement using your own muscle power. You might begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing joint.
At about six weeks, you will start more active strengthening. Exercises will focus on improving strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus centered in the socket. This helps your shoulder move smoothly during all your activities.
Some of the exercises you'll do are designed to get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don't put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Thursday, 7 March 2013

Labral Tear -

Labral Tear -

An unstable shoulder joint can be the cause or the result of a labral tear. "Labral" refers to the glenoid labrum—a ring of cartilage that surrounds the base of the shoulder joint. Injuries to the labrum are common, can cause a great deal of pain, and may make it hard to move your arm. A labral tear can occur from a fall or from repetitive activities or sports that require you to use your arms raised above your head. Some labral tears can be managed with physical therapy; in severe cases, surgery may be required to repair the torn labrum.

  Labral Tear-Small

What is a Labral Tear?

The glenoid labrum provides extra support for the shoulder joint, helping to keep it in place. A labral tear occurs when part of this ring is disrupted, frayed, or torn. Tears may lead to shoulder pain, an unstable shoulder joint, and, in severe cases, dislocation of the shoulder. Likewise, a shoulder dislocation can result in labral tears.
When you think of the shoulder joint, picture a golf ball (the head of the upper-arm bone, or humerus) resting on a golf tee (the glenoid fossa, a shallow cavity or socket located on the shoulder blade, or scapula). The labrum provides a rim for the socket (golf tee) so that the humerus (golf ball) does not easily fall off. If the labrum is torn, it is harder for the humerus to stay in the socket. The end result is that the shoulder joint becomes unstable and prone to injury.
Because the biceps tendon attaches to the shoulder blade through the labrum, labral tears can occur when you put extra strain on the biceps muscle, such as when you throw a ball. Tears also can result from pinching or compressing the shoulder joint when the arm is raised overhead. There are 2 types of tears:
  • Traumatic labral tears usually happen because of a single incident, such as a shoulder dislocation or an injury from heavy lifting. People who use their arms raised over their heads—such as weight lifters, gymnasts, and construction workers—are more likely to have traumatic labral tears. Activities the force is at a distance from the shoulder, such as striking a hammer or swinging a racquet, also can create shoulder joint problems.
  • Nontraumatic labral tears most often occur because of muscle weakness or shoulder joint instability. When the muscles that stabilize the shoulder joint are weak, more stress is put on the labrum, leading to a tear. People with nontraumatic tears tend to have more "looseness" or greater mobility throughout all their joints, which might be a factor in the development of a tear.
Labral Tear-Small Labral Tear: See More Detail

How Does it Feel?

With a labral tear, you might have:
  • Pain over the top of your shoulder
  • "Popping," "clunking," or "catching" with shoulder movement,  because the torn labrum has "loose ends" that are flipped or rolled within the shoulder joint during arm movement and that may even become trapped between the upper arm and shoulder blade
  • Shoulder weakness, often on one side
  • A feeling that your shoulder joint will pop out

How Is It Diagnosed?

Not all labral tears cause symptoms. In fact, when tears are small, many people are able to function without pain. In some instances, the labrum might even heal on its own, if care is taken not to stress the injured tissues. Due to the lack of blood supply available at the labrum, complete healing may be difficult. The shoulder with a labral tear may pop or click without being painful; however, if a tear progresses, it is likely to lead to pain and weakness.
If your physical therapist suspects that you may have a labral tear, the therapist will review your health history and perform an examination that is designed to test the condition of the glenoid labrum (the ring of cartilage at the base of the shoulder). The tests will place your shoulder in positions that may recreate some of your symptoms, such as "popping," "clicking," or mild pain. Using this examination, your physical therapist will determine whether your shoulder joint is unstable. Magnetic resonance imaging (MRI) also may be used. Labral tears may be difficult to diagnose with certainty without arthroscopic surgery, where a tube-like instrument called an arthroscope is inserted into the joint through a small incision to view or repair an injury.

How Can a Physical Therapist Help?

When labral tears cause minor symptoms but don’t cause shoulder instability, they usually are treated with physical therapy. Your physical therapist will:
  • Educate you about positions or activities to avoid
  • Tailor a treatment plan for your recovery
  • Design specific shoulder strengthening exercises, such as external rotation and internal rotation exercises, to help support the joint and decrease strain on the glenoid labrum
  • Design stretching exercises, such as the cross-body stretch or the doorway stretch, to help improve the function of the muscles surrounding the shoulder
  • Perform a special technique called manual therapy to decrease pain and improve movement
In more severe cases, when conservative treatments are unable to completely relieve the symptoms of a labral tear, surgery may be required to re-attach the torn labrum. Following surgery, your physical therapist will show you how to slowly and safely return to your daily activities.
A surgically repaired labrum takes 9 to 12 months to completely heal. Immediately following the repair, you should avoid putting excessive stress or strain on the repaired labrum and should increase stress to your shoulder slowly over time. Your physical therapist is trained to gradually introduce activity in a safe manner to allow you to return to your usual activities without re-injuring the repaired tissues.

Can this Injury or Condition be Prevented?

Forceful activities with the arms raised overhead may increase the likelihood of developing a labral tear. To avoid putting excessive stress on the labrum, you need to develop strength in the muscles that surround the shoulder and scapula. Your therapist will:
  • Design exercises to help you strengthen your shoulder
  • Show you how to avoid potentially harmful positions
  • Determine when it is appropriate for you to return to your normal activities
  • Train you to properly control your shoulder movement and modify your activities to reduce your risk of sustaining a labral injury

Real Life Experiences

After a day of heavy upper-body lifting at the gym, Jill notices that her shoulder is aching. She ignores the discomfort, thinking that it’s just post-workout soreness, and she continues with her normal routine. But when Jill returns to the gym the following week, she is unable to exercise as aggressively as she usually does because of right shoulder pain. Almost every time she raises her arm overhead, she feels a “clicking” in the shoulder that was never there before. What should she do?
    • Rest.Jill should avoid overhead activities, to allow the irritated tissues to heal.
    • Ice. Ice applied to the shoulder may help decrease her pain and any swelling.
Rest and ice do not completely get rid of her symptoms, so Jill decides to visit a physical therapist. The therapist conducts an examination designed to detect the amount of injury and how it is affecting her shoulder’s function. Based on the findings of the physical exam, Jill’s physical therapist determines her diagnosis is consistent with a labral injury and recommends the following treatments:
      • Strengthening exercises. Improving the strength of the muscles of the shoulder will help Jill decrease the stresses placed on the torn labrum and allow for better healing. The therapist designs external rotation and internal rotation exercises that target the muscles of the shoulder blade and the shoulder joint.;
      • Stretching exercises. An imbalance in the muscles or a decrease in flexibility can result in poor posture or excessive stress within the shoulder joint. Jill's therapist prescribes stretching exercises to restore the normal balance of the muscles surrounding the shoulder to help them work better together.
      • Education. Education is an important part of any physical therapy treatment plan.  If Jill understands the injury, the reasons for modifying her activities, and the importance of doing the exercises provided by the physical therapist, she can help decrease her risk of future injury.
      • Home exercise program. A home exercise program is an important companion to treatment in the physical therapy clinic. The physical therapist identifies the stretching and strengthening exercises that will help her continue to make improvements and meet her goals.
Following 6 weeks of physical therapy, Jill begins a progressive return to her weight-lifting activities. Her physical therapist gives her instruction in proper lifting techniques and training intensity, and Jill is able to make a safe and effective transition back to her lifting program. If Jill's pain and other symptoms return, her physical therapist will work with her and with an orthopedist to help determine whether she needs surgery to repair her labrum.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients who have a dislocated shoulder, but you may want to consider:
  • A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with an orthopedic focus.
  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedics physical therapy has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with labral tears.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
APTA has determined that the following articles provide some of the best scientific evidence for how to treat labral tears. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.
Mazzocca AD, Cote MP, Solovyova O, et al. Traumatic shoulder instability involving anterior, inferior, and posterior labral injury: a prospective clinical evaluation of arthroscopic repair of 270° labral tears. Am J Sports Med. 2011;39:1687-1696.  Article Summary on PubMed.
Dodson CC, Altchek DW. SLAP lesions: an update on recognition and treatment. J Orthop Sports Phys Ther. 2009;39:71-80. Article Summary on PubMed.
Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009;17:627-637. Article Summary on PubMed.

Acknowledgement: Charles Thigpen, PhD, PT, ATC and Lane Bailey, PT, DPT, CSCS

Labral Tears |

Labral Tears |

What is the labrum?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

A part of the scapula, called the glenoid, makes up the socket of the shoulder. The glenoid is very shallow and flat. The labrum is a rim of soft tissue that makes the socket more like a cup. The labrum turns the flat surface of the glenoid into a deeper socket that molds to fit the head of the humerus.
The rotator cuff connects the humerus to the scapula. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm. As the arm is raised, the rotator cuff also keeps the humerus tightly in the glenoid of the scapula.

The soft labral tissue can be caught between the glenoid and the humerus. When this happens, the labrum may start to tear. If the tear gets worse, it may become a flap of tissue that can move in and out of the joint, getting caught between the head of the humerus and the glenoid. The flap can cause pain and catching when you move your shoulder. Several tendons and ligaments attach to the labrum that help maintain the stability of the shoulder. So when the labrum tears, the shoulder often becomes much less stable.


What causes labral tears?

Labral tears are often caused by a direct injury to the shoulder, such as falling on an outstretched hand. The labrum can also become torn from the wear and tear of activity, a condition called overuse. An injured labrum can lead to shoulder instability. The extra motion of the humerus within the socket causes additional damage to the labrum. An extremely unstable shoulder may slip or dislocate. This can also cause the labrum to tear.

Related Document: A Patient's Guide to Shoulder Instability

The biceps tendon attaches to the front part of the labrum. The biceps is the large muscle on the front of your upper arm. Sports can cause injuries to the labrum when the biceps tendon pulls sharply against the front of the labrum. Baseball pitchers are prone to labral tears because the action of throwing causes the biceps tendon to pull strongly against the top part of the labrum. Weightlifters can have similar problems when pressing weights overhead. Golfers may tear their labrum if their club strikes the ground during the golf swing.

Related Document: A Patient's Guide to Biceps Tendonitis

Understanding shoulder instability – Red Sports. Always Game.

Understanding shoulder instability – Red Sports. Always Game.

By Dr Lim Yeow Wai, Consultant Orthopaedic Surgeon, Changi General Hospital; Consultant Orthopaedic Surgeon, Raffles Hospital

The shoulder joint is considered one of the most elegant joints in the human body because it has tremendous range of motion. But being the most mobile joint in the body also come with a price: it undergoes tremendous stress and is also the most common joint to be dislocated.

Shoulder instability simply means that the shoulder joint is too loose and slides around too much in its socket. In most cases, the shoulder slips and causes discomfort, but in some instances it may slip completely out of the joint and become dislocated.

What makes up the shoulder joint?

The shoulder is made up of 3 bones: the humerus (upper arm bone), the scapula (shoulder blade) and the clavicle (collarbone). The head of the humerus forms the ball of the shoulder joint while part of the scapula (glenoid) forms the socket.
shoulder joint

Parts of the shoulder joint.

The glenoid is shallow and flat, like a golf tee, allowing the humerus head to slip out easily. This is prevented by a rim of soft tissue called labrum. The labrum surrounds the edge of the glenoid, hence deepening the socket so that it molds and fits the head of the humerus. Encasing the humerus head and the glenoid is a watertight sac called the capsule. The capsule holds the fluid which lubricates the joint. The wall of this sac is made up of ligaments. Ligaments are soft connective tissues that attach bone to bone. There are various ligaments which tighten at different position of the arm so that they can confer stability without restricting movements.

There are also muscles surrounding this capsule called the rotator cuff muscles. This group of muscles confers dynamic stability to the shoulder joint. This means that when they contract they will encourage the humerus head to sit in the glenoid. However if they are weak, injured or fatigue, then this ability is compromised.

What makes the shoulder joint dislocate?

Dislocation happens when a force overcomes the strength of the muscles and ligaments of the shoulder. This is usually when the arm is in a "ball-throwing" position. Sometimes the shoulder does not come out of the socket completely. It slips out partially and then returns to its normal position, this is called subluxation.

The initial treatment would be to put the shoulder back into its socket. The shoulder will usually be sore for up to 2 weeks after a dislocation. Although the shoulder may subsequently appear normal with full motion and no pain, it will still remain unstable. This is because often the labrum and ligaments that restrain the shoulder would have been stretched and even torn from the socket (see Bankart lesion diagram below). This causes the shoulder to become loose especially in certain position or when the muscles around the shoulder are fatigued.
Bankart lesion

The labrum torn off from the glenoid.

In some cases, shoulder instability can occur without previous dislocation. This is common among athletes who do repetitive shoulder motion which stretches out the capsule and ligaments over time e.g. in sports like volleyball, swimming, baseball, handball and cricket. If the joint capsule and ligaments are stretched out and the shoulder muscles are weak, the ball of the humerus begins to slip around too much within the socket causing irritation and pain in the shoulder joint.

A third group of patients has a genetic problem with the connective tissue. Their ligaments are too elastic resulting in them being easily stretched and unable to restrain the shoulder. This is usually manifested in other joints like the elbow, wrist and finger joints.

Not uncommonly there is overlap between these three groups.

What are the usual symptoms?

Frequent dislocation can be a very disturbing problem. Initially it may occur while you are raising your arm above your head in a throwing position. But subsequently when the shoulder becomes looser, it may even dislocate while you sleep or try to put your arm across your friend's shoulder.

A dislocated shoulder can damage the nerves around the shoulder, and can also be painful. Frequent dislocation can also damage the cartilage or cause impaction fracture in the humerus head. This can lead to arthritis of the shoulder at a later age.

Sometimes one may experience frequent subluxation instead of frank dislocation. This is a feeling that the shoulder is loose and about to "drop" out. The feeling can also be one of slipping or pinching in the shoulder. This is often due to excessive movement of the humeral head in the socket. The position that commonly causes this is in an overhead position.

How is the condition usually diagnosed?

The doctor will usually ask you a few questions about your shoulder and your general medical condition. He will then examine your shoulder and other parts of the joint to confirm that you have an unstable shoulder joint. This usually includes a test called an “apprehension and relocation test", where he will put your arm in a "ball throwing" position. You will feel a slipping sensation or pain. This is alleviated when he pushes the humeral head in.

He will then order an X-ray to exclude any fracture or to check that there is no evidence of previous fracture that may result in your shoulder being loose. In the immediate dislocation setting, he may order the X-rays to make sure your shoulder is enlocated. Sometimes an MRI of the shoulder may be ordered to look at the torn labrum or other associated injuries in the shoulder.

What is the treatment?

Non-surgical – The initial phase after dislocation includes resting the shoulder and allowing the inflammation and pain to settle. This will usually take two weeks. Your surgeon may then prescribe some strengthening exercises for your rotator cuff and biceps muscle. However if you are young and active and have a torn labrum, then the chances of you dislocating your shoulder again would be very high.


Three anchors used to reattach the torn labrum to the glenoid.

Surgical – There are many surgeries that can be done to stabilise the shoulder. But most surgeons would perform an arthroscopic surgery (keyhole surgery) to stabilise your shoulder joint. This involves making two to three tiny cuts that is no more than a centimeter in length. A tiny TV camera called an arthroscope is then inserted into the shoulder joint to examine the torn structures, loose capsule and ligaments. Special instruments are then used to tighten the torn and loose structures. This is usually achieved by tying them down onto the bone with the help of small plastic-like screws. This can be done as day surgery which means you don't have to stay overnight in the hospital.

What is the rehabilitation like?

Different surgeons have slightly different protocols. But in general it can be divided into 4 phases. The first phase is to control the inflammation and allow the repaired structures to heal. This would usually mean resting the shoulder in a sling for 3 weeks and taking anti-inflammatory medicines to control the swelling and pain. The second phase concentrates in getting back the range of motion in the shoulder. This may include some passive stretching and active assisted exercises. The third phase is the strengthening phase. This involves doing isometric exercises for the rotator cuff and biceps muscle. This is usually progress to doing active exercises for the same group of muscle. The final phase involves getting you back to whichever sports you play. You can usually expect to go back to contact or rigorous sports after 6 months.

Shoulder Labrum Tears: An Overview - - Hospital for Special Surgery, New York

Shoulder Labrum Tears: An Overview - - Hospital for Special Surgery, New York

Dr. Fealy on treatment of labral cartilage tears and shoulder instability

Stephen Fealy, MD

Associate Attending Orthopaedic Surgeon, Hospital for Special Surgery
Associate Professor of Orthopaedic Surgery, Weill Cornell Medical College


The labrum is the cup-shaped rim of cartilage that lines and reinforces the ball and socket joint of the shoulder, which is comprised of the glenoid - the shallow shoulder socket - and the head, or ball, of the upper arm bone known as the humerus. The labrum is the attachment site for the ligaments and supports the ball and socket joint along with the rotator cuff tendons and muscles. It contributes to shoulder stability and, when torn, can lead to partial or complete shoulder dislocation.

Anatomy of the shoulder, featuring the humerus (upper arm bone) and the labrum,
which rims the glenoid (shoulder socket). [Illustration by Robert O'Conor]
The two most common types of labral injuries are SLAP (Superior Labrum from Anterior to Posterior) tears and Bankart tears. “SLAP tears occur at the front of the upper arm where the biceps tendon connects to the shoulder,” says Dr. Stephen Fealy, an orthopedic surgeon in the Sports Medicine and Shoulder Service at Hospital for Special Surgery in New York. “Athletes most prone to this injury include baseball pitchers and volleyball players who engage in high-energy, quick-snap motions over the top of the shoulder.”

Bankart tears, on the other hand, typically occur with shoulder dislocation in younger patients; the head of the humerus either shifts toward the front of the body, leading to “anterior instability,” or the back of the body, called “posterior instability.”

Both types of tears are usually accompanied by aching pain and difficulty performing normal shoulder movements. With Bankart tears in particular, patients may feel apprehension that the shoulder may slip out of place or dislocate in certain positions. Patients with SLAP tears may experience pain at the front of the shoulder near the biceps tendon.

Unfortunately, labral tears are hard to prevent, especially in athletes, because the force of the overhead motion contributes to the injury. Although athletes are most prone to labral tears, people who experience a traumatic event - such as falling down a flight of stairs - are also at risk, particularly older adults whose cartilage becomes more brittle with age.


“Surgeons should try to be as conservative as possible when treating a torn shoulder labrum,” says Dr. Fealy. Surgeons will usually conduct a physical exam and MRI or x-ray, if necessary, to determine the severity of the injury and the treatment needs.

SLAP tears are usually treated with rest, anti-inflammatory medications and, in some cases, an in-office cortisone injection. This is followed by gradual stretching of the shoulder, initially with a physical therapist, for six weeks to two months.

If the injury is a minor Bankart tear with a dislocation, the physician (or even the coach or patient themselves) can usually pop the shoulder back into place - a process called reduction - followed by physical therapy to strengthen the muscles.

“If physical therapy fails and the athlete still can’t complete overhead motions, or the shoulder continues to dislocate, surgical treatment might be required to reattach the torn ligaments and labrum to the bone,” says Dr. Fealy. Arthroscopic procedures, in which the doctor operates through a small incision, are usually preferred because they are less invasive than open surgery.

In general, non-surgical treatment is usually most appropriate for older patients who do not engage in regular physical activity, while younger athletes who regularly participate in higher impact sports can expect recurrence and may want to consider arthroscopic surgery.


Patients who undergo arthroscopic repair can expect shorter recovery times and less pain. Those undergoing open surgery should expect more pain, longer recovery, and in some cases incomplete shoulder rotation.

Regardless of treatment type, almost all athletes are advised to wear a sling for the first four weeks post-surgery to protect the shoulder as it heals. Following surgery, athletes may require six months to one year for full recovery, with overhead throwing athletes taking the longest.

“If fixed properly, most athletes should be able to return to at least 80 percent of their pre-injury level of play,” says Dr. Fealy.

Rotator cuff injury - exercises for rotator cuff injury

Rotator cuff exercises for rotator cuff injury

The rotator cuff muscles are generally responsible for rotating the shoulder, assisting with lifting the arm out to the side, and generally stabilising the shoulder joint. We demonstrate a few simple rotator cuff injury exercises which can be used as part of a rotator cuff injury rehab program.

The following guidelines regarding Rotator Cuff Injury strengthening exercises are for information purposes only. We recommend seeking professional advice before beginning rehabilitation. The best exercises for rotator cuff strain are outlined below and should always be done pain free.

Static exercises

Static (or isometric) exercises are some of the first torn rotator cuff exercises to be done as they do not involve any movement. The patient pushes against a stationary object such as a wall, doorframe, or resistance provided by another person.

Because there is no movement, static exercises can be performed soon after injury, usually within 3-7 days, provided they are pain-free. If any exercises are painful, then do not continue with them. Rest for a longer period until they are comfortable.

Lateral rotation

  • The video above shows static lateral rotation performed against a wall.
  • Push against the wall, start off gently, (e.g. about 50% max) and gradually increase the intensity.
  • Keep the shoulder and upper arm still. Aim to hold the position for 10 seconds, relax for three seconds and contract again for 10 seconds.
  • The duration of hold and number of repetitions can be increased until the athlete feels confident enough to move onto dynamic exercises.

Medial rotation

  • Stand facing the corner of the wall, with the palm and lower forearm against the wall (the other side from the photo opposite).
  • Push against the wall, as if trying to rotate the forearm towards the body, keep the shoulder and upper arm still.
  • Again, start off at 50% for 10 seconds, repeated twice.
  • Gradually increase the intensity, duration and repetitions.


  • Stand side-on to a wall, with the elbow bent and side of the forearm against the wall.
  • Push outwards, against the wall, as it trying to lift the arm above the head.
  • Start at 50%, hold for 10 seconds and repeat twice.
  • Gradually increase as above.

Resistance band exercises

Resistance bands are great for strengthening the shoulder muscles. They can be used in many different positions and can easily be progressed as your strength improves. Tie one end of the band to something sturdy at waist height, such as a door handle (make sure the door is closed!). Always start with the band just taught to make sure you are working the muscles through the whole range. These exercises can replace the static exercises (above) as soon as pain allows (usually 7 days plus)

Lateral rotation

  • Hold the untied end of the band in the injured hand
  • Keep the elbow bent by your side and start with the forearm/hand close to your stomach
  • Make sure you keep the elbow in as you rotate the shoulder so that the arm moves away from the stomach as far as you can.
  • Slowly return to the start position
  • Repeat this 10 times initially (provided it is pain free).
  • Gradually increase the number you perform up to 20 and then increase the intensity by shortening the section of band you hold.

Medial rotation

  • Turn around so that the attachment point of the band is on the same side as your injured shoulder
  • Make sure the elbow is bent and by your side
  • Start with the arm laterally rotated, with the forearm away from the body (the end position of the above exercise)
  • Rotate the shoulder so that the forearm moves in towards your stomach as far as you can.
  • Keep your elbow still and by your side throughout.
  • Slowly return to the starting position.
  • Repeat 10 times initially and gradually increase as above.


  • Stand with the bands attachment point on the opposite side to your injured shoulder.
  • Hold the free end of the band and start with the arm straight by your side.
  • Raise your arm out to the side and as high as you can - keep your elbow straight
  • Slowly return to the starting position.
  • Repeat 10 times initially and gradually increase as above.

Weight exercises

Once the strength in your shoulder is really improving, you may want to start performing weight exercises. The same movements can be repeated with a dumbbell:

Lateral rotation

  • With a small dumbbell (start at around 2-3kg), lay on your side on a bench, with the injured shoulder on top.
  • Position the arm with the upper arm against your body, elbow bent and forearm and hand pointing down to the bench.
  • Keep the elbow still as your rotate the shoulder so that the forearm moves up past horizontal and as far as you can.
  • Slowly return to the starting position and repeat 10 times initially.
  • Gradually increase the number to 20 and then slowly increase the weight you use.

Medial rotation

  • Lay on your side on a bench with the injured shoulder on the bottom.
  • Make sure the upper arm is supported and the elbow is bent to 90 degrees (the forearm will be horizontal).
  • Rotate from the shoulder so that the hand moves towards your body as far as you can.
  • Slowly return to the starting position.
  • Repeat 10 times initially and gradually increase


  • Stand up and hold a small dumbbell in the hand of the injured shoulder.
  • With the elbow slightly bent, lift the arm up out to the side, to just above shoulder height.
  • Slowly return to the starting position.
  • Repeat 10 times initially and gradually increase as above.
  • At this point you can add in other shoulder strengthening weight exercises, such as shoulder presses and front raises.

Glenoid Labrum Tear

Glenoid Labrum Tear

The glenoid labrum in the shoulder which can be torn from repetitive movements or accidents such as falls.

The glenoid labrum is a fibrous ring of tissue which attaches to the rim of the glenoid (shallow depression of the scapula or shoulder blade where the ball of the humerus sits).

Symptoms of Glenoid Labrum tears

  • Shoulder pain which cannot be localized to a specific point.
  • Pain is made worse by overhead activities or when the arm is held behind the back.
  • Weakness Instability in the shoulder.
  • Pain on resisted flexion of the biceps (bending the elbow against resistance).
  • Tenderness over the front of the shoulder.

What is the Glenoid Labrum?

The glenoid labrum is a fibrous ring of tissue which attaches to the rim of the glenoid (shallow depression of the scapula or shoulder blade where the ball of the humerus sits). The glenoid labrum increases the depth of the shoulder cavity making the shoulder joint more stable. The glenohumeral ligaments (which secure the upper arm to the shoulder) and shoulder capsule attach to the glenoid labrum.

How is the Glenoid Labrum injured?  

  • Repetitive overhead throwing.
  • Lifting heavy objects below shoulder height or catching heavy objects.
  • Falling onto an outstretched arm.
Glenoid labrum injuries are classed as either superior (towards the top of the glenoid socket) or inferior towards the bottom of the glenoid socket. A superior injury is known as a SLAP lesion (superior labrum, anterior (front) to posterior (back) and is a tear of the rim above the middle of the socket that may also involve the biceps tendon. A tear of the rim below the middle of the glenoid socket is called a Bankart lesion and also involves the inferior glenohumeral ligament. Tears of the glenoid labrum may often occur with other shoulder injuries, such as a dislocated shoulder.

Treatment of Glenoid Labrum tears

  • Rest.  
  • Cold therapy to reduce pain and inflammation.
  • Doctor may prescribe NSAID's (non steroidal anti inflammatory drugs such as ibuprofen) - don't take if you have asthma.
  • A full and gradual rehabilitation programme to restore full function.
  • Unstable injuries will require surgery to re-attach the labrum to the glenoid.
  • Bankart lesions will require surgery.
  • Any underlying causes which contributed to the injury such as shoulder instability should be addressed.
  • Following surgery the shoulder will usually be kept in a sling for 3 or 4 weeks.
  • After 6 weeks more sports specific training can be done although full fitness may take 3 or 4 months.

Shoulder Surgery: SLAP Lesion Repair - Hospital for Special Surgery, New York

Shoulder Surgery: SLAP Lesion Repair - Hospital for Special Surgery, New York

Minimally invasive surgery to repair capsule and labral damage in the shoulder and prevent instability and dislocation

The shoulder is a complex, multi-directional ball-and-socket joint which allows movement in many directions. Shoulder instability and dislocation occur when the shoulder capsule is stretched or torn, and/or when the labrum is detached from the glenoid.
A scope and surgical instrument are inserted into the joint. The instrument will be used to reattach the labrum to the glenoid using suture and anchor-like devices.

Posted: 6/14/2011

Friday, 1 March 2013

Shoulder Dislocation / Shoulder Instability

Shoulder Dislocation / Shoulder Instability

Shoulder Dislocation / Shoulder Instability

What is Shoulder Dislocation / Shoulder Instability?

The shoulder (gleno-humeral joint) is a ball and socket joint and is the most mobile joint in the body. It is largely dependent on its surrounding soft tissues to hold it in place.  When the ball displaces out of the socket completely, this is called a dislocation. When the ball moves in the socket beyond its normal capacity, but doesn’t leave the socket, this is called shoulder instability. Dislocations tend to occur due to a trauma or maneuver that pushes the arm beyond its normal range of motion.

How long will it last?

If a true dislocation has occurred it will mean tissues of the shoulder have been torn or damaged and this may involve the ball (humeral head), the socket (the glenoid or the cartilage in the socket called the labrum), the ligaments or your rotator cuff. In a young person who wants to perform overhead or contact sports there is a high chance it will dislocate again and surgery may be considered. In an adult, there is less of a chance of re-dislocation and rehabilitation through physiotherapy will be beneficial to avoid surgery.


The symptoms of shoulder dislocation or ongoing shoulder instability are:
  • A sudden pop. The shoulder may relocate by itself and you feel another pop.
  • A sudden weakness in the arm or a ‘dead arm’. Pins and needles may also follow.
  • Apprehension with twisting your shoulder and fear that it may ‘pop’ out.
  • Weakness / pain with throwing.

Suggestions for managing Shoulder Dislocation and Shoulder Instability

  • If you are unsure if your shoulder is still dislocated contact us during business hours for advice and to make an appointment or call our after hours emergency number for instructions and immediate advice.
  • Taping from your physiotherapist or the use of a sling short term to improve your shoulder posture in the early stage and avoid re-dislocating.
  • Gentle exercises to strengthen the scapula (shoulder blade) muscles can commence after 3 days and gradually improving the strength of your rotator cuff muscles should commence early to avoid weakness.
  • If you have been injured at work or in sport, our practitioners have approved conditioning programs for your shoulder dislocation that will get you back on track sooner with your tailored exercise plan for you. Your physiotherapist may also recommend Massage Therapy or Acupuncture to assist in reducing pain and improving movement
  • Your practitioner may refer you to a Sports Physician for further investigations if your shoulder instability does not respond in our suggested time frames. Sometimes surgery is necessary for a functional recovery.
  • Resting your shoulder from all movements for 4-6 weeks is not recommended.

Rotator Cuff Injury

What is Rotator Cuff Injury?

The shoulder is at risk from injury in many activities. The rotator cuff can be injured through overuse or through trauma. Rotator cuff tendinopathy is common in overhead sports as well as any repeated manual tasks of reaching or lifting. Rotator cuff tears can occur if the tendons are overloaded with both repetitive tasks or a sudden movement. Occasionally a calcium deposit may form in the rotator cuff. We call this calcific tendinopathy.

The rotator cuff tendons are also susceptible to the process of aging. As we get older, the rotator cuff tendons degenerate and weaken. A rotator cuff tear can occur due to this degeneration alone, or when the weakened tendons are stressed during activities or accidents.

How long will it last?

Recovery from Rotator Cuff Injury depends on the severity of the injury. In most cases of rotator cuff pain, a conservative program of physiotherapy guided exercises and massage therapy or myotherapy will be suggested to help improve the pain associated with the injury. Your practitioner at The Sports Injury Clinic will recommend you see a Sports Physician or your GP for further investigation if pain persists for greater than 6 weeks from the start of treatment.


The symptoms of Rotator Cuff Injury are:
  • Pain or aching in the shoulder, often referring down the side of the arm. Pain may refer to the elbow.
  • Pain that is aggravated by lifting with an outstretched arm or twisting (hand behind back / putting on a seat belt / taking off a jumper).
  • Pain with laying on the shoulder at night.
  • Sometimes a catching or ‘arc’ of pain with lifting arm above head.
  • Weakness / heaviness in the arm with activities.

Suggestions for managing Rotator Cuff Injury

  • Staying active as advised by your physiotherapist and modification of how you use your arm. The practitioners at The Sports Injury Clinic will show you ways of improving how you can use your shoulder with advice and instruction. Keeping your shoulder back and your thumb pointing ‘up’ with lifting is a good start!  Click here for programs to assist with your Rotator Cuff Injury.
  • Taping from your physiotherapist to improve your shoulder posture in the early stage. This assists in teaching you how to use the correct muscles and assists in reducing pain in the rotator cuff.
  • Gentle exercises to strengthen the scapula (shoulder blade) muscles and gradually improving the strength of your rotator cuff muscles.
  • If you have been injured at Work or in Sport, our practitioners have approved conditioning programs that will get you back on track sooner with your tailored exercise plan for your rotator cuff injury. Your physiotherapist may also recommend Massage Therapy or acupuncture to assist in reducing pain and improving movement.
  • Your practitioner may refer you to a Sports Physician for further investigations if your rotator cuff injury does not respond in our suggested time frames.

Professional treatment options

Contact us now for immediate advice regarding Rotator cuff injury.

Can I heal my torn ROTATOR CUFF?

Uploaded on 10 Jun 2011
Chad Madden, Physical Therapist, discusses the potential healing of a torn rotator cuff.

Can A Rotator Cuff Tear heal by itself.mp4

Uploaded on 29 Jan 2010 If you have a rotator cuff tear, will it heal by itself? Will you be able to use your shoulder long term without any limitation? Find out more in this video. Free resources and further tips for pain relief at -

You will pay for it later, I'm speaking from a current condition of 3 tendon tears, chronic labrum and AC degeneration, tendinosis and osteophytes as a result of two moderate traumas in youth and early adulthood. If it's broke, get it fixed. YMMV, always get a second opinion before they slice and dice.

This guys an idiot, one of the first things he says in his video is wrong. First he said that the other three muscles rotate the arm internally then 5secs later saying the one muscle rotates the arm internally and the other three externally, haha cut the video after that, didn't even watch the rest.

Shoulder Rehab for Bodybuilders

Uploaded on 1 Nov 2010
The most common injury for a bodybuilder is a partial rotator cuff tear. In this video I show you how to nurse it back to health if you have injured it and if you dont have a rotator cuff problem, I show you how to keep it that way.

Bodybuilders make HORRIBLE patients when it comes to doing physical therapy rehabilitation exercises because we are used to pain.physical therapy.

my 9/13/2010 surgery - Scooby's Home Workouts

my 9/13/2010 surgery

My upcoming shoulder surgery is not related to weight lifting. I feel this is important to point out because one point I repeat time and time again is that good form is essential for preventing injury. It would look mighty stupid if I got an injury from lifting weights! I have lifted 5 days a week, 52 weeks a year since 1983 without a single weight lifting injury or accident. A very common injury from using bad form at the gym is a torn rotator cuff – I do NOT have that. People screw up their rotator cuff all the time from:
  • letting their elbows go behind the plane of their back (bench, mil prs, lat pulldowns, etc)
  • using too much weight on shoulder exercises (these are really small muscles)
  • using ballistic pushes at the bottom of the range of motion
  • doing reps too fast
  • bouncing
  • jerking
Again, I do not have a rotator cuff injury, you dont want one either. A full rotator cuff tear will not heal by itself and requires surgery (expensive) and 6 months of rehab before you get your life back. Lift carefully, do not destroy your shoulder with bad form!
What I have is chronic shoulder tendonitis caused by impingement. I have two bone spurs (bumps on my bones) that poke into the shoulder joint at inconvenient locations narrowing the space where the tendons are supposed to be. Every time I move my shoulder, the tendons have to squish by those bumps and each crunch/brush causes the tendon to get more inflamed. Not only does the inflammation cause pain but it causes swelling that makes it even harder (and more painful) for the tendons to slide around. What the surgery involves is grinding off those bone spurs which I am told is not as painful as it sounds.

The recovery should be significantly faster than for a rotator cuff tear but will still keep me away from heavy weights at least for 3 months. I will be a good patient and follow my surgeons recommendations to the tee, and even more important, I will listen to my physical therapist!
You can read more about injuries and how to prevent them if you want.

Shoulder Arthroscopy and Rotator Cuff Repair (Animation)

post operative - sling for 3 - 6 weeks, physio, and 6 to 12 months for full healing !!