Shoulder arthroscopy is a minimally invasive procedure for surgical treatment of conditions around the shoulder.
The purpose of the shoulder is to position the arm and hand in space. Although the shoulder is often referred to as a “ball and socket” joint, in reality, it more closely resembles a golf ball sitting on a tee. For this reason, the shoulder is the most mobile joint in the human body, allowing people to reach overhead, behind their back, across the body, and out to the side. This freedom of motion makes it possible to throw a ball, swing a golf club or tennis racket, get dressed, perform personal hygiene, or reach for something on a high shelf.
While the unique evolutionary morphology of the shoulder allows for this broad range of motion, this often comes at a price of: instability, soft tissue injuries, or degenerative joint disease of the shoulder.
At Palm Beach Hand to Shoulder, Dr. Veronica Diaz specializes in providing targeted care of the shoulder. Your consultation with her will involve establishing the cause of your symptoms or limitations. It will also include coming up with a tailored treatment plan that considers your activity demands and goals, the condition of your shoulder, and your general health status. To schedule a consultation, please call (561) 746-7686 or submit an online appointment request.
Shoulder arthroscopy is a minimally invasive procedure performed through several small incisions around the shoulder. The procedure uses a camera to visualize structures and special instruments to clean out, repair, or reconstruct injured or worn out parts.
Rotator Cuff Tears
Rotator cuff disease affects millions of people. The rotator cuff is important for providing stability and motion of the shoulder. It is comprised of four tendon-muscle units that wrap around (i.e. form a “cuff”) around the shoulder and allow movement of the shoulder. The spectrum of rotator cuff problems includes partial tears, complete tears amenable to repair, massive chronic tears that are no longer repairable, and rotator cuff tear arthritis. Symptoms of rotator cuff tears include:
Some rotator cuff tears occur after a distinct injury, but most rotator cuff tears are degenerative, meaning they develop gradually over time. Studies have shown that up to 50% of people over the age of 60, whether they have symptoms or not, have a rotator cuff tear. Additionally, over the course of 5 years, many tears that were not causing pain or perceived functional limitations could become symptomatic. The reason for this high incidence of rotator cuff tears is multifactorial. One main reason is that as we age, the blood supply to the rotator cuff tendons diminishes, so the tendon is not able to recover from the stresses and strains placed on it through every day activity. Certain patients have bone structure that can predispose to tears of the rotator cuff.
Dr. Diaz helps hundreds of patients a year achieve reduced pain and better shoulder function with arthroscopic rotator cuff repair. The goal of arthroscopic rotator cuff repair is to reattach the torn tendon to bone. This is accomplished through several small incisions around the shoulder and with special instruments that enable Dr. Diaz to insert “anchors” into bone, pass heavy rope-like suture through the torn tendon, and re-approximate the tendon to bone.
Not all rotator cuff tears merit surgical repair. Taken on a case-by-case basis, good results can be obtained in terms of pain relief and function with physical therapy, activity modification, and periodic follow up with Dr. Diaz to make sure the tear has not worsened.
For an animation of this procedure, please visit:
Subacromial Impingement (Bursitis)
The bony ceiling of the shoulder is a part of the shoulder blade or scapula called the acromion. There is wide variability in the shape of the acromion from one person to the next. Certain people are predisposed to inflammation in the space below the acromion (subacromial space) and above the rotator cuff. This often manifests as pain halfway down the arm that is provoked by reaching behind one’s back or above the head. Occupational or recreational pursuits that involve sustained eye-level or above motions can increase the risk of this condition, called impingement or bursitis.
If the acromion is prominent towards the front or side of the shoulder, this may predispose to impingement. Poor posture from muscle imbalance or from curvature of the spine as we age and lose bone mass can also increase the risk of this and other shoulder conditions. Most cases of subacromial impingement can be managed with a high quality physical therapy or physician-directed home exercise program. Some patients may benefit from a local injection to calm down the pain and inflammation. Other patients may benefit from an arthroscopic procedure to remove inflamed tissue and smooth out the undersurface of the bony prominence. This is especially true if there is a co-existing rotator cuff tear.
Shoulder Instability and Labral Injuries
A labral tear results when there is injury to the ring of tissue that surrounds the glenoid. This cartilage acts as a bumper to stabilize the humeral head (ball) in the center of the glenoid (socket) and prevent dislocation. It can be torn with traumatic dislocations or with overuse injuries such as overhead sports. Initial treatment may consist of rest and activity modification accompanied by strengthening of the shoulder. If a course of nonoperative management fails, then surgical intervention is considered.
Many overhead athletes or patients with early degenerative changes of the shoulder can develop painful tears of the top part of the labrum, called SLAP lesions. SLAP stands for superior labral anterior posterior, and refers to labral tears involving the origin of the biceps tendon. For patients under 35 with high athletic demands, repair of unstable SLAP tears
is sometimes warranted. In patients 40 and older, most superior labral tears are degenerative and if patients do not improve without surgery, are best managed with debridement and disconnecting of the biceps from the labrum with a biceps tenotomy (allowing the disconnected biceps to heal on its own with scar) or tenodesis (reattaching biceps to upper arm outside of shoulder with an implant).
Young patients with a shoulder dislocation or instability are susceptible to tears of the front and lower part of the labrum, called a Bankart lesion. If they plan on continuing to play sports where there is risk of their shoulder being forced out of socket (ex: participation in contact sports such as football, wrestling, or lacrosse, or other high risk activity such as surfing or wakeboarding), or if nonsurgical rehabilitation is unsuccessful, surgical repair is an option.
Adolescents or young patients engaged in activity that poses a high risk for recurrent instability often require a stabilization procedure for Bankart tears. First-time dislocators can often be treated with a period of immobilization followed by physical therapy to strengthen the stabilizing muscles of the shoulder and prevent reinjury. Shoulder surgeons consider the following factors when recommending surgical stabilization vs a trial of non-surgical treatment:
Shoulder dislocation and the treatment for it can result in premature arthritis. When the shoulder is treated with surgical stabilization, it may mean losing some degree of external rotation (rotation of the hand away from the body).
Biceps Tears and Tendinitis
One of the biceps tendons originates in the shoulder joint and travels between two of the rotator cuff tendons before passing into the front of the arm and connecting to the biceps muscle belly. The long head of the biceps can be a considerable source of pain in shoulder conditions. It is often seen in the presence of associated problems with the labrum and rotator cuff.
The acromiclavicular, or AC joint, is formed by the end of the clavicle (collar bone) and a part of the shoulder blade called the acromion (the bony “ceiliing” of the shoulder). This joint is small and experiences tremendous stress with forceful activity above eye level, resulting in early degeneration. Acromioclavicular arthritis results when there is loss of cartilage in this joint. Laborers and weightlifters tend to be at risk for symptoms of AC arthritis. AC joint arthritis is characterized by pain and swelling on the top of the shoulder. Pain from AC joint arthritis typically has exacerbations and remissions. Most people have symptoms while performing forceful overhead activity (overhead military press), reaching across their body, or sleeping on the affected shoulder.
If nonsurgical management fails, surgery may be an option. Surgical treatment of painful AC arthritis involves removing a small portion of the end of the clavicle to eliminate pain from bone rubbing on bone at the top of the shoulder. Dr. Diaz mostly performs this operation arthroscopically, which carries the advantage of a quicker recovery, less risk of destabilizing the end of the clavicle, and no incision over the top of the shoulder where it can be sensitive from contact with clothing (bra) or bag straps. Most patients can resume their pre-surgical level of activity and most athletics by 6 weeks. If distal clavicle resection is combined with a reconstructive procedure, the restrictions for that procedure (ex: rotator cuff or labral repair), informs the recovery time, restrictions, and rehabilitation.
The AC joint can be separated if one lands hard on the point of the shoulder. Cyclists and football players are particularly at risk for this kind of injury. Many of these injuries can heal without surgery and will yield full painless function, even if there is some deformity to the shoulder. Some patients have such severe displacement of the AC joint that an arthroscopically-assisted reconstruction of the ligaments that stabilize the AC joint is recommended.
In frozen shoulder, also known as adhesive capsulitis, the lining of the shoulder joint, called the capsule, becomes sequentially inflamed, thickened, and scarred. It most commonly affects people between the ages of 40 and 65, with women more commonly affected than men. Although frozen shoulder can be associated with a history of major trauma or prior shoulder surgery, many cases develop with no obvious cause. Risk factors for developing frozen shoulder include diabetes, thyroid disease, and Dupyutren disease.
Patients typically present with pain without prior injury, or with seemingly minor injury. Night pain is fairly common, as is difficulty with activities of daily living like brushing one’s hair or getting dressed. This pain is eventually accompanied by stiffness. Eventually, the pain quiets down and the shoulder “thaws” out, yielding recovery of motion. Getting to that point requires diligence with a stretching program, correction of any thyroid problems or tight control of diabetes, and patience.
The majority of patients with frozen shoulder will have successful treatment without surgery. Treatment for the reduction of symptoms from frozen shoulder may include physical therapy, oral anti-inflammatories, and injections of steroid +/- an injectable NSAID called toradol. Acupuncture has also been described, and meditation techniques and biofeedback may also be helpful. Adhering to a low inflammation diet that is high in fiber and eliminates sugar-laden and processed or packaged food can be helpful. In cases where recovery of motion is incomplete and recalcitrant to nonsurgical therapies, an arthroscopy of the shoulder for release of the scarred capsule combined with manipulation under anesthesia can yield improvement in pain and mobility.
The majority of cases resolve within 12-18 months, although some can take longer to show improvement. The shoulder community has not come up with a precise way to determine the length of disability from this condition. In patients with diabetes, frozen shoulder generally lasts longer and is more prone to recur. Frozen shoulder caused by trauma generally demands more intensive therapy and may not resolve on its own.
Shoulder injuries and dysfunction tend to be more common in people who perform repetitive overhead motion or weight bearing activities with their shoulders. People engaged in overhead or racket sports, throwing athletes, and athletes participating in contact sports are at a higher risk for sholder injuries. Many of the sports that are popular in South Florida can lead to shoulder pain, including baseball, volleyball, tennis, golf, surfing, stand up paddleboarding, swimming, water polo, and gymnastics. Patients who practice yoga and martial arts or participate in CrossFit or high intensity training are also susceptible to shoulder injuries. Shoulder injuries can affect athletes of all ages, including adolescent and collegiate athletes, professionals, weekend warriors, and the senior athlete.
Patients whose interests or occupations involve sustained above eye level activity or heavy lifting with their arms are also at risk. There is also a genetic predisposition to certain shoulder conditions, and many are linked to medical diagnoses. For example, patients with high cholesterol are considered to be at higher risk for rotator cuff disease. Similarly, diabetes, thyroid disease, and Dupuytren disease can all be risk factors for developing a frozen shoulder.
If you are having symptoms of shoulder pain, limited mobility, or weakness, consider scheduling a consultation with a shoulder specialist like Dr. Diaz.
If you are concerned about your shoulders and want to protect them, daily shoulder stretches and strengthening exercises as recommended by a physician may be helpful. These sorts of techniques are especially beneficial if you have a history of shoulder pain, as they can help prevent future injury. Consulting with a shoulder specialist before engaging in any new fitness or shoulder conditioning program can help avoid injury or worsening of existing symptoms. As a general rule, open chain exercises (ex: lifting free weights out to the sides) , strengthening that involves fast, uncontrolled, or jerky motions or excessive weight, or ramping up your exercise routine too rapidly can all lead to injury. Maintaining good posture and overall bone and joint health are also important for preventing shoulder pain and dysfunction. Adhering to a mostly plant-based diet that limits sugar and eliminates packaged, processed, or genetically modified foods, can also improve shoulder health and overall musculoskeletal health.
Check out the Shoulder Home Exercise Program (HEP) (opens in a new tab).
Because shoulder conditions affect each individual differently, please contact us at (561) 746-7686 or submit an online appointment request form to schedule a consultation with Dr. Diaz.
I get asked by almost every rotator cuff repair patient how soon after surgery they can drive. I tell them short familiar distances in a car with automatic transmission after their first post op visit at 2 weeks, but this advice was based on expert opinion alone and not a scientific study.
Now there is great news for patients having shoulder surgery for rotator cuff repair! that it is safe for patients to drive with a sling on as early as 2 weeks after rotator cuff surgery. The study measured driving performance in patients before and at different time points after rotator cuff surgery. The research team evaluated the patients' ability to park, turn, yield to oncoming traffic, make a U-turn, and merge onto the highway, among other measurements of 'driving fitness'. They found that rotator cuff surgery and the use of a sling did not negatively impact their driving ability as early as 2 weeks after surgery.
This finding should come as a great relief to patients who keep putting off rotator cuff surgery because of concerns over not being able to drive, patients who live alone or with someone who works or doesn't drive, as well as patients who live in areas lacking in robust public transportation infrastructure. It gives patients peace of mind to drive as early as two weeks after their surgery, and means they don't have to rely on someone else or incur transportation costs to attend in-person therapy.
Note: Patients should only drive if they feel comfortable doing so and only if they are not requiring prescription pain medication. It always helps to have another licensed driver in the passenger seat on the first attempt, in case one doesn't feel ready. It stands to reason that these findings apply to operating a vehicle with automatic transmission. Remember: safety is always first.
Many of my patients are rightly motivated to avoid or limit the use of opioids after shoulder surgery. Opioids have obviously led to a devastating addiction and overdose crisis in our society, not to mention the nasty side effects of nausea, vomiting, and constipation. In this video, , presents his group's research into the use of CBD in dissolvable form (to minimize loss of efficacy when metabolized by the gut when taken in swallowed form) after rotator cuff surgery. Patients who took CBD reported better pain control compared to those who were given a 'sugar pill' or placebo. CBD is a promising alternative to opioids for postoperative pain control.