Rotator Cuff

Do You Have Shoulder Instability?

Shoulder instability is caused when the head of the upper arm bone is forced out of the shoulder socket. Because the shoulder joint is the most mobile joint in our bodies, it is also the joint that is most frequently dislocated. Shoulder instability can develop in a variety of ways:

  • Shoulder InstabilityTrauma or injury, including labral tears and/or dislocations of the shoulder joint.
  • Repetitive motion injury, especially among athletes who would make the same overhead motions again and again, causing excessive wear and tear on the shoulder joint (as in baseball, tennis, swimming or volleyball
  • Genetic factors, which can cause general looseness in the joint and surrounding ligaments, tendons, and muscles, especially when the shoulder is put under strain or stress.

Common Symptoms of Shoulder Instability

  • Pain in shoulder caused by injury
  • Dislocated shoulders due to sports, vehicular, or other types of injury
  • History of shoulder “slipping” in and out of socket
  • Acquired shoulder laxity from repetitive activities such as throwing or swimming.

Diagnosing Shoulder Instability

Shoulder instability can be diagnosed with a careful and thorough physical examination. Imaging tests such as x –rays or a magnetic resonance imaging (MRI) help confirm the diagnosis and locate the exact area of injury. MRIs show the soft tissues a bit better than traditional x-rays.

Treatment of Shoulder Instability

Typically shoulder instability is treated with nonsurgical options. If non-operative treatments don’t relieve the pain and instability, surgery is often necessary. If surgery is required to treat shoulder instability, the goal should be to render the shoulder more stable without sacrificing motion. Whenever possible, minimally invasive surgery is done to repair shoulder instability. Minimally invasive arthroscopic surgery is generally less painful, less likely to cause complications, and enables a rapid early recovery process compared to traditional open surgery. Minimally invasive surgery does not require large dissections and splitting muscle layers; as a result the pain from shoulder stabilization surgery is decreased.

The surgery is carried out under general and regional anesthesia. A small fiber optic scope allows the physician to see inside the joint, and instruments are inserted through two small incisions in the joint to repair the ligaments and the labrum. Depending on the severity of the damage inside the shoulder, surgery may involve labral repair, ligament tightening or both.

Recovery from Shoulder Instability

If surgery is required, the patient may need to wear a sling for a few days or weeks. When the sling is removed, the patient will begin physical therapy. The exercises will improve the range of motion and gradually increase the strength in the shoulder. Physical therapy usually lasts 12-16 weeks.

About Spero Karas, M.D.

Dr. Spero Karas Dr. Karas joined the Emory Orthopaedic & Spine Center physician team in 2005. Dr. Karas is a recognized expert in the field of shoulder surgery, knee surgery, and sports medicine, and has been awarded numerous grants for research and product development. A frequent speaker throughout the United States and internationally, his work has been featured in Ski Magazine, Men’s Health, and on NBC, FOX, and CNN network television. He is also active in quality musculoskeletal research, and has been honored by his peers with nominations for numerous research awards. He actively collaborates with medical corporations by developing cutting-edge technology to improve the instruments and techniques in orthopedic surgery.

Dr. Karas received his undergraduate degree from the University of Notre Dame, and his Doctor of Medicine degree from Indiana University School of Medicine. After medical school, he completed a residency in Orthopedic Surgery at Duke University Medical Center. After residency, Dr. Karas completed a Knee, Shoulder, and Sports Medicine Fellowship at the prestigious Steadman Hawkins Clinic in Vail, Colorado. While in Colorado, he served as an Associate Team physician for the Denver Broncos and Colorado Rockies professional sports teams.

In addition his role as an Emory Sports Medicine Center physician, he currently serves as the head team physician for the Atlanta Falcons, a consulting team physician for Georgia Tech University, Emory University, Oglethorpe University, Georgia Perimeter College, and Lakeside High School. Prior to this, he served as chief of the Shoulder Service, team physician, and director of the Orthopaedic Sports Medicine Fellowship at the University of North Carolina at Chapel Hill Department of Orthopaedics. Dr. Karas was selected as one of America’s “Top Sports Medicine Specialists” in Men’s Health Magazine. He has also been named one of the “Top Sports Medicine Doctors for Women” by Women’s Health magazine, “Best Orthopaedic Surgeons in America” by Castle Connolly, and the most trusted sports specialist in Atlanta, Georgia by Atlanta Magazine.
Dr. Karas was a varsity letterman in wrestling at the University of Notre Dame and continues to participate in sports such as golf, skiing, snowboarding, and fitness training. He also coaches little league sports, and is an active member of his church and community. Dr. Karas and his wife, Johanna, are blessed with three very active and beautiful children – Gus, Elena, and Nicholas.

Understanding the Potential Benefits of Physical Therapy

National Physical Therapy MonthThe American Physical Therapy Association (APTA)’s National Physical Therapy Month (NPTM) is celebrated each October as a way to bring awareness around the potential health benefits to be sustained via physical therapy. Over 90% of back and neck problems, for example, will resolve themselves without surgery, and for some patients, there are unique benefits achieved from treatment by a physical therapist.

Physical therapy is a form of treatment—practiced by a licensed physical therapist under the referral of a physician. The purpose of physical therapy is to improve and/or restore mobility in patients for whom it is limited due to a medical condition, surgical procedure, accident or fall, neurological disease or other medical condition that has limited a patient’s functional mobility.  Often the injury limits the performance of everyday tasks.

Physical therapy programs at Emory Healthcare are available to support every type of mobility and functionality issue patients may experience. Whether a patient’s functional mobility issues relate to a neurological occurrence like a stroke, or an athletic injury like a torn ACL, our physical therapists available on both an inpatient and outpatient basis are here to help.

For more information on our physical therapy programs, including information on our department of Rehabilitation Medicine, please visit the links below.

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Why Your Rotator Cuff Matters More Than You Think – Part 2: Treatment & Prevention

Rotator Cuff pain

In part one of my rotator cuff blog series, I discussed how the rotator cuff works and what happens when it is injured. The good news is that many rotator cuff injuries can be treated with physical therapy alone, particularly if you seek care at Emory Sports Medicine at the first sign of an injury. So let’s now look at the treatment options available to you if you injure your rotator cuff, and how you can prevent a rotator cuff injury from occurring in the first place.

Rotator Cuff Treatment

Every rotator cuff injury has its own unique cause, its own particular damage, and its own best path to recovery. It’s like detective work, figuring out which rotator cuff muscles and tendons are causing the problem, whether the problem is weakness, stiffness or inappropriate mechanics, and then deciding which treatments will be most effective. At Emory Sports Medicine, we first want to figure out why you’re experiencing rotator cuff pain. Is your problem caused by an underdeveloped muscle or one that has poor flexibility? Are you moving with poor mechanics? Is an anatomical abnormality to blame?

Once we know what’s causing the problem, we create a custom physical therapy program that may include targeted strengthening exercises, stretches, manual therapy and reeducation of the muscle.

For example, if a patient comes to Emory Sports Medicine with a rotator cuff problem but he seems to have good strength in his shoulders, we may stand him in front of a mirror and ask him to raise his arms. Maybe we’ll notice that his whole shoulder is lifting up along with the arm, a “shoulder shrug.” If he’s just lifting his arm to wave at someone, it probably doesn’t matter, but when he applies force in that position – say pitching a baseball – he’s putting a lot of unnecessary strain on his rotator cuff. So we’ll work with him to reeducate his muscles, keeping his shoulders down and engaged correctly when he raises his arm. This approach often fixes bad mechanics and the problem goes away.

Rotator Cuff Injury Prevention

Of course the very best strategy is to prevent a rotator cuff injury from happening in the first place. Major league pitchers make rotator cuff training one of their top priorities in the off-season, not because they want to go around flexing their rotator cuff to impress people, but because they know they’ll have longer, more successful careers if they do. Any qualified coach, athletic trainer, or physical therapist should be able to guide you in developing a rotator cuff training program, and anyone at risk for rotator cuff injuries should strongly consider starting and sticking to such training.

Developing strong and flexible pectorals, deltoids, lats, biceps, triceps and other upper body muscles is all good, but if you want to put all that strength to good use, don’t neglect developing your rotator cuff. It matters more than you think.

Do you have questions or comments about rotator cuff injuries? If so, I welcome you to leave them for me in the comments section below.

Michael Biller is the director of physical therapy for Emory Physical Therapy’s Perimeter and Sugarloaf locations and currently treats patients at the Perimeter location. He graduated from the University of North Carolina at Chapel Hill with his physical therapy degree in 1992. He is a board certified clinical specialist in orthopedics and is a McKenzie credentialed practitioner. Biller is a guest lecturer on many topics, including the spine and extremities, and serves as a book reviewer for the Journal of Orthopedic & Sports Physical Therapy. He is also Emory Physical Therapy’s clinical coordinator for student education. He is married to his lovely bride, Rachel, who is also a physical therapist, and has two children. Biller enjoys getting outdoors on the weekends, especially to go mountain biking and hiking.

 

Why Your Rotator Cuff Matters More Than You Think – Part 1: How Your Rotator Cuff Works & What Happens When It Fails

Rotator Cuff painIt’s no surprise that the rotator cuff muscles are often ignored and rarely properly trained. A set of four relatively small muscles and tendons in the shoulder, their job is to keep the ball of the shoulder joint in place. That task may sound relatively simple, but consider the enormous forces that sometimes pass through our shoulders, putting serious strain on the little rotator cuff muscles. If they fail, a combination of pain, weakness and inefficient mechanics may prevent you from performing certain activities, limit your athletic pursuits or hurt your job performance.

The good news is that rotator cuff problems can often be prevented, and, if caught early, these injuries can often be treated with physical therapy alone. More serious rotator cuff injuries may require surgery. Our surgeons at Emory Sports Medicine are experts at performing rotator cuff surgery and getting you back to regular activity as soon as possible.

When The Rotator Cuff Fails…

Let’s back up and talk about what happens when your rotator cuff develops a problem. There are three stages of rotator cuff injury. The first stage is tendonitis, a simple inflammation of the rotator cuff, which can be painful but is relatively simple to treat. The second stage is tendinosis, in which the tendons of the rotator cuff start to degenerate. The third stage is a tear of the rotator cuff.

Tendonitis and tendinosis can usually be treated with physical therapy alone, with a high success rate. Very small tears may also be treatable with physical therapy, but generally a larger tear will require surgery to repair, followed by physical therapy to rebuild the rotator cuff and help prevent a future injury.

Signs of a Rotator Cuff Injury

The very best thing you can do to successfully treat a rotator cuff injury is to recognize it early and seek treatment promptly, hopefully before a tendonitis or tendinosis becomes a tear. Early treatment can mean the difference between physical therapy and surgery, and the difference between returning soon to the game or your work and an extended absence while recovering from surgery.

Early warning signs of a rotator cuff injury include:

  • Pain in your shoulder when you’re getting dressed, particularly when you are putting your shirt on or taking it off.
  • Pain in your shoulder when you’re reaching behind your body, such as to grab something out of the back seat of your car.
  • Pain when sleeping on your shoulder.

If any of these signs persist for more than a couple weeks, you should get your shoulder looked at promptly.

Signs of a more advanced rotator cuff injury include:

  • Weakness or a sense of instability in the shoulder.
  • “Night pain” in the shoulder: pain experienced when you are lying on your back and resting, pain that continues through the night.

If you have these symptoms, you should get your shoulder examined at Emory Sports Medicine right away. People over 50 who experience any of these symptoms are considered even more likely to have a rotator cuff injury.

So what are your treatment options if you injure your rotator cuff? And, more importantly, how can you prevent rotator cuff injuries from occurring in the first place? I’ll address those questions in part two of this post, so check back on the blog in about a week.

Michael Biller is the director of physical therapy for Emory Physical Therapy’s Perimeter and Sugarloaf locations and currently treats patients at the Perimeter location. He graduated from the University of North Carolina at Chapel Hill with his physical therapy degree in 1992. He is a board certified clinical specialist in orthopedics and is a McKenzie credentialed practitioner. Biller is a guest lecturer on many topics, including the spine and extremities, and serves as a book reviewer for the Journal of Orthopedic & Sports Physical Therapy. He is also Emory Physical Therapy’s clinical coordinator for student education. He is married to his lovely bride, Rachel, who is also a physical therapist, and has two children. Biller enjoys getting outdoors on the weekends, especially to go mountain biking and hiking.

 

Using -Skin- to Repair Your Rotator Cuff?

Dr. Spero KarasThe rotator cuff is the group of muscles and tendons that serve to stabilize the shoulder. The rotator cuff plays a key role in upper body mobility and ability when it comes to daily activities and athletic participation. Unfortunately, injuries to the rotator cuff, and specifically rotator cuff tears, are among the most common conditions affecting the shoulder.

Traditionally, surgeons have treated severe rotator cuff tears in one of three ways: simply removing dead and inflammatory tissue and bone spurs; transferring a tendon from another part of the body to the rotator cuff; or using freeze-dried human tissue or animal grafts to replace the missing tissue.

Unfortunately, in many cases, those rotator cuff tear treatments have been inadequate. Removing the inflammatory tissue and bone spurs certainly helps with the pain, but does nothing to improve motion. Transferring a tendon causes a lot of pain and trauma for patients who have to undergo surgery on two different sites on the body and, what is more, these extensive procedures may result in excessive complications.

As an alternative treatment for rotator cuff tears, I began using human skin grafts to perform a procedure called the “Bridge Technique.” In this procedure, the graft is surgically attached from the deficient tendon to the bone, forming a “bridge” over the empty space that once was a healthy tendon. Preliminary results in a study using human skin grafts to repair severe tears to the rotator cuff show that patients’ mobility is improved and pain is decreased.

In order to determine how the graft held up in 15 of my patients who were nearly a year or more out from having the procedure, I used Magnetic Resonance Imaging (MRI) and Ultrasound. In doing so, I found that in almost all of those patients, there was substantial healing of the graft and no complications related to the graft itself. Additionally, one year after the operation, patients had significant improvements in range of motion and a significant decrease in pain.

It’s very encouraging that in the evaluation of our early outcomes, nearly every one of our patients in this small series had favorable results, and their quality of life has improved. Using human tissue that has been properly processed for safety and durability has thus far provided a reliable option for patients who have had few alternatives for treatment.

Candidates for this procedure must be non-smokers with an irreparable rotator cuff tear, minimal arthritis, no joint dislocation and have less than 50% atrophy of their involved rotator cuff muscles.

I’ve included a video below that discusses the Bridge Technique and rotator cuff tear repair via skin grafts in more detail. Take a few minutes to check it out, and if you have questions for me, leave them in the comments below!

 

About Spero Karas, MD:

Dr. Karas joined the Emory Orthopaedic & Spine Center on February 1, 2005. Prior to that he served as chief of the Shoulder Service, team physician, and director of the Orthopaedic Sports Medicine Fellowship at the University of North Carolina at Chapel Hill Department of Orthopaedics. In addition to his role as director of the Orthopaedic Sports Medicine Fellowship Program at Emory, he serves as a consulting team physician for Georgia Tech and Emory University Athletics. Dr. Spero Karas is also an associate professor in the Department of Orthopaedics at Emory University School of Medicine and head team physician for the Atlanta Falcons.