My shoulder pops, I hear a click … why?

A shoulder that makes popping noise is a fairly common and is one of the most common questions I get asked on this site.

Since the shoulder joint is very complex, composed of several bone heads, coated with articular cartilage, with a joint capsule, and has got ligaments that reinforce it and several tendons which pass over it as a bridge, normally tissues move without friction because of the presence of what we call synovium, a smooth lubricated articular tissue, but this mechanism can generate a small effusion in articular or bursal space that can produce a phenomenon of ‘cavitation’ between the opposite surfaces which is perceptible as a snap, with sudden slight disjunction of articular surfaces covered by the viscous liquid in excess. Similarly, if any structure among those we have listed before also has a small lesion, simply due to repeated every day’s motions, or chronic repetitive stress sports, or to significant trauma, direct or indirect, by fall or accident, shoulder joint that normally has a working mechanism extremely well lubricated and accurate can instead begin to emit clicks, snaps, more or less noisy, accompanied by pain.

Therefore not necessarily the snap joint can be a pathological symptom.

 

I have to worry if the shoulder pops?

Normally the aging process makes in time less smooth, and even a little ‘rough, the opposite surfaces of the joint (humeral head and scapular glenoid surface, and, at the top, rotator cuff undersurface and the bottom surface of the acromial bone), and such a change can cause shoulder noise, which therefore requires no therapy until shoulder pain or joint limitation appear and a real degeneration of the inflamed tissue takes place.

In other cases, however, the joint noise can appear after a sports trauma or an accident, and can therefore be the indicator of a lesion which can be significant from the clinical point of view.

The following list of possible diseases related to the more or less sudden onset of a snap joint or the hearing of an articular ‘click’:

-if your shoulder had an accident and now you feel it slipping out of place (instability), this may be the cause of pop or ‘clicking’ in movement that you are hearing;

-if there is an small injury up to a full-thickness rotator cuff rupture, the torn edge of the cuff can snap and this can cause a ‘click’ during articulation movements;

-if the seal (‘labrum’) of shoulder is torn, this can cause a joint noise during movement and also during rest, in the changes of position;

-if there is a detached piece of articular cartilage (sometimes even with a piece of bone too: osteo chondrite) it can interfere in the articular range of motion when you don’t expect it and cause a snap or a click when pinched;

-if the snap joint is felt mainly at the top (and this is common), it can be frequently caused by the instability of the long head of the biceps (SLAP lesion);

-if the noise is felt mainly in the posterior part of the shoulder, it could be related to an alteration of the movements of the scapula on the chest (scapular dyskinesia).

-if the noise is felt mainly in the anterior region of the shoulder, it may be related to an arthritic alteration of the acromio-clavear joint.

In summary: in most cases a ‘snapping’ or clicking is not pathological.

If along with the noise you’re feeling pain in the shoulder or alteration of the movement or even if you are concerned by this noise, and certainly if the shoulder has become noisy after a trauma or an effort, a visit to an orthopedic specialist will be able to minimize your fears and tosolve your doubts.

Book a visit: 339.8694709.

 

I hurt my shoulder, do I have to put ice on it?

‘Ice or no ice: that is the question …’: that is, the acronym RICE (rest-ice-compression-elevation) of the classic protocol of the 70’s years is still valid?

Ice placed on the injured part determines temporary vasoconstriction and therefore reduces post-traumatic inflammation; but today we know that inflammation is in fact the first major event of the healing process. Dilatation of blood vessels as a result of trauma creates swelling and heat by increasing blood flow which leads cells, proteins and powerful chemical factors in the injured part: it initiates a cascade of reactions that we call inflammation, but that really is first part of the healing process of traumatic injury; therefore the use of ice is a symptomatic therapy that can bring temporary relief but which must not be abused because it can delay the healing process.

 

I have shoulder pain: why?

Shoulder pain is a frequent clinical situation for all ages but depending on the age group has different main causes. While young people are more easily subject to acute trauma, the shoulder of the adult typically has more chronic injuries from repeated trauma.

In young athletes there are more often injuries regarding the long head of the biceps (SLAP) and instability or dislocation of the shoulder (anterior, posterior or multidirectional lesions of the seal of the joint, called labrum, complicated or not with bone detachments, and variously extended). Those who practice throwing sports, volleyball and swimming may also suffer from chronic repeated trauma injuries of the tendons of the rotator cuff and shoulder muscles.

The most common causes of shoulder pain in the older people are related to the articular degeneration due to the normal daily use of the joint and not necessarily to efforts or trauma, and include:

tendonitis of the shoulder by overloading;

degenerative tendinosis;

distractions of rotator cuff;

lesions of the rotator cuff;

frozen shoulder;

shoulder dislocation or instability;

rotator cuff injury concomitant to arthritis;

calcific tendinitis of the rotator cuff;

tendinitis of the long head of the biceps.

If you’ve had an injury and your pain lasts more than two or three days, or if it gets worse, talk to your orthopedic. Many patients with shoulder pain have difficulty in sleeping at night, and therefore will go to the specialist after a shorter time.

Book your visit: 339.8694709.

What is following is a personal guide line for the treatment of lesions of the rotator cuff, shoulder instability and acromioclavicular pathology; if you know you have one of these conditions, you can also enter the discussion group on the rotator cuff, or the panel discussion on the shoulder dislocation, or the panel discussion on acromioclavicular disease.

 

What are the rotator cuff and the impingement syndrome?

The rotator cuff is a group of four tendons (the tendon of the subscapularis muscle, and the tendons of the supraspinatus, infraspinatus and teres minor) that are the main engines of shoulder movement. In addition to the role of starter of joint movement, the integrity and the contraction of the rotator cuff keeps the humeral head centered on the glenoid of the scapula, and prevents the upward migration of the humerus when you raise your arm and also at rest.

The impingement syndrome is a common cause of shoulder pain. Its hallmark is a pain that radiates to the arm and is aggravated by lifting objects or by applying resistance to the elevation of the arm. The two most common explanations of the conflict are:

1) the acromion (upper lateral part of the scapula) deforms developing bony protrusions that from its bottom surface projecting downwards and in this way reduce the space for the tendon of supraspinatus;

2) similarly, the coracoid (anterior superior part of the scapula) deforms developing bony protrusions that are projected from its surface back and forth in this way reduce the space for the tendon of the subscapularis;

3) repeated trauma of the supraspinatus tendon when striking against the acromion with arm raised above 90 ° determine the lesion.

All of these situations can cause pain and inflammation in the shoulder with initial lesion of the tendon involved, which can develop into progressive lesion of the rotator cuff.

Initially the treatment is conservative: a few inflitrations of the shoulder and rehabilitation is often sufficient, but you have to rule out other causes of shoulder pain, as small lesion of the rotator cuff (traumatic or degenerative), already present but not yet symptomatic. If the patient does not respond to conservative care, you can give an indication for surgical care, which consists in arthroscopic acromioplasty (or, in the case of the subscapularis, coracoplasty), resecting bone with a motorized burr and creating more space for the humeral head under the so-called time acromioclavicular arch and allowing elevation of the arm without pain.

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What is frozen shoulder (adhesive capsulitis)?

It is an inflammatory condition of the capsular tissue that tends to solve spontaneously, and that results in a syndrome characterized by onset of shoulder pain and progressive stiffness; normally, the start is slow with symptoms that can appear without previous trauma. The attempts to mobilize the shoulder in any direction evoke acute pain due to a reduction of capsular volume supporting rigidity. Normally, this condition occurs in people between 40 and 60 years, often with diabetes or thyroid problems, and especially women. Classically, three phases are described: early, mainly shoulder pain with initial stiffness; subsequently, prevailing rigidity with reduction of pain; finally, progressive functional recovery with complete healing and disappearance of symptoms. Although it is a disease that tends to a slow spontaneous resolution frozen shoulder is very disabling, as it can last up to 24-36 months, although the patient controls pain by submitting to various conservative therapies.

Clinical diagnosis must rule out other disorders with similar manifestations and must be supported by the performance of the normal protocol for radiological shoulder and an MRI that, if done with contrast liquid, allows to appreciate the presence of reduced joint volume, indirect sign of adhesive capsulitis.

In real cases of frozen shoulder treatment is initially and prevalently conservative, as already mentioned. Injections of anti-inflammatory drugs can help to control the pain in the first stage of the disease. In rare cases, rebels to rehabilitative therapy, you can proceed to a treatment of shoulder arthroscopy, which provides the improvement of range of motion by the section, sometimes almost circumferential, of the capsule with instruments of radio frequency, but the results of this intervention are often temporary, and therefore, since the spontaneous recovery is the norm, the adoption of this surgical procedure is extremely limited.

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What is rotator cuff injury?

The lesion of the rotator cuff is a lesion of the continuity of one or more of the four tendons of the rotator cuff and can be degenerative (frequently in older people) or resulting from trauma. The tendon more likely involved is the supraspinatus and the symptoms that the patient experiences are severe pain with more or less acute functional limitation. These tendon injuries may occur as an avulsion of the supraspinatus tendon from his bone insertion (mainly degenerative lesions) or as an intratendinous  break (traumatic): anyway, they do not heal spontaneously.

After an initial phase during which medical therapy, physiotherapy and steroid injections can relieve symptoms, once the lesion in established and documented (with X-ray protocol and MRI), the patient should know that the natural evolution of these lesions is their progressive enlargement up to the point of engaging the other cuff tendons. Recent studies have shown that untreated injuries of the rotator cuff lead to a progression of the lesion until they result in the appearance of degenerative arthritis changes within four years.

Both in Europe and in the United States there is general consensus in the rotator cuff repair using techniques as less invasive as possible, and therefore I do not use anymore open and ‘mini-open’ techniques but arthroscopy, which allows to the repair the lesion of rotator cuff and also to treat in the same operative session all the possible pathologies associated using the same small incisions and with significant reduction of postoperative complications.

Book your visit: 339. 8694709.

 

What is the instability of the long biceps head tendon?

The instability of the biceps tendon is a condition in which the stabilizing means of the long head of the biceps tendon, represented by the ligaments that hold it in suspension along the bicipital groove, have one or more lesions, usually traumatic. This instability consists of a pop and a painful palpation tenderness in the anterior portion of the shoulder: it is present in 49% of patients with a rotator cuff injury, and it’s the most common cause of ‘clicks’ into the shoulder.

The treatment involves arthroscopic biceps tenodesis at the inferior part of the groove or its tenotomy at the basis of its intertion onto the superior portion of the glenoid cavity, and can be is carried out if necessary during treatment of associated diseases.

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What is the glenohumeral eccentric secondary osteoarthritis, or Cuff Tear Arthropathy?

This particular form of glenohumeral arthritis is due to the absence of functional rotator cuff: in patients with irreparable rotator cuff injury, the occurrence or aggravation of pain and the sudden total inability of shoulder movement (so-called pseudo paralysis of the shoulder) is expression of the collapse of the last fibers of tendons that were still present and operating (normally the lower portion of the subscapularis and of infraspinatus), resulting in immediate prevalence of elevation action exerted by the deltoid muscle on the arm, what causes ascent of the head of the humerus upwards and places it in mechanical conflict with the lower surface of the acromion. This mechanical conflict determines the progressive deformity of the two bones in mutual friction.

The treatment is exclusively surgical, and is achieved using the system of the so-called reverse shoulder arthroplasty, a solution that brings medially the center of rotation of the articulation allowing the biceps fibers to be used as the motor of the shoulder in elevation and rotations of the arm.

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What is a dislocated shoulder?

The dislocation of the shoulder is a sudden and painful loss of articular relationship between the head of the humerus and the joint surface of the shoulder blade (glenoid), generally due to a trauma. The glenohumeral joint can be represented as the mechanical correlation between an hemispherical surface (the humeral head) with a quarter of a sphere (the glenoid cavity), and as one can easily guess it is an highly mobile but unstable joint, made more congruent by capsule and ligaments that act as a reinforcement (the so-called capsular complex); when a trauma occurs the labrum may break compromising the stability of the system and creating an escape for the head of the humerus. Once reduced the dislocation with orthopedic atraumatic maneuvers, the anatomical lesion remaining causes post-traumatic shoulder instability (and supports the recurrent dislocation).

Therefore, after immediate manual treatment of the dislocation and following immobilization for 30 days with Itoi tutor sling (in extra rotation of about 10 °) and further appropriate period of rehabilitation therapy, if the shoulder is still felt unstable by the patient, we must confirm the diagnosis by documenting the lesion of the labrum (radiological xray protocol and MR with liquid enhancement) in order to proceed to surgical arthroscopical treatment.

Such a treatment consists of reduction and stabilization of the lesion with absorbable anchors, and it is performed through small incisions in the skin and with the use of disposable cannulas. After surgery the patient will wear and use for about a month a postop sling in slight abduction allowing the mobilization of the elbow and wrist without disturbing the shoulder; the subsequent treatment consists  of functional rehabilitation of the joint and the restoring of the athletic action in the case of sportsmen.

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What are the long-term consequences of a shoulder instability if untreated?

Patients who have had several dislocation of the shoulder not treated surgically or have had relapse after surgery may present:

weak or absent labrum

stretched capsular ligaments

deformity of both glenoid cavity and humeral head

early osteoarthritis of the shoulder

As long as joint injuries are capsule-labral, the arthroscopic option is viable and limitations of this are represented on the judgment and experience of the orthopedic specialist (arthroscopic repair). When, however, in a young person remarkable damages of the joint are detected (with MR and 3dTCscan), the surgical transfer of the coracoid process according Latarjet solves the problem by acting as a reinforcement of the glenoid bone and as a safety tendon sling in active opposition to shoulder dislocation.

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What are the most common diseases of the acromion-clavicular articulation?

The most common diseases are dislocation, iuxta-articular distal clavicle fractures and osteoarthriti.

Dislocation is traumatic, and may be more or less severe depending on the involvement of the joint capsule including its small meniscus, and conoid and trapezoid ligaments that keep the coracoid close to the clavicle.

When the dislocation is partial it can be treated with functional rest using a specific sling (Dennis Howard) for one month with subsequent functional rehabilitation. If the dislocation is more serious the choice treatment is arthroscopy stabilization (dogbone technique) or, in chronic cases, mplantation of an artificial ligament under the coracoid properly fixed to the clavicle, with a sling to be used for one month.

Similarly, the fracture of the clavicle (the distal end of the clavicle) can be treated with arthroscopic stabilization similar to the one above descripted (in this case, tight-rope technique), with no need to touch directly the distal fragment clavicle. After surgery, it is recommended functional rest in a slight abduction brace for one month.

Osteoarthritis acromionclaveare, documented with X-rays and magnetic resonance imaging, can be also treated electively, when symptomatic, through specific arthroscopic portals using a drill of small diameter, without damaging ligaments (conoid and trapezoid). After surgery, it is recommended functional rest in slight abduction brace for 15 days.

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What is omoarthrosis, or concentric osteoarthritis of the shoulder?

Osteoarthritis of the shoulder is a disease characterized by the progressive loss of articular cartilage and formation of osteophytes, bone tree-like structures that branch from the joint surfaces. The function of articular cartilage is to allow joint movement, smooth and painless, so its gradual loss characterizing the process of arthritic degeneration of the joint leads the onset of symptoms that include pain and joint stiffness. Osteoarthritis of the shoulder is the typical outcome of traumatic fractures of the humeral head, the result of multiple chronic shoulder dislocations and common in people employed in heavy manual work, as well as in sports activity at a high level, especially in contact sports.

In the early stages of the deformities which are typical of osteoarthritis medical therapy with anti-inflammatory and physical therapy, together with articular injection of steroids, may be of some benefit to the patient; but in advanced stages of arthritis, total or partial shoulder prosthesis (in younger athletes the latter) is the treatment of choice, and consists of the resection of the articulating surfaces and osteophytes, careful dissection of the capsule respecting as much as possible the rotator cuff if still in good condition.

In the case where the rotator cuff, despite a prevailing concentricity of arthritis, does not give sufficient guarantee of functionality, the option of the reverse prosthesis is to be kept in mind, often despite the patient’s age.

Book your visit: 339. 8694709.

 

What is the suprascapular nerve entrapment syndrome?

This syndrome consists of shoulder pain, mostly in the back, associated with scapular dyskinesia and evident weakness of supra and infraspinatus, as an effect of the neurological sufference: the suprascapular nerve, innervating both of the two muscles, when entering the groove above scapula or where it comes out of that can be compressed by the thickening or calcification of the transverse scapular ligament. Alternatively, arthrogen cysts often departing from the back of the joint labrum can grow with valve mechanism and extend up to the area where suprascapular nerve runs.

To formulate a diagnosis of suprascapular nerve entrapment, electromyography shall document the presence of any abnormalities of electrical conduction of the nerve, and x-ray protocol of the shoulder, always necessary, together with MR will verify the possible presence of cysts.

When the diagnosis is established, and the use of local infiltrative therapy with corticosteroid does not give a positive result, nerve decompression may be done via the arthroscopical transverse scapular ligament dissection or, in the case of the presence of cysts, with ablation of cyst and repair of the injury of posterior labrum.

Subsequently, a two-week period of rest in a slight abduction sling will precede functional rehabilitation.

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What are the infiltration of steroids?

The infiltration of the shoulder is carried out with steroids para-articular injection: steroids are a group of drugs derived from squalene which have an analgesic (pain relief) and anti-inflammatory effects. Their use is indicated when the action of NSAIDs assumption does not alleviate the inflammatory state. The abuse of anti-inflammatory steroids, however, can weaken tendons over time: as in all things, skillfulness and common sense must guide decision making (“est modus in rebus”).

 

What can I expect after surgery?

Surgical procedure may be performed in outpatient hospital or week hospital depending on the pathology. Before being transferred to the operating room the patient will be given a broad-spectrum antibiotic to reduce the risk of surgical infections. A catheter for the infusion of painkiller drugs will be applied to facilitate the control of pain after surgery. Shoulder surgery can be performed under general anesthesia (mainly in trauma surgery and prosthetic implant surgery) or regional plexus anesthesia (arthroscopic surgery) according to anesthesiologist decisions. Depending on the problem to be resolved, you may need implant of non absorbable or bio-resorbable anchors to achieve the surgical solution of your problem.

 

What can I expect after surgery?

After shoulder arthroscopy, during the very first hours, the shoulder will appear significantly swollen and bigger than the contralateral, but after five to six hours swelling will decline rapidly: it is normally due to the use, during surgery, of a pump which keeps the intraarticular intra-articular stable in order to control any bleeding and maintain a good joint space and a clear vision on the video to allow the surgeon to conduct the operation intervention in the safest way. The infusion liquid in the articular space comes out from small arthroscopic wounds, and in greate part is absorbed and filtered by the kidneys.

As already mentioned above, depending on the surgical operation to which you’ll be subjected there will be need to use a sling in slight or medium abduction for a period from two to five weeks. The removal of the arthroscopical or surgical stitches is carried out between 10 and 14 days after surgery. You will be given a post surgical rehabilitation protocol that you will deliver to your chosen physiotherapist.

Book your visit: 339. 8694709.