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Adhesive capsulitis, or frozen shoulder, is a common but poorly understood condition that can affect the shoulder in a variety of patients. Its name suggests the fact that the shoulder looses range of motion, and deep pain is a common component of this troublesome malady.

Cause 
Very frequently, the condition develops because of trauma to the shoulder, which can include prior surgical intervention; however, many patients develop this condition spontaneously for unknown reasons. It is commonly seen in older women as well as patients with certain metabolic conditions including diabetes, thyroid hormone imbalances, and even Parkinson’s disease. While the causes are not well understood, the pathology is typically characterized by thickening of the joint capsule. This thickening leads to a loss in tissue mobility and consequently inhibits the shoulder range of motion.

Three stages Adhesive capsulitis generally presents in a series of three stages. The first is a painful stage where deep persistent pain develops and often does not allow the patient to sleep well. The range of motion is not affected until the second stage, known as the freezing stage. In this stage, the shoulder loses a significant amount of its motion capability. In the third stage, known as the thawing stage, the patient begins to incrementally regain much of the range of motion, but during this stage pain can reappear.

Conservative Treatment 
While many patients go through all stages, and eventually regain a near normal range of motion, it is important to monitor the progress and be ready to intervene because some of this motion loss can be permanent. This is particularly true in patients who have had a fracture or a surgical procedure so that capsulitis does not limit the return of function. Frequently, this cascade of events worsens and then resolves within a one to two year period. During that time, anti-inflammatories or a corticosteroid injection in the shoulder joint can offer some relief. Corticosteroid injections can be detrimental to normal tissues in the long run, though, and should be used sparingly. Particular exercises instituted by a physical or occupational therapist are crucial in order to maintain range of motion and stimulate recovery.

Surgical Options 
When the range of motion does not respond to conservative measures and pain magnifies, surgical treatment may be indicated. Traditional treatment involves manipulating the shoulder while under an anesthetic, which can lead to an improvement in motion that might only be temporary. The reason is that manipulation itself can cause tearing of the soft tissue structures that often heal by forming additional scar tissue. Therefore, it is best to perform manipulation in conjunction with an arthroscopic procedure where the tissues are released during the surgery (arthroscopic capsulectomy), which limits the scarring. This is a minimally invasive procedure where a tiny camera is inserted into the joint so that the joint capsule can be visualized from the inside, allowing the release of the tissue using either mechanical instruments or even radiofrequency probes in a traumatic fashion.

After Surgery 
Once motion is restored, it is important to maintain it. Maintaining motion may include the use of a continuous passive motion (CPM) machine, which the patient will often use at home. Therapy begins within a few days after surgery.

Deep persistant pain in the shoulder can affect young and old alike. The causes, however, can be very different and require a thorough diagnostic process to understand the underlying problem and lead to a solution. Young, active patients often feel that there is an overuse syndrome. This may be the case, but it is important to understand why. Current exercise regimens usually emphasize strengthening the deltoid muscles, but the rotator cuff is largely ignored. This leads to an instability syndrome that can cause pain and even worse, a mechanical deficiency of the shoulder joint. If this is a chronic problem, with no history of a single traumatic event, the patient will usually respond to a strengthening therapy protocol that requires diligence on the part of the patient and therapist.

The most common cause of shoulder pain in older people is known as impingement syndrome. Bursitis is often an element of this syndrome and this frequently used term is much more accurate in depicting the problem than the term “arthritis”. Impingement refers to the mechanical process where the overlying bony arch of the shoulder (acromion of scapula and clavicle) is pressing on or rubbing on the underlying rotator cuff tendons and bursa. With age, the blood supply to the rotator cuff is diminished, and small microtears in the tendon leads to tendonitis and bursitis and even larger tears. This situation may respond to conservative treatment including a cortisone injection to reduce the bursitis, and shoulder therapy to improve the strength of the intact rotator cuff.

What does it imply to have a complete rotator cuff tear?

A complete rotator cuff tear implies that the torn tendon has pulled away from the bone and hence, cannot stabilize the head of the humerus against its cup joint (glenoid). The patient will either be unable to physically raise the arm or they can do this only with severe pain. This whole range of impingement problems is characterized by pain with elevation of the arm, pain worse at night, and inability to lie on the side of the affected shoulder. Once the pain is severe enough and does not respond to therapy and other conservative means, then surgery is indicated. Some smaller tears can be repaired through arthroscopic means, but larger tears are usually repaired through a traditional incision. Most repairs require a one month period of immobilization in a sling and several months of post-operative therapy closely directed by the surgeon. Local Barbadian, Karen Meakins, managed to win her 12th straight squash national singles title barely 6 months after similar arthroscopic rotator cuff repair, and then went on to take 4th in the world masters championship !! Many other citizens of Barbados also had arthroscopic rotator cuff repairs by Dr. Badia including local prominent physicians and community leaders. Shoulder pain should not be ignored and requires appropriate diagnostic studies and examination by a shoulder specialist. Dr. Alejandro Badia, Hand & Wrist Surgeon Miami, FL

By Alejandro Badia, M.D.Frozen shoulder, or adhesive capsulitis, is a common but poorly understood condition that can affect the shoulder in a variety of patients. Its name suggests the fact that the shoulder loses range of motion, and deep pain is a common component of this troublesome malady. Very frequently, the condition develops because of trauma to the shoulder, which includes prior surgical intervention; however, many patients development this condition spontaneously for unknown reasons. It is commonly seen in older woman as well as patients with certain metabolic conditions including diabetes (see also “Common Hand Problems in Diabetics“), thyroid hormone imbalances, and even Parkinson’s disease. Read the full article on this page that discusses the three stages and learn why therapy is crucial for this…

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The Painful Shoulder

Deep persistant pain in the shoulder can affect young and old alike. The causes, however, can be very different and require a thorough diagnostic process to understand the underlying problem and lead to a solution. 

Young, active patients often feel that there is an overuse syndrome. This may be the case, but it is important to understand why. Current exercise regimens usually emphasize strengthening the deltoid muscles, but the rotator cuff is largely ignored. This leads to an instability syndrome that can cause pain and even worse, a mechanical deficiency of the shoulder joint. If this is a chronic problem, with no history of a single traumatic event, the patient will usually respond to a strengthening therapy protocol that requires diligence on the part of the patient and therapist. 

An acute injury, such as fall or impact on the raised arm, may lead to a discrete anatomic injury that may require repair. Because of this, it is critical to make a diagnosis and this is often dictated by the patient’s history of the problem. When acute injury leads to persistant pain, we often order an MRI which is a diagnostic study that best looks at the soft tissue structures deep in the shoulder. A plain xray only looks at the bony structures and is usually normal in people with painful shoulder syndromes. The MRI can often indicate the severity of the soft tissue injury and can dictate whether continued conservative treatment (anti-inflammatories, cortisone injection, and therapy) or surgical intervention is warranted. A true anatomic disruption, such as a torn cartilage rim or tendon rupture, will usually not get better on its own hence a mechanical solution may be necessary. In today’s modern age of medicine, we can fortunately solve many of these problems through arthroscopic surgery. This means that the joint is visualized through a small camera inserted through tiny holes in the skin outside the joint. This minimizes scarring, improves the surgeon’s visualization of the problem, and speeds the recovery. In certain cases, an open incision may be required depending on the severity and location of the problem. 

Older patients often attribute their shoulder pain to “arthritis”. In fact, arthritis in the shoulder joint (particularly the ball and cup joint) is rather rare. Arthritis is when there is loss of cartilage in a joint and can lead to bone grinding against bone. This osteoarthritis condition is more commonly seen in the knee, hip or even the base of the thumb, but much less so in the shoulder. 
The most common cause of shoulder pain in older people is known as impingement syndrome. Bursitis is often an element of this syndrome and this frequently used term is much more accurate in depicting the problem than the term “arthritis”. Impingement refers to the mechanical process where the overlying bony arch of the shoulder (acromion of scapula and clavicle) is pressing on or rubbing on the underlying rotator cuff tendons and bursa. With age, the blood supply to the rotator cuff is diminished, and small microtears in the tendon leads to tendonitis and bursitis and even larger tears. This situation may respond to conservative treatment including a cortisone injection to reduce the bursitis, and shoulder therapy to improve the strength of the intact rotator cuff. A complete rotator cuff tear implies that the torn tendon has pulled away from the bone and hence, cannot stabilize the head of the humerus against its cup joint (glenoid). The patient will either be unable to physically raise the arm or they can do this only with severe pain. This whole range of impingement problems is characterized by pain with elevation of the arm, pain worse at night, and inability to lie on the side of the affected shoulder. 

Once the pain is severe enough and does not respond to therapy and other conservative means, then surgery is indicated. Some smaller tears can be repaired through arthroscopic means, but larger tears are usually repaired through a traditional incision. Most repairs require a one month period of immobilization in a sling and several months of postoperative therapy closely directed by the surgeon. The shoulder is a demanding joint and requires patience on the part of both patient and treating surgeon. The recovery is usually not rapid, but diligent adherence to the therapy protocol will in most cases yield a good result and a functional shoulder with minimal or no pain.

Alejandro Badia, MD Upper Extremity Surgeon Miami Hand Center

 

With great joy Karen Meakins recently wrote Dr. Alejandro Badia, to let him know of her recent athletic achievements. Karen won her 12th National Title, a record for this sport. This amateur athlete and squash coach from Barbados suffered from a partially torn shoulder tendon that prevented her from playing. On October of 2011 she decided to get it corrected after her local physician recommended she see Dr. Alejandro Badia, upper body orthopedic surgeon in Miami. After the procedure she had intense occupational therapy for 3 months followed by gym work with a trainer. She says the success of the procedure has resulted in her being able to get back to competitive squash. Karen is grateful for Dr. Badia’s surgical skills and for his open communication style. His habit of returning emails promptly and answering her questions has given her tremendous comfort during the recuperation stages. She tells us “I think I am very lucky because I had a great surgeon, a great therapist and a great trainer. I am back to 90% mobility right now and my shoulder is stronger than it has ever been because of all the hard work in the gym. I plan to play in the World Masters in July which was always my goal post surgery. I wasn’t sure even 2 weeks ago that I would be ready to play but I am extremely satisfied with where my shoulder is right now so I have decided to enter.” Go team Karen!

Please call (305) 227-4263 to request an appointment with Dr. Alejandro Badia.

Read also: Thumb arthritis is the most common form of osteoarthritis affecting the hand

Deep persistent pain in the shoulder can affect young and old alike. The causes, however, can be very different and require a thorough diagnostic process to understand the underlying problem and lead to a solution.

Young active patients often feel that shoulder pain stems from overuse. This may be the case, but it is important to understand why. Current exercise regiments usually emphasize strengthening the deltoid muscles, but the rotator cuff is largely ignored. This leads to an instability syndrome that can cause pain and even worse, a mechanical deficiency of the shoulder joint. If the pain is a chronic problem, with no history of a single traumatic event, the patient will usually respond to strengthening therapy. This therapy will require diligence from the patient and the therapist.

An acute injury, such as a fall or an impact on a raised arm, may lead to a discrete injury that could require repair. When an acute injury leads to persistent pain, we often order an MRI, which is a diagnostic tool that examines the soft tissue deep in the shoulder. An ordinary x-ray examines bony structures, and often displays as normal in people with painful shoulder symptoms. The MRI can often indicate the severity of the soft tissue injury and can dictate whether continued conservative treatment (anti-inflammatories, corticosteroid injections, and therapy) is required, or if surgical intervention is warranted. A torn cartilage rim or tendon rupture will usually not get better on its own; hence a mechanical solution may be necessary. In today’s modern age of medicine, we can solve many of these problems through arthroscopic surgery. This procedure allows the joint to be visualized with a small camera inserted through tiny holes in the skin outside the joint. This procedure minimizes scarring, improves the surgeon’s visualization of the problem, and speeds the recovery. In certain cases, an open incision may be required depending on the severity and location of the problem.

Older patients often attribute their shoulder pain to “arthritis”. In fact, arthritis in the shoulder joint (particularly the ball and cup joint) is rather rare. Arthritis is the loss of cartilage in a joint that leads to bone grinding against bone. This osteoarthritis condition is more commonly seen in the knee, hip, or even the base of the thumb, but is much less common in the shoulder.

The most common cause of shoulder pain in older people is known as impingement syndrome. Bursitis is often an element of this syndrome, and this frequently used term is much more accurate in depicting the problem than the term “arthritis’. Impingement is the mechanical process of the overlying bony arch of the shoulder (acromion of scapula and clavicle) pressing on or rubbing on the underlying rotator cuff tendons and bursa. With age, the blood supply to the rotator cuff is diminished, and small micro-tears in the tendon leads to tendinitis, or bursitis, or even larger tears. This situation may respond to conservative treatment of a corticosteroid injection to reduce the bursitis, or therapy to improve the strength of the intact rotator cuff. A complete tear in the rotator cuff implies that the torn tendon has pulled away from the bone; in this case, the patient will either be physically unable to raise the arm or will experience severe pain when the arm is raised. Impingement syndrome is characterized by pain when the arm is elevated, pain that is worse at night, and inability to lie on the side of the affected shoulder.

Once the pain is severe enough and does not respond to therapy and other conservative means, surgery is indicated. Most repairs require a one month period of immobilization in a sling and several months of post-operative therapy closely directed by the surgeon. The shoulder is a demanding joint and requires patience on the part of both patient and treating surgeon. The recovery is usually not rapid, but diligent adherence to the therapy protocol will in most cases yield a good result and a functional shoulder with minimal or no pain. The key to treating shoulder pain is to seek the appropriate specialist and undergo a thorough physical examination of the shoulder with the indicated studies ordered by that surgeon. Therapy often plays a major role in the recovery of this particular joint and arthroscopic techniques allow a faster, minimally painful recovery if surgical repair is indicated.

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