For this section, I want you to remember our discussion regarding the importance of coordination for your shoulder to function. As we discussed in the introduction section, the rotator cuff muscles are a set of four muscles that act together to produce a stable pivot point for larger shoulder movements in addition to providing rotation of your arm. These muscles act in force couples. This means the function of one is essential for the remaining muscles to act. Think of four people holding hands in a square and leaning back. If all of them keep holding on, they will lean back safely and not fall because they are all holding each other up. If someone lets go, they all fall down because the chain is broken. So it goes with the shoulder. When there is an injury to a rotator cuff tendon in the shoulder (can be a different structure, too), this linkage is broken, and the balance is lost or changes. There are many, many muscles responsible for the shoulder complex to move. These muscles must now compensate and work in a different way than they were intended. This leads to different movement patterns when you try to move your arm above your head, behind you, and up from your side. If these movement patterns change, the bony structures come in close contact with the rotator cuff and pinches or impinges upon them. Thus, the term Shoulder Impingement, more specifically it can be subacromial or subcoracoid impingement. These are just two different locations where it can occur. We will discuss them in the office-based on your presentation.

Most cases require dedicated retraining of the muscles. Surgery is rarely indicated. Often the pain can be lessened by oral medications and shoulder injections. The goal of medications, in this case, is to allow you to perform the therapeutic exercises, which will be the long-term solution in the vast majority of cases. Medication alone will rarely solve problems in my world.

We will start our discussion with a review of the rotator cuff anatomy. This is a group of four muscles designed to keep the golf ball on the tee. More specifically, they act in a balanced set of force couples to provide a fixed center of rotation for the larger muscles (deltoid, pectoralis major, and latissimus dorsi) to move your arm in space -recall the metaphor with four people standing in a square holding hands and leaning back. They provide a compression force on the humeral head (our golf ball), keeping it fixed onto the glenoid (our golf tee). While they may not move your arm above your head, without their balanced action, you will not be able to do so normally.

The first of the four muscles, the subscapularis, exists purely in the front of your shoulder and is primarily responsible for your shoulder’s internal rotation. The neighboring rotator cuff tendon forms a stabilizing structure for (one of) the biceps tendon(s) as it enters the shoulder.

The neighboring rotator cuff tendon, the supraspinatus, exists primarily on the top of your shoulder. It helps initiate moving your arm up and out from your side, but, again, the rotator cuff’s primary role is to keep that golf ball on the tee. The supraspinatus is the most commonly injured tendon, and its attachment site forms a very important contribution to the stability of the remainder of the rotator cuff. If you have an injury to this structure, we will discuss it as its treatment may need to be addressed differently from other structures based on the tear’s nature and location. As I noted above, it also helps stabilize your biceps tendon as it enters the shoulder. It is not uncommon to see injuries to the subscapularis (rotator cuff muscle in the front), the long head of the biceps (the biceps tendon which enters your shoulder), and the supraspinatus. Not everyone is the same, so we work together to devise the best plan to address this.

The infraspinatus is the next rotator cuff muscle and exists behind (or posterior to) the supraspinatus. The importance of this muscle has increased over the last decade as we understand the anatomy, specifically where it attaches to the bone. This muscle exists both on the top of the shoulder and on the back of the shoulder, providing external rotation and a significant balance to the muscles mentioned above.

The final rotator cuff muscle is called the Teres Minor and exists only on the back of the shoulder. This muscle’s tendon is very rarely injured, so we will not mention it beyond noting its existence.

Most cases require dedicated retraining of the muscles. Surgery is rarely indicated. Often the pain can be lessened by oral medications and shoulder injections. The goal of medications, in this case, is to allow you to perform the therapeutic exercises, which will be the long-term solution in the vast majority of cases. Medication alone will rarely solve problems in my world.

Imagine this very common scenario I encounter when counseling patients: a patient presents with six months of shoulder pain that just hasn’t gone away. Their primary care provider ordered an MRI, which revealed a rotator cuff tear. They have yet to do any physical therapy, oral medications, nor injections. -OR- A patient comes in with shoulder pain that went away, but they got an MRI which shows a tear. Now what? Well, again, we emphasize the individuality of patients.

For the first patient, it all depends on the quality of the tear and the biology of their tissue. You can get a lot of information from an MRI, but it is far from the whole story. Only you, the patient, can give me the entire story. In all patients, I will start with a dedicated regiment of physical therapy and home exercise, with anti-inflammatories to make physical therapy and exercise possible if needed. Additionally, I will need to assess the amount – if any – of arthritis present in your shoulder. The best study for this is a plain X-Ray. If you present with only an MRI, I will order an X-Ray. Please do not be surprised. The presence of arthritis drastically changes our treatment choices.

For the second patient, I would recommend physical therapy and a dedicated home exercise program to optimize the shoulder’s strength and function and hopefully minimize the recurrence of symptoms.

Beyond this, the difference of treatment I will recommend depends on individual patient goals, overall health, the tear’s characteristics, and its ability to heal. As I tell all patients, we can repair almost anything, but if there is little to no chance for the tear to heal, there is little to no point in repairing it.

We will have an individualized discussion regarding your goals and decide upon the best course of action. Surgery will guarantee a very intense rehabilitation, brace use for 6-8 weeks, and restrictions for up to a year. This is not an easy task and can be very intrusive in your life. Thus we attempt to achieve your goals without it if possible.

While we avoid surgery if possible, we must also respect the biology of your tissue. In cases where the tear occurred from a traumatic event, for example, you had a specific episode where the tear occurred. The timeline to surgery is different from tears resulting from years of smaller injuries leading to a near–death by a thousand cuts. We know from the scientific literature that pain can be a very useful indicator for the biology and size of the tear. We know from the time of pain onset to tear enlargement can be as quick as one year. We know from the time of enlargement to tissue degeneration to be one to two years. Most importantly, we know that larger tears with more degeneration are less likely to heal. Thus, we discuss these indicators and must respect tissue biology when devising a plan for you.

If surgery becomes necessary to achieve your goals, we will always attempt to repair the tissue anatomically. However, if this is not possible, then we are not without options. Ten years ago, the main treatment option for such irreparable rotator cuff tears was shoulder replacement. This is no longer true. Thanks to our Japanese colleagues, we can now reconstruct the shoulder using a graft – typically from a cadaver – without the need to replace the shoulder. In many patients, a shoulder replacement can be avoided altogether. The rehabilitation for this reconstruction is nearly identical to that of a rotator cuff repair. While this reconstruction is not for everyone, it provides a very valuable option for some.

For certain people, shoulder replacement (also known as Arthroplasty) is the better option. We can discuss this on an individual basis.

If you have ever dislocated your shoulder, you likely tore your labrum. The direction of your dislocation will determine which part of your labrum was torn. But not to worry! Not all shoulder dislocations require surgery. Recall our above discussion on the anatomy (if you don’t, go back and review now). The labrum acts as a bumper, but more importantly, an attachment site for stabilizing ligaments which act more like a continuous sheet of tissue than isolated bands. This sheet will be tensioned in different areas depending on the position of your shoulder. The position of your shoulder at the time of dislocation will determine the direction of your dislocation and thus the location of your injury. Just as importantly, the action of shoulder dislocations causes impaction of the humeral head – golf ball – on the glenoid – golf tee. Based on some very fancy work done in biomechanics labs, we now know the injury to your bone (humeral head and/or glenoid) is very important in determining how likely you are to re-dislocate, but also what treatment options are best.

First-Time Shoulder Dislocation Treatment

If this is your first dislocation, we will keep you in an immobilizer or sling only until your symptoms decrease and you can do physical therapy. I want that shoulder moving – in a safe manner – as soon as you are able. Physical therapy can help train the shoulder muscles not only to be stronger but also to act in a more coordinated fashion to protect your shoulder into the future. The key to all physical therapy and strengthening is a dedication to the process. That means exercises are done at home, daily. Physical therapy visits are coaching sessions only.

Multiple Shoulder Dislocation Treatment

If you have had multiple shoulder dislocations, then we need to dig a little deeper. Your goals will guide our options. If you have not exhausted all nonoperative options, then we will exhaust them. However, if you are at the end of the line for nonoperative management, then we will discuss surgery at your discretion. Remember, surgery is not a silver bullet. It takes a lot of planning and effort on both of our parts. Further, the postoperative course requires respect and dedication. Only those who dedicate themselves to their rehabilitation can expect the best result.

This injury pattern is widespread as we gain more experience on this Earth and use our shoulders as it was intended, living active lives. Additionally, it is common in throwing or overhead athletes.

The cause of these injuries can be cumulative (death by a thousand cuts), poor mechanics, shoulder and core weakness, prior injury, or traumatic injury in an accident.

The first step in management is a dedicated course of therapy, home exercise, technique modification (if applicable), and core strengthening on top of shoulder strengthening. Yes, if you come to my office complaining of shoulder pain, I will probably make you do sit-ups.

If nonoperative management doesn’t get you to your goal, we discuss surgery, always at your discretion. Here the literature is also clear. If you are over the age of 35, I recommend a biceps tenodesis. This is where I unplug the long head of the biceps (which travels into your shoulder, the other head of the biceps attaches to a bony structure called the Coracoid outside your shoulder. For those interested, Biceps is Latin “bi-” meaning two and “ceps” meaning head from the Latin word for head, “caput”). If you are below the age of 35 and a professional or high-level overhead or throwing athlete, we will discuss repair. The recovery for the two is different and will be discussed if we come to the point you become a surgical candidate.