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  • 5 Exercises to Prevent Shoulder Injury

    5 Exercises to Prevent Shoulder Injury

    The shoulder is a large, complex joint formed where the humerus (upper arm bone) meets the scapula (shoulder blade). Several other bones are associated with the joint, and all are kept in position by tendons, ligaments, and muscles. The rotator cuff consists of tendons and muscles that form a supportive, stabilizing structure around the shoulder joint.

    The shoulder has a wide range of motion, but is vulnerable and is one of the most commonly injured parts of the body. To avoid injury, it is important to build strength and flexibility, particularly in the rotator cuff.

    Always warm up before exercising; tissue fibers are less flexible when cold and therefore more likely to tear.

    Lying external rotation:
    Lie on your side on the floor, with your upper arm against your body and your elbow at a 90-degree angle. Hold a 5–10 pound weight in your hand; lower the weight to the floor in front of you then, keeping your elbow against your body, lift the weight up so that your hand points to the ceiling. Lower the weight to the floor again. Repeat 10–15 times for 1 set. Do 1–2 sets.

    Standing external rotation:
    Tie a stretchy exercise band into a loop large enough so that when holding your elbows at your sides and your forearms parallel to the floor, your hands are about 6–8 inches apart. Stand with your shoulders aligned over your hips and feet, elbows at your sides and forearms parallel to the floor, hands in the band with your thumbs pointing up. Pull your hands apart, focusing on keeping your shoulder blades squeezed together. Release to the beginning position. Each repetition should take 2 seconds: 1 to stretch and 1 to release. Repeat 10–15 times for 1 set. Do 3 sets.

    Straight arm lift:
    Stand with your feet shoulder-width apart. Keep your shoulder blades squeezed together and raise your arms to extend straight out to the sides, parallel with the floor. Keep your arms straight and thumbs pointing up. Move your hands 1–2 feet forward so they are slightly ahead of your shoulders. Return your arms to the starting position then raise them so your hands finish level with the top of your head. Do the exercise as a flowing sequence, 1 second for each movement. Continue for 2 minutes for 1 set. Do 3 sets.

    Ball on wall:
    Stand facing a wall with one arm extended straight in front of you, parallel to the floor and your palm almost touching the wall. Place a tennis ball between your hand and the wall. Squeeze your shoulder blades together. Roll the ball with the palm of your hand in small circles, clockwise, for 15 seconds, then switch direction and roll it anticlockwise for 15 seconds. Continue for 2 minutes for 1 set. Do 3 sets. Repeat with your other arm.

    Hitch hiker:
    Lie on the floor on your stomach with your arms stretched straight out to the sides, thumbs pointing up. Squeeze your shoulder blades together. Lift your arms off the floor and move them slightly towards your head to make a ‘Y’ shape. Hold for 1–2 seconds then return to the starting position. Repeat for 2 minutes for 1 set. Do 3 sets.

  • Acromioclavicular Joint Separation

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    Acromioclavicular Joint Separation

    Definition:

    The acromioclavicular (AC) joint is formed at the junction of the clavicle (collar bone), the part of the shoulder blade called the acromion, and the humerus (arm bone). The end of the clavicle meets the acromion, which is a bony extension that curves forward from the upper part of the scapula (shoulder blade). Together they form a socket, into which the round head of the humerus fits. There are also several ligaments associated with the joint, with the most important being the acromioclavicular ligament. This helps to hold the bones in position. An acromioclavicular joint separation, also known as a shoulder separation, occurs when the joint between the clavicle and the acromion is damaged. It is not the same as a dislocated shoulder.

    AC separations are graded according to severity and the extent of bone displacement, with grade 1 being a relatively mild strain to the ligaments and capsule of the joint, and grade 6 being torn ligaments and a complete disruption of the bones with the clavicle being displaced downwards and behind part of the scapula. Grade 1 and 2 shoulder separations are by far the most common. Grade 6 separations are rare.

    AC Separation Causes:

    An injury to this joint is normally the result of landing heavily, or receiving a strong blow, on the shoulder or the elbow. Falling onto an outstretched hand might also cause a shoulder separation. People playing contact sports are obviously at increased risk of this type of injury.

    AC Joint Separation Symptoms:

    Pain is the main symptom of an injury of this type. The pain is commonly felt at the outer end of the clavicle, nearest the arm, at the moment of impact. Pain may also be felt all over the shoulder, particularly if any movement is attempted, and especially when trying to lift the arms above shoulder height. Later such pain may become more localized to the site of injury. There may be swelling and bruising. If the injury is severe, a noticeable lump, made by the tip of the collarbone, might be visible on the front or top of the shoulder.

    AC Joint Separation Diagnosis:

    A physical examination and detailed questioning usually provides a clear diagnosis of a shoulder separation. The doctor will also take your pulse to check for damage to blood vessels, test the range of motion of your shoulder and test muscle strength in your shoulder and arm. An x-ray is useful in assessing the extent of the damage.

    AC Separation Treatment:

    For mild cases of shoulder separation, gentle exercise should be started once the initial pain has lessened, usually after a couple of weeks. Commencing exercise reasonably quickly minimizes the danger of developing shoulder stiffness (frozen shoulder). More serious injuries will take longer to heal. Be guided by your doctor or physiotherapist. A physiotherapist can supervise and advise on suitable exercises to restore normal motion of the joint and to build up muscle strength. Gradual resumption of normal activity as the pain reduces is usually the most effective way to heal.

    • A mild injury can be treated with ice to reduce inflammation. Use ice on the joint for 15 minutes at a time, every 4 hours.
    • Using a sling to restrict movement will ease the pain and allow healing. There are several types of collarbone supports and shoulder supports available.
    • Pain medications such as Tylenol will help, and NSAIDs such as ibuprofen will assist in reducing inflammation.
    • The joint can be taped to provide further restriction of movement and support while it heals. The tape will probably have to stay in place for at least a couple of weeks.
    • A physiotherapist might apply ultrasound or TENS, depending on the severity of the injury.
    • Occasionally surgery will be needed for grade 3 separations, as there is some evidence that certain people (athletes, manual laborers) benefit from early surgical intervention. Surgery will almost certainly be necessary for grade 4, 5 and 6 shoulder separations, but these are rare injuries.

    What to look for in a brace to help a shoulder separation injury:

    A comfortable brace, made with breathable fabric, and which provides good support and protection to the shoulder. You might prefer a brace that does not have restrictive straps, which can be uncomfortable.

    AC Separation Rehabilitation Exercises:

    Do not undertake any exercise without prior approval from your health care provider, unless the joint separation was very mild and that you are free from significant pain, usually after 1 to 2 weeks.

    To restore mobility you can try the following:

    Pendulum

    While lying on your front on a bench or bed, or bending forward, gently swing the arm backward and forward. Increase the range gradually. Repeat with the arm moving from side to side.

    Front shoulder stretch

    With one forearm resting against a doorframe, carefully turn away from the arm to feel a gentle stretch in the front of the shoulder. There should be no pain. Hold for 10-20 seconds. Repeat 3 times.

    For strengthening:

    External rotation

    With your side to a wall and the upper arm against your side, bend your elbow to a 90 degree angle and place the back of the wrist against the wall. Push gently against the wall with the back of the wrist. Your shoulder should not move. Hold for 10 seconds, release for 5 seconds. Do this 10 times.

    Internal rotation

    Use a wall with a corner for this exercise, or a doorframe. Facing the wall, with your upper arm against your side, bend your elbow to form a 90 degree angle. Place the front of your wrist against the doorframe and press, as though trying to turn your arm towards you. Hold for 10 seconds, release for 5 seconds. Do this 10 times.

    Abduction

    Standing sideways to the wall, straighten the arm and place the back of the wrist and hand against the wall. Push against the wall. Hold for 10 seconds, release for 5 seconds. Do this 10 times.

    AC Joint Separation Prevention:

    Because injuries of this nature are caused by traumatic events, there is not a lot that can be done to prevent them. However, people playing contact sports such as football, hockey or rugby should wear shoulder pads to protect the tip of the shoulder. Maintaining muscle strength and stability of the shoulder may help to prevent injury.

  • Broken Collar Bone / Clavicle Fracture

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    Broken Clavicle

    The collarbone (clavicle) is one of two long, slender bones found on either side of the chest. Each clavicle is attached to the breastbone (sternum) at one end and to the shoulder blade (scapula) at the other end. They connect the arms to the trunk of the body.

    Most clavicle fractures occur in the middle of the bone.

    Causes:
    Because the clavicles do not completely harden until around the age of 20, a broken collarbone is a fairly common injury amongst young people. Because bones become more brittle with age, elderly people are also more at risk of this injury. Occasionally, a high birth weight causes an infant to break a collarbone during labor and delivery.

    Usually, a fracture happens as a result of a fall onto the shoulder, or occasionally a fall onto an outstretched arm. Vehicle accidents are a common cause of clavicle fractures, as are injuries sustained while playing sports.

    Conditions such as osteoporosis, cancer, or a genetic defect causing weak bones will increase the risk of breaking a collarbone.

    Symptoms:
    If you are experiencing any of the following symptoms, seek medical attention as soon as you can. Delaying treatment of a broken collarbone can result in imperfect healing.
    • Pain, which can be severe, made worse with movement of the shoulder
    • Holding arm close to the body and supporting it with the other hand
    • Diminished ability to move the shoulder due to pain
    • Shoulder on damaged side sagging down and forward
    • Tenderness, swelling and bruising over the injured area
    • A bulge along the line of the collarbone
    • A crunching or grinding sensation (crepitus) on movement of the shoulder
    Diagnosis:
    Diagnosis of a fractured clavicle is relatively straightforward. Your doctor will ask you questions relating to the circumstances of the injury, and your symptoms. Your shoulder and collarbone will be physically examined, including gently palpating along the line of the collarbone. Your doctor will listen to your chest in order to rule out damage to the lungs, check for any possible nerve damage and order X-rays to view the bones and determine the location and severity of the fracture. He or she will also be looking at the joints to see if they have suffered any damage.

    If it is considered necessary to view the injury in greater detail, a CT (computerized tomography) scan will be performed.

    Treatment:
    Treatment depends on the location and severity of the fracture. If the broken ends of the bone have not shifted out of place, conventional (non-surgical) treatment will be sufficient.

    An open (compound) fracture, where the broken bone has pierced the skin, will require immediate surgery and antibiotics to reduce the chance of developing an infection.

    A displaced fracture, where the two pieces of bone are misaligned, may need surgery to position the pieces so that they heal together in correct alignment.

    If the collarbone has been broken into several pieces (comminuted fracture) surgery may well be necessary in order to realign the bone.

    Surgical treatment usually involves fixing the pieces of broken bone together with the aid of screws, rods or plates. These fixation devices are normally left in place, although they can be removed after healing if they are causing discomfort.

    If immediate surgery is not required, ice, crushed in a bag and wrapped in a towel, can be applied to the injured area for as long as is comfortable, several times a day for the first few days after the injury. This will help reduce swelling and therefore relieve pain.

    Over-the-counter pain medication such as acetaminophen (Tylenol) or NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Advil), naproxen (Aleve) or aspirin can be used, although there is some evidence to show that using NSAIDs may inhibit bone repair. Your doctor may prescribe stronger medication if the pain is severe.

    In order that the collarbone can begin to heal, it must be immobilized. This is normally achieved by wearing a sling or, often, a figure-of-eight strap that effectively prevents movement of the clavicle. This strap may need to be worn for up to 12 weeks, depending on the severity of the fracture.

    After you have finished wearing the strap, some rehabilitation for the shoulder will be necessary. Your doctor will advise you on when to start gently moving the shoulder. An exercise program that gradually increases range of motion, strength, and flexibility will be developed for you. You may be advised to work with a physical therapist. It is important to follow medical advice carefully, as trying to do too much, too soon may result in improper healing or broken fixation devices, and mean that treatment has to begin again.

    You can expect to resume your normal daily and sporting activities within three months of the initial injury.

    Exercises:
    When your doctor advises that it is safe to do so, you may begin some gentle rehabilitation exercises. These should be done on a daily basis. You may be prescribed specific exercises, but you can begin with the following:

    Pendulum:
    Bend forward at the waist and allow your injured arm to hang straight down towards the floor. Gently move your hand in small circles, both clockwise and anticlockwise. The momentum will cause your arm to move.
    Ball grip:
    Hold a small ball in the hand of your injured arm. Squeeze the ball gently and evenly several times.
    Wand flexion:
    Standing, hold a stick in both hands with your palms facing down. Slowly, keeping your elbows straight, lift your arms above your head. Hold the stretch for 5 seconds then lower your arms. Repeat 10 times.
    Wand extension:
    Standing, hold a stick behind your back, using both hands. Slowly lift the stick away from your back. Hold the stretch for 5 seconds then lower. Repeat 10 times.
    Scapular range of motion:
    Standing, shrug your shoulders up. Hold for 5 seconds. Squeeze your shoulder blades back towards each other. Hold for 5 seconds. Drop your shoulder blades down as though putting them in a back pocket. Hold for 5 seconds. Repeat exercise 10 times.

  • Dislocated Shoulder

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    Dislocated Shoulder

    The shoulder is a highly mobile joint, allowing the arm to move in almost any direction. The joint is formed by the connection of the humerus (the upper arm bone) and the scapula (shoulder blade). The articular end of the humerus is rounded and fits into a shallowly concave surface of the scapula called the glenoid fossa, forming a flexible ball-and-socket joint. Helping to stabilize the joint are ligaments running from bone to bone, tendons that connect bone to muscle, and a ring of cartilage surrounding the glenoid.

    The flexibility of the joint and the shallowness of the glenoid fossa means that the joint is fundamentally unstable and the humerus can quite easily be pushed out of place as a result of a trauma. The joint may be completely or partially dislocated, and the shoulder muscles, ligaments, and tendons stretched or torn. There may also be nerve or blood vessel damage.

    A severe dislocation will increase the risk of repeated shoulder dislocations.

    Causes:
    The shoulder is the most commonly dislocated joint in the body. Dislocations are usually caused by trauma, either falling onto the shoulder, or receiving a strong blow to the shoulder, often during contact sports or a vehicle accident. Attempting to break a fall by stretching out an arm can also result in dislocation, as can sharply twisting the arm.

    Some sports carry a higher than usual risk of sustaining a dislocated shoulder. These include football, hockey, soccer, rugby, volleyball, rock climbing, and skiing.

    Symptoms:
    The main symptoms are:
    • Severe pain, felt in the shoulder and upper arm, made worse with movement
    • A visible deformity in the front or back of the shoulder, depending on the dislocation
    • Swelling or bruising, increasing with time
    • Possible numbness or tingling in the neck or down the arm
    • Muscle spasm, causing extreme pain and unwillingness to move the arm at all
    Diagnosis:
    While waiting for medical attention, immobilize the joint. Do not try to reposition it yourself as further damage might result. Ice can be applied to relieve swelling.

    Your doctor will ask you questions relating to the circumstances of the injury, and any previous injuries to the shoulder that you might have suffered. A physical examination of the arm and shoulder will help your doctor determine whether there is a dislocation. X-rays may be taken if broken bones are suspected, and possibly an MRI (magnetic resonance image) scan if the soft tissues of the joint need to be viewed in greater detail.

    Treatment:
    Because a dislocated shoulder is extremely painful, and swelling will increase with time, it is important to reposition the joint as soon as possible. Your doctor will, if achievable, physically manipulate the arm back into the shoulder socket in a procedure known as a closed reduction. You will probably be given a muscle relaxant or sedative before this is done. Once your shoulder bones are back in position, the pain normally diminishes significantly. Another X-ray may be taken to confirm the reduction.

    To help relieve pain and swelling, ice can be applied to the shoulder. The ice should be crushed in a bag, the bag wrapped in a towel, and placed on the shoulder for as long as is comfortable, several times a day.

    Over-the-counter pain medication can be taken, such as NSAIDs (non-steroidal anti-inflammatory drugs). Examples of such drugs are Advil, Motrin and Aleve.

    Your doctor will advise you as to whether you should wear a sling or shoulder immobilizer. If necessary, you will probably need to wear it for a period lasting from a few days to three weeks. You will also receive advice about rehabilitation of the shoulder. When you should start gentle stretching and strengthening exercises will depend on your particular injury. It is very important to follow medical advice, as trying to resume normal activity before the shoulder is completely healed could result in permanent damage to the joint.

    Most dislocated shoulders are treated with conservative (non-surgical) methods such as those described above, but in some cases, surgery will be necessary. Such instances might include a situation where damage to blood vessels and nerves needs to be repaired, or repeated dislocations have loosened the tendons around the joint, so that they need to be surgically tightened.

    Exercises:
    Your health care provider or physical therapist will design an exercise program specifically for you, but, with medical approval, doing the following exercises will help you begin to rehabilitate your shoulder.

    Isometric external rotation:
    Stand in a doorway with the injured shoulder nearest the doorframe. Bend the elbow and press the back of the wrist against the doorframe. Hold for 5 seconds. Repeat 10 times for 1 set. Do 3 sets.
    Isometric internal rotation:
    Standing just to the side of a doorway, bend the elbow of the injured arm and press the front of the wrist against the doorframe. Hold for 5 seconds. Repeat 10 times for 1 set. Do 3 sets.
    Isometric adduction: Hold a pillow between the chest and arms. Squeeze the pillow and hold for 5 seconds. Repeat 10 times for 1 set. Do 3 sets.
    Isometric extension:
    Stand with your back to a wall so that your bent elbows just touch the wall. Press your elbows back against the wall and hold for 5 seconds. Repeat 10 times for 1 set. Do 3 sets.
    Shoulder flexion:
    Standing with your arms straight by your sides. Keeping your elbows straight, lift your arms up as high as you can. Hold for 5 seconds. Repeat 10 times.
    Shoulder extension:
    Stand with your arms straight by your sides. Keeping your elbow straight, move one arm backwards as far as it will go, without forcing. Hold for 5 seconds. Repeat 10 times. Repeat exercise with the other arm.
    Shoulder abduction:
    Standing with your arms at your sides, slowly lift the arms straight out and up. Hold for 5 seconds. Repeat 10 times.

    Prevention:
    Wear proper protective equipment if you play contact sports, and make sure that you exercise regularly to keep your joints and muscles strong and flexible.

  • Distal Humerus Fracture

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    Distal Humerus Fracture

    A distal humerus fracture is the term used to describe a type of elbow fracture where the lower end of the upper arm bone (humerus) has been broken. It is a relatively uncommon injury in adults, accounting for only about 2% of fractures. Children are more likely to suffer this type of injury.

    Three bones articulate with each other to form the elbow: the humerus in the upper arm, and the radius and ulna in the lower arm. Together they allow the arm to move in a hinge-like manner, and also to turn the hand palm up or palm down. The way the bones are shaped keeps the elbow joint in its correct alignment, with a cup-shaped part of the ulna (olecranon) holding the end of the humerus and moving around it as the elbow bends. Muscles and tendons cause movement and ligaments run from bone to bone, helping to maintain alignment and prevent excessive mobility.

    The humerus can often break into several pieces when it is broken at the distal end. This is known as a comminuted fracture. Fractures are named and graded according to location and severity. Due to the structure of the elbow and the associated muscles, nerves, and blood supply, a distal humerus fracture can be challenging to treat.

    Causes:
    A strong impact, such as during a motor vehicle accident, or falling and landing on the point of the elbow, are common causes of a distal humerus fracture.

    Another type of fall that produces such a fracture is when the elbow is straight and the person lands on the outstretched arm. In this instance it is possible for the ulna to be forced into the humerus, breaking it.

    Fractures from falls are more likely to happen to elderly people, while fractures from a blow happen more often to younger people.

    Symptoms:
    • Severe pain on impact
    • Pain so severe that the patient is unable to move the elbow at all
    • Swelling, bruising, and tenderness of the elbow
    • Rarely, the fracture may be compound, meaning that a piece of bone has pierced the skin
    • The elbow will feel extremely unstable and vulnerable
    • Occasionally numbness or tingling may be felt in the wrist or hand
    Diagnosis:
    The doctor will ask for a medical history, including any previous injuries to the elbow. The elbow will be physically examined. The entire arm and shoulder may be examined at the same time, to rule out other injuries. The examination will include checking the skin for abrasions or lacerations. If the broken bone has pierced the skin there is a real risk of infection. The doctor will gently palpate (touch) the entire elbow area to determine if there might be other injuries, such as another broken bone, or a dislocation of the elbow. Blood flow to the hand and fingers will be checked, and the patient will probably be asked to move the fingers. This is because there is a nerve (radial nerve) that can be damaged during this sort of injury. For the same reason, the patient will probably be asked if he or she feels any numbness or tingling. It is unlikely that the patient will be able to straighten the elbow when asked by the doctor.

    X-rays will be taken of the elbow. X-rays show bones in great detail so are very useful if a distal humerus fracture is suspected.

    Treatment:
    Initial treatment is to place the arm in the correct position for healing and immobilize the elbow in a splint or brace. The splint will be worn for at least a week, but possibly up to six weeks. Pain medication will be administered.

    The need for surgery will depend on whether or not the humerus has been displaced. If the bone is still in its correct position treatment may consist of continuous wearing of the splint and sling for several weeks, with regular follow-up appointments with the doctor and further X-rays.

    Many distal humerus fractures require surgery to reposition the humerus or to reassemble pieces of broken bone. Fixation devices such as orthopedic pins, screws, and plates are often used to hold the bones in position during healing. Compound fractures will always need surgery.

    Regardless of whether surgery was performed or not, physical therapy is necessary to rehabilitate the elbow. The patient will be advised when to start, with the probable recommendation to work with a physical therapist. An exercise program would be developed beginning with gentle range of motion exercises, followed by strengthening exercises once the bone was fully healed. These exercises would have to be done several times a day. An elbow fracture and the required time in a splint results in considerable stiffness in the elbow, so the patient would have to be prepared for a lengthy period of rehabilitation. Regaining as much use of the elbow as possible requires dedication to the physical therapy aspect of recovery.

    Prognosis:
    The outcome of having sustained a distal humerus fracture depends on the severity of the fracture and the patient’s willingness to adhere to the exercise program. It is likely that, for some patients, full healing may take over a year, although many people can return to their normal activities within about four months. Residual stiffness in the elbow will gradually improve with use, and strength return. It is likely that for some people complete straightening of the elbow will no longer be possible, but the difference is usually small and most people do not find that the loss of extension is a problem.

    A rare occurrence is the growth of extra bone around the joint. This can impede movement of the elbow and will require later surgery to remove the extra bone. Further physical therapy would be necessary following the surgery.

    Arthritis in the elbow is a fairly common consequence of a distal humerus fracture. This will not necessarily hinder use of the elbow, or be painful.

    Any nerve damage sustained during the fracture normally improves with time.

    Braces:
    A hinged elbow brace is often the most appropriate brace for a distal humerus fracture. This can initially be fixed at a 90% angle, then gradually regulated to allow the elbow to begin flexing and extending a little more with each adjustment.

  • Erb’s Palsy

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    Erb's Palsy

    Erb’s palsy, also known as brachial plexus paralysis, is a condition of partial or complete paralysis of the arm caused by damage to a network of nerves near the neck. It is a condition most often found in newborns, although trauma to an older person can also result in Erb’s palsy.
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    Five large nerves leave the spinal cord from positions between the cervical vertebrae (bones in the neck) and come together to form the brachial plexus at the side of the neck. Nerves positioned slightly higher in the plexus branch out to innervate the shoulder, while nerves in the lower parts of the plexus pass behind the collarbone and down into the arm, with the lowest travelling the length of the arm to innervate the hand and fingers.

    The most common brachial nerves affected during birth are the upper nerves. The damage to one or more of the nerves results in a loss of movement in the shoulder, the extent of which will depend on how many nerves have been injured and the severity of the injury. If lower nerves are also stretched the loss of movement will extend further down the arm.

    The injury can range from a relatively mild neuropraxia that stretches but does not tear the nerve, to a complete avulsion where the nerve has been torn away from the spinal cord. The degree of recovery from Erb’s palsy depends largely on the severity of the original injury.

    Causes:
    A difficult delivery is the usual cause for Erb’s palsy in an infant. Several situations can result in brachial nerves being stretched, for example, a breech presentation, extended labor, or a complication during delivery that requires the baby to be delivered swiftly from the birth canal. Any circumstance that causes the neck to be stretched may damage the brachial nerves.

    Other situations where the brachial plexus can be damaged are:
    • A trauma to the side of the neck, for instance a motor vehicle accident, fall or heavy blow
    • A stretch injury sustained while participating in a sport
    • An attempt to reduce a dislocated shoulder
    Symptoms:
    • Typically an infant will have one arm that hangs down by the side, with the elbow pointing out, the forearm rotated in towards the chest, and the hand turned backwards (a position sometimes described as ‘waiter’s tip’)
    • Partial or total lack of muscle control in the shoulder and perhaps the arm
    • Weakness in the arm
    • Numbness in the arm
    • Atrophy of the arm muscles
    • Possible drooping of the eyelid on the affected side
    • Pain, possibly severe, at the time of injury, typically described as burning, crushing or pins and needles
    Diagnosis:
    If the patient is a baby, the pediatrician is likely to make the diagnosis. He or she will examine the baby’s neck, shoulder, and arm and evaluate the degree of weakness. X-rays may be taken to view the structures of the neck and shoulder. MRI (magnetic resonance imaging) or CT (computed tomography) scans can be used to assess the amount of damage to the nerves. Nerve function tests, which may include EMG (electromyogram) or NCS (nerve conduction study), are normally only performed after a three month period of observation.

    Treatment:
    Most cases of Erb’s palsy in newborns resolve successfully on their own, with time and dedicated physical therapy. Regular check-ups with the doctor would be required to monitor the recovery. Physical therapy, which is critical to recovery, would consist of massage, range of motion exercises, performed several times a day to prevent permanent stiffness in the shoulder, arm, and wrist, and strengthening exercises. Therapy might also include sensory stimulation as Erb’s palsy can result in a loss of sensation in the arm. Exercises should be done only under instruction from the doctor or physical therapist.

    Older patients are generally also treated with a period of observation for the first three months. Some recovery of function often occurs spontaneously. Any pain would be treated, and physical therapy undertaken.

    If, after the observation period, no improvement in the condition was evident, exploratory surgery might be considered. Further surgery that might improve function could be considered at a later date. Surgical options include nerve transplants or muscle adaptions. As with all surgery, there are both risks and benefits to be carefully evaluated before a decision should be made. A successful outcome after surgery is not guaranteed and it can take several months for nerves, repaired in the neck, to finally reach the lowest affected parts of the arm. Nerve regeneration takes place at a rate of about one inch every month.

    Prognosis:
    Recovery depends on the extent of the original injury and, to a large degree, on the age of the patient. Neuropraxia is relatively mild and most cases spontaneously recover full function of the arm. In more serious cases of Erb’s palsy, where nerves have been ruptured or avulsed, regaining full use of the arm is less certain. Generally, the recovery of range of motion in children under one year old is likely. Older children will usually have some lasting functional loss and permanent arm weakness. Stiffness in the shoulder may restrict the child’s ability to raise the arm above shoulder height.

    Nerves have a certain affect on growth, so a child with a lasting disability may have one arm smaller and weaker than the other, with a degree of muscle atrophy. The arm will continue to grow, but at a slower rate than the unaffected arm. He or she may also suffer from a reduced ability to heal in the affected arm, so care must be taken to keep any scratches or cuts clean. Damage to the circulatory system also means that the arm cannot adequately regulate its temperature. Again, care must be taken to make sure that the arm does not become too cold during the winter months.

  • Forearm Fracture

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    Forearm Fracture

    A break in one or both of the bones in the lower part of the arm is called a forearm fracture.

    The two bones in the forearm are the radius and the ulna. The radius is the bone nearest your thumb and the ulna nearest the little finger. A strong membrane between the two bones holds them close together but allows them to rotate around each other to a certain degree. At the proximal (upper) end of the bones, the ulna articulates with the radius and the humerus (upper arm bone) to form the elbow joint, and at the furthest (distal) end, the radius articulates with the ulna and three of the wrist bones. Together they allow a great deal of mobility in the arm, wrist, and hand.

    Forearm fractures can happen at any location along the length of the bones and may involve muscles, tendons, or ligaments. There are several types of fracture that may or may not involve the elbow or wrist joints. The various fractures include:

    Torus fracture:
    Often called a buckle fracture. Compression of the top layer of bone causes the other side of the bone to bend. The broken bones are still in position.

    Greenstick fracture:
    Only children sustain these fractures. Part of the bone is broken, but not all the way through.

    Metaphyseal fracture:
    Refers to a fracture of the metaphysis (the upper or lower part of the bone shaft) but does not involve the growth plate.
    Growth plate fracture: A fracture involving the physis (growth plate found at either end of the bone where cartilage gradually becomes bone). The growth plate of the radius at the wrist end is the most common location for this fracture. Most fractures of this sort heal well with no residual bone growth problems.

    Colles’ fracture:
    A fracture that extends across the end of the radius. This injury is more common in adults due to bone brittleness.

    Galeazzi fracture:
    An injury that combines a fracture of the radius, with displaced pieces of bone, and a dislocation of the ulna at the wrist.

    Monteggia fracture:
    Again, this injury involves both forearm bones, but in this instance the location is at the proximal end of the forearm, the ulna is fractured and the radius dislocated.

    Up to half of all childhood fractures are forearm fractures, and of these, about three-quarters are fractures of the radius, near the wrist.

    Causes:
    A fall onto an outstretched arm is the most common cause of a forearm fracture. Falls from monkey bars at school are notorious for causing such injuries. Other traumatic causes may include a heavy blow to the forearm or a twisting of the arm that forces the elbow beyond its normal range of motion. Examples of such situations are motor vehicle accidents or contact sport accidents.

    Some diseases or conditions can increase the risk of sustaining a forearm fracture. These include osteoporosis, congenital bone conditions, the normal aging process, poor nutrition, and decreased muscle.

    Symptoms:
    • Pain, possibly severe, made worse with movement of the elbow or wrist
    • Possible numbness in the forearm and hand
    • Deformity of the forearm, for example an unusual curve or lump
    • Tenderness, swelling, and possible bruising of the forearm, wrist or hand
    • Inability to turn the palm of the hand up or down
    Diagnosis:
    Diagnosis of a forearm fracture is based on questions about the circumstances of the injury, your symptoms, a physical examination of the arm, and X-rays. Computed tomography (CT) scans may be used to view the soft tissues in the forearm, such as cartilage and tendons. Your doctor will also check blood flow and nerve responses in the hand and fingers to rule out damage to the blood supply or nerves.

    Treatment:
    While waiting to see the doctor a splint can be applied to the underside of the hand, wrist, and forearm. The arm should be elevated, if possible. An ice pack, placed on the injured area, will start to reduce swelling. It is important not to try to realign any bones, but instead seek medical attention.

    If the fractured bone or bones are still in their correct position, and the fracture is relatively straightforward, treatment will consist of immobilizing the bones while they heal. This is achieved with a cast or splint. Depending on the injury, the splint may be only on the forearm, or it may cover the arm from the hand to above the elbow.

    A simple fracture usually requires 3-4 weeks in a cast, while a more complicated injury may need 6-10 weeks.

    Pain medication may be prescribed, or you can take, with medical approval, over-the-counter pain relieving medicines such as acetaminophen (Tylenol).

    Elevating the forearm above the level of the heart whenever possible will help to reduce swelling and thereby relieve pain.

    Sometimes the doctor is able to realign displaced bones by physically manipulating them without the need for surgery. If not, or if the bone fragments are unstable and unlikely to remain in position for healing, if the bone has pierced the skin, or if the bones have already begun healing but they are incorrectly aligned, surgery will be needed. Orthopedic fixing devices such as screws, pin, or plates may be used to hold the bones in place until healing is complete.

    Prognosis:
    The degree of recovery depends somewhat on the age and general health of the patient. A child will recover much more rapidly and with a greater chance of regaining full mobility of the wrist and elbow joints. An older person may never regain total pre-injury mobility, and may also have an increased risk of developing carpal tunnel syndrome as a complication of the injury.

    After the cast has been removed, the elbow and wrist joints will probably be stiff, but with time and movement the stiffness will usually go away. The muscles of the forearm and joints will have weakened through lack of use, and the actual bones themselves will still be slightly fragile. Care should be taken for a few weeks to allow strength to build up again.

    If the fracture involved the growth plate in a child, regular monitoring by a physician is recommended, to make sure that the bones are growing normally.

  • Frozen Shoulder

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    Frozen Shoulder

    Frozen shoulder is a condition of stiffness and pain in the shoulder that limits normal movement of the joint. It is also known as adhesive capsulitis.

    The shoulder has two joints. The glenohumeral joint is a highly flexible ball-and-socket joint, formed by the connection of the humerus (upper arm) and the scapula (shoulder blade). The upper end of the humerus has a rounded shape that fits into a shallow concavity of the scapula called the glenoid fossa. There is a strong capsule of connective tissue that surrounds the joint, partially formed from ligaments. Contained within the capsule is synovial fluid, a nourishing and lubricating substance. If the capsule becomes too tight, the range of motion of the shoulder is restricted, causing pain and immobility.

    The second shoulder joint is the acromioclavicular joint, formed by the connection of a different part of the scapula, the acromion, and the clavicle (collarbone). Both joints need to be working properly for full motion of the shoulder, although the glenohumeral joint is responsible for most movement.

    Frozen shoulder happens when the shoulder capsule becomes thicker. Bands of stiff tissue called adhesions form, causing the capsule to tighten up. The condition develops gradually. In the beginning stages, pain slowly increases and the range of motion of the shoulder decreases. This stage can last anywhere from six weeks to nine months.

    The second stage is the classic ‘frozen shoulder’ stage. The pain may diminish at this time, although the stiffness in the joint continues to develop and the resultant loss of range of motion may cause difficulties in performing daily activities.

    Gradually, over the course of up to two or three years, full motion and strength returns to the joint.

    Causes:
    It is not completely understood what causes a frozen shoulder. What is clear is that there are factors that increase the risk of developing the condition. People with diabetes are much more likely to suffer from a frozen shoulder, as are people with other medical conditions such as Parkinson’s disease, cardiovascular disease, tuberculosis, and thyroid disorders.

    A frozen shoulder can also develop as a result of immobilization of the joint, for example after an injury or surgery. For this reason, patients are encouraged to begin moving their shoulders soon after a medical procedure.

    Women, and people over the age of 40, are more likely to develop a frozen shoulder.

    Symptoms:
    • Frozen shoulder pain is typically described as ‘dull’ or ‘achy’. It is felt over the outer area of the shoulder and sometimes in the upper arm. Movement makes the pain worse.
    • Movement of the shoulder becomes increasingly difficult due to stiffness and pain.
    • Some people experience more pain at night.
    Diagnosis:
    Your doctor will ask you questions about the duration and severity of your symptoms. You will have a physical examination, during which time the range of motion of your arm and shoulder will be carefully tested. Your doctor will move your shoulder around to assess the passive range of motion, and you will be asked to move the shoulder by yourself so that active range of motion can also be determined. A frozen shoulder usually limits both passive and active range of motion.

    X-rays may be taken, primarily to rule out other conditions such as arthritis. Ultrasound or MRI (magnetic resonance imaging) scans may also be done to view the soft tissues of the joint.

    Treatment:
    Treatment of a frozen shoulder is designed to restore movement to the shoulder, and reduce pain. Over 90% of sufferers improve with simple treatment.

    To reduce pain and swelling, your doctor will probably prescribe NSAIDs (non-steroidal anti-inflammatory drugs). Examples of such drugs are Advil, Motrin and Aleve. Sometimes you may be prescribed stronger pain and anti-inflammatory medication.

    You may also receive a corticosteroid injection directly into the shoulder joint, which will normally provide rapid relief from pain and inflammation. Such injections are highly effective but, due to possible side effects, cannot be repeated more than two or three times a year.

    Physical therapy, possibly under the supervision of a physical therapist, will include exercises to gradually stretch the muscles around the joint and improve range of motion. Sometimes heat is applied to the shoulder before beginning treatment.

    Very occasionally, if conservative treatment has not provided relief, surgery is performed. Under anesthetic, the surgeon might stretch or tear the capsule and adhesions by forcibly manipulating the shoulder in order to release the tightness. Another procedure is to cut through the tight areas, using thin instruments inserted through tiny incisions around the shoulder area. Results from surgical intervention are normally very successful.

    Exercises:
    It is extremely important to try to maintain and increase the range of motion of the shoulder. Exercising several times daily is necessary. Pain felt while doing exercises should not be worse than mild. Stop exercising and consult your doctor if you feel a sharp or tearing pain.

    Pendulum:
    Standing or sitting, let your arm hang down at your side. Allow your arm to swing from side to side and back and forth, then in small circles. Keep the distances short. Repeat this exercise for 3-7 days then add a small weight (1-2 lbs). Gradually increase the range of motion.
    Passive stretches:
    These are best performed after the above pendulum exercise. Do 2 sets of 10-20 repetitions twice each day and do not stretch to the point of pain, only tension.
    Armpit stretch:
    Lift the arm of the affected side onto a surface that is about chest-high. Slowly bend your knees so that your armpit gradually opens. Increase the bend as the shoulder loosens.
    Wall walking:
    Standing and facing a wall that is about three-quarters of your arm’s length away, walk your fingers up the wall until your arm is at shoulder level. Do not use your shoulder muscles to achieve this - just your fingers.
    Towel stretch:
    Hold a towel behind your back in both hands. Use the unaffected arm to pull on the towel so that the affected arm moves across your back.
    Circles:
    Place the affected arm on the other, unaffected, shoulder. Rotate the elbow of the affected side in very small circles, increasing the range as the shoulder loosens and discomfort allows.

    Prognosis:
    In most cases, a frozen shoulder resolves itself, but it may take up to three years for full mobility to be restored and occasionally a small amount of stiffness remains. Exercising the shoulder regularly will be greatly beneficial.

  • Lymphedema

    Lymphedema

    What is Lymphedema?

    Lymphedema is an abnormal accumulation of protein-rich fluid in the interstitial space. This not only can cause swelling, but can also result in changes to the skin, infection, and decreased wound healing where wounds are present.

    What is the cause of Lymphedema?

    There are two main classes of Lymphedema - Primary and Secondary. Primary lymphedema in some instances is congenital or often arises later in life. Secondary lymphedema arises as the result of damage to components of the lymphatic system, (i.e. radiation, surgery, trauma, or infection).

    Symptoms

    The primary clinical presentation of lymphedema is swelling, caused by the accumulation of fluid and protein in the interstitial space. As lymphedema progresses, the skin can become fibrotic and darkened. This is due to the accumulation of proteins and other elements that would normally be removed by the lymphatic system.

    With lymphedema, there is an increased risk of infection because protein rich fluid accumulation creates an environment favorable to bacterial growth.

  • Radial Head Fracture

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    Radial Head Fracture

    The two bones in the forearm are the radius and the ulna. The radius is the bone nearest your thumb and the ulna nearest the little finger. A fall onto an outstretched arm can result in a fracture of the upper end of the radius (the radial head). Radial head fractures are relatively uncommon injuries that can happen in isolation but frequently occur during an elbow dislocation, when the realignment of the humerus and ulna cause a piece of the radial head to be broken off.

    At the proximal (upper) end of the bones, the ulna articulates with the radius and the humerus (upper arm bone) to form the hinge-like elbow joint. At the furthest (distal) end of the forearm, the radius articulates with the ulna and three of the wrist bones. A strong membrane between the radius and ulna holds the bones close together but allows them to rotate around each other to a certain degree so that we can turn our palms up and down.

    Radial head fractures are classified according to their severity and the degree of separation between the bone pieces:

    Type I:
    These fractures are typically stable in that the bone is not displaced. The fractures tend to be small and crack-like.
    Type II:
    The bone pieces are slightly separated. The fracture involves a larger piece of bone, and there may be fragments broken off.
    Type III:
    The entire radial head has been broken into pieces (a comminuted fracture).
    Type IV:
    These comminuted fractures are often combined with a dislocation and affect associated soft tissues such as ligaments. A Monteggia fracture-dislocation with the radial head fractured is an example of a Type IV injury.

    Causes:
    A fall onto an outstretched arm, with the forearm angled, is the most usual cause of a radial head fracture. Rarely, this type of injury occurs as a result of a heavy blow, such as during a motor vehicle accident. In some cases, deterioration of the bone due to osteorarthritis or rheumatoid arthritis may result in a fracture.

    Symptoms:
    • Pain, sometimes severe, on the outer, upper or lower side of the elbow
    • Desire to guard the elbow
    • Holding the elbow in a flexed (bent) position
    • Swelling and tenderness of the outer side of the elbow
    • Loss of range of motion. Difficulty bending or straightening the arm, and difficulty turning the palm up or down.
    • Possible numbness or tingling sensation
    • Depending on injury, visible deformity of the elbow
    Diagnosis:
    The doctor will ask you about the circumstances of your injury. He or she will gently palpate (touch) your elbow, feeling for signs of fracture or dislocation. You will be asked to try to straighten your arm and move your hand. The doctor will probably do some passive tests (the doctor moves your arm for you) to assess the stability of the elbow joint ligaments. Your wrist will be checked for injury as wrists are often damaged at the same time as an elbow injury.

    The blood and nerve supply will be carefully checked as several nerves and blood vessels pass through the elbow joint.

    X-rays show bone structure very clearly. Several will taken of the elbow from different angles to aid diagnosis and ensure that any other bone injuries are discovered. If damage to soft tissues such as ligaments is suspected, CT (computed tomography) scans of the elbow may also be taken.

    Treatment:
    The aim of treatment is to regain maximum function and stability of the elbow joint. The method used will depend on the type of fracture.

    First aid will consist of applying ice to the elbow to relieve swelling, and administering pain medication. The elbow will be placed in a splint and supported in a sling. If a bone fragment has pierced the skin (a compound fracture) there is a serious risk of infection so surgery would be immediate. The wound would be thoroughly cleaned and any repair to the bone or soft tissues performed at the same time.

    Type I fractures are usually treated conservatively (non-operatively). If the patient is an adult and the degree of bone displacement is less than 2 mm, the doctor will attempt to realign the bone without the need for surgery. This is called a closed reduction. If there is no displacement, there is no need for manipulation. Following reduction, the elbow would be placed in a sling, with perhaps a few days wearing a splint as well. Pain medication, non-steroidal anti-inflammatory drugs (NSAIDs) and icing of the elbow would continue to provide relief.

    Type II, III, and IV fractures require surgery. The best results are achieved with a technique called open reduction internal fixation. During surgery the bone pieces are realigned and held in position with orthopedic fixing devices such as screws, pins or plates. Damaged soft tissues would be trimmed or reattached as necessary. After surgery the arm would be placed in a long arm cast with the elbow bent at 90 degrees. This would be worn for two weeks and then changed to a hinged brace to allow range of motion exercises to begin.

    Your doctor or physical therapist will develop a program of rehabilitation exercises, starting at the correct time for your particular injury. Because of the complexity of the elbow joint it is important to follow medical advice and to perform the recommended exercises regularly. Physical therapy may include massage, initial passive movement of the elbow, ultrasound, and exercises to restore range of motion and strength.

    Prognosis:
    With any bone fracture there is a risk of developing arthritis, particularly if the articular surface of the bone has been damaged. Stiffness in the joint, even with physical therapy, may be a long-term problem, but will be minimized with proper attention to rehabilitation.

    Exercises:
    You should only begin rehabilitation exercises when your doctor has confirmed that the fracture is stable enough for you to do so. Try to do the exercises three times a day. You should not feel any pain when doing these exercises. If you do, stop.
    Elbow Flex and Extend:
    Standing, simply bend and straighten your elbow as far as it will go without force. You should not feel any pain. Repeat 10 times.
    Rotations:
    With your elbow by your side and bent to 90 degrees, carefully turn your hand up and down as far as it will go without force. Repeat 10 times.
    Ball Squeeze:
    Hold a soft ball, about the size of a tennis ball, in your hand. Squeeze the ball as hard as possible with causing yourself pain. Hold for 5 seconds. Repeat 10 times.

  • Rotator Cuff Injury

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    Rotator Cuff Injury

    A rotator cuff injury refers to damage sustained by any part of the rotator cuff structure in the shoulder.

    A collection of muscles and tendons form the rotator cuff, connecting the humerus (upper arm) to the scapula (shoulder blade). Each of the four muscles of the cuff has an insertion into the scapula, and a tendon that originates in the muscles and attaches to the humerus. The muscles and associated tendons are the supraspinatus, infraspinatus, teres minor, and subscapularis. Together they form a cuff that allows extensive movement of the arm and shoulder while helping to stabilize the shoulder joint.

    The rotator cuff can be damaged in different ways. A tendon may be torn, muscle fibers may be stretched or torn, adhesions may form in the joint capsule, causing a frozen shoulder, the bursa (fluid-filled cushion between the tendons and the scapula) may become irritated, or the tendons might be pinched between the humerus and scapula.

    Injury to the rotator cuff can range from relatively mild, which will resolve with conservative treatment, to a partial or complete tearing of the muscle that may need surgical repair. Any injury to a muscle or tendon is described as a strain, and is graded according to severity, with stretched fibers designated as Grade I, partial tearing of fibers designated as Grade II, and a complete tear of a muscle or tendon designated as Grade III.

    Causes:
    • Overuse: repetitive motions can cause injury. Common examples are throwing a ball, lifting heavy objects, or having a job that involves a lot of overhead work such as painting or carpentry.
    • Aging: the normal aging process will cause muscles and tendons to gradually degenerate, making them more vulnerable to injury. Tendons have a poor blood supply, so a fairly mild strain can take a long time to heal.
    • Trauma: an accident, falling onto an outstretched arm, or grabbing at something overhead to prevent a fall can result in damage to the rotator cuff. A rotator cuff injury may happen at the same time as another injury such as a dislocated shoulder or a broken collarbone.
    • Chronic injury: a previous injury may have caused a structural change in the anatomy of the rotator cuff that affects normal function of the shoulder joint, or causes inflammation (tendinitis). Tendinitis is more common in women between the ages of 35 and 50.
    Symptoms:
    If the injury is acute:
    • Sudden and severe pain with sensation of tearing running from the shoulder down the upper arm
    • Loss of range of motion
    • Sensation of grinding when moving the shoulder
    • Loss of use of shoulder joint due to pain and muscle weakness
    Chronic injury:
    • Pain, worse at night, that may be severe enough to disrupt sleep
    • Increasing loss of use of shoulder due to pain
    • Weakness of the shoulder joint
    • Increased inability to raise the arm up or out to the side
    Tendinitis:
    • Deep ache felt in the shoulder and outer area of upper arm
    • Possible tenderness over injured area
    • Pain made worse with raising the arm to the side or turning it inwards
    Diagnosis:
    In order to assess whether you have an acute or chronic condition, your doctor will ask questions relating to any previous shoulder injuries, as well as the circumstances surrounding your current injury and the symptoms that you are experiencing.

    Your doctor will physically examine your shoulder and upper arm, palpating (touching) it for areas of tenderness or deformity. The range of motion of the shoulder joint, as well as its strength, will be assessed, unless a broken bone is suspected. Various tests, each using muscle contractions, may be performed to try to identify which muscle is damaged.

    Nearby structures such as the neck may also be examined, to rule out pain referred from another condition.

    X-rays, although they normally will not show rotator cuff injury, are often taken to rule out broken bones or arthritis as causes of your symptoms. MRI (magnetic resonance imaging) scans are regularly used for diagnosis of shoulder conditions as they show soft tissues in great detail. CT (computed tomography) scans and ultrasound are other diagnostic techniques that may be employed.

    Treatment:
    Continuing to use the shoulder if you have a rotator cuff injury may cause the injury to worsen. Early treatment will result in an easier and quicker recovery.

    Ice, crushed in a bag and wrapped in a towel, can be applied to the painful area several times a day to help reduce inflammation.

    You can use a sling to rest the shoulder, but you should continue to use the shoulder gently and often in order to decrease the risk of the shoulder becoming so stiff that you will difficulty regaining full use of it.

    With the approval of your doctor you can take over-the-counter NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen or aspirin. Your doctor may inject a corticosteroid directly into the joint. This usually provides a rapid decrease in inflammation and relief from pain, but can only be administered two or three times a year due to potential side effects.

    Physical therapy to increase the range of motion, flexibility and strength of the shoulder will be necessary for a good recovery. Your doctor or physical therapist will develop a graduated exercise program for you.

    If conservative (non-surgical) treatment fails after about eight weeks, acute rotator cuff injuries may require surgical repair, depending on the type and severity of the damage. Younger patients with a complete tear, or people whose sporting or occupational needs require repetitive shoulder use, are the usual candidates for surgery.

    If you have a chronic rotator cuff injury that failed to respond with conservative treatment, you also may benefit from surgery. You will be referred to an orthopedic surgeon to discuss your options. Surgery can be either open (traditional) or arthroscopic.

    The results of your treatment will depend on your age, the severity of the injury and the particular treatment chosen. In general, conservative treatment has a success rate of 40-90%, and surgical repair 94%.

  • Shoulder Bursitis

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    Shoulder Bursitis

    A bursa is a fluid-filled sac that lies between various tissues and structures to allow smooth movement. If the bursa is injured or inflamed it causes the space within which other tissues move to become restricted, leading to friction, irritation, and pain. Shoulder bursitis is a condition of inflammation of the bursa in the shoulder, and is also known as impingement syndrome.

    The shoulder is a complex, highly mobile arrangement of bones, muscles, tendons, ligaments, and associated connective tissues that together form two joints: the glenohumeral and the acromioclavicular.

    The glenohumeral joint is formed where the rounded upper end of the humerus (upper arm) fits into a shallow concavity of the scapula (shoulder blade). A collection of muscles and tendons form a rotator cuff that helps to keep the humerus in the socket of the scapula, stabilizing the shoulder.

    The acromioclavicular joint is formed by the connection of a different part of the scapula, the acromion, and the clavicle (collarbone). Both joints need to be working properly for full motion of the shoulder, although the glenohumeral joint is responsible for most movement.

    In the shoulder the bursa lies between the acromion and the humerus. It protects the tendons of the rotator cuff from friction as they move. Inflammation of the bursa causes a reduction in available space, which causes the tendons to become irritated and swollen, leading to a further reduction in space. Eventually, if the condition continues, every time the tendons move, they and the bursa get pinched between the bones. This is what is called impingement syndrome.

    Causes:
    In some people, their natural anatomical structure means that they have a smaller space between the humerus and acromion than others, and therefore an increased risk of developing shoulder bursitis.

    Other people suffer an injury that triggers inflammation of the bursa that gradually worsens, as described above.

    Another cause is the natural aging process: with age, tendons become more brittle and liable to tear.

    Bursitis can also develop as a result of overuse of the shoulder, poor posture, insufficient warming up before exercise, or some medical conditions such as rheumatoid or psoriatic arthritis, gout or a thyroid disorder.

    An infection of the bursa is a rare cause of shoulder bursitis.

    Symptoms:
    • Pain is the main symptom. It may develop gradually or have a sudden onset, in which case the pain may be severe.
    • Pain will be worse on raising your arm over your head, or moving your shoulder.
    • The pain, which may be aching, might interfere with your sleep.
    • You may experience a loss of range of motion in the shoulder, which also may be weaker.
    Diagnosis:
    There are many conditions that cause pain in the shoulder, so you should seek medical advice if you have any pain or swelling.

    Your doctor will ask you questions about your general health, lifestyle and activities, and about any circumstances relating to your current symptoms. Your shoulder will be physically examined for areas of tenderness, range of motion, strength, and stability. X-rays may be taken, as may MRI (magnetic resonance imaging) scans.

    Treatment:
    Shoulder bursitis usually resolves with the use of conservative (non-surgical) treatment.

    Your doctor may give you a corticosteroid injection into the shoulder joint that can provide rapid relief. Although effective, such injections cannot be given more than three times a year due to possible damage to the tendons. Another technique your doctor may use is aspiration of the bursa, a procedure during which a needle is used to remove fluid.

    If the onset of shoulder bursitis is sudden and severe, the application of crushed ice, in a bag wrapped in a towel, will help to reduce the inflammation and therefore the pain. Ice can be applied several times a day for as long as is comfortable.

    After a couple of days, applying heat to the shoulder, especially before any kind of exercise, will provide relief and promote healing by bringing extra blood to the area.

    Rest your shoulder: in particular, avoid any movement or activity that makes the pain worse. Avoid such things as throwing or lifting a weight above your head. Do not completely immobilize the shoulder, however, as you could increase the risk of developing a frozen shoulder (adhesive capsulitis).

    Over-the-counter medication such as NSAIDs (non-steroidal anti-inflammatory drugs) will relieve inflammation and pain. Examples are Advil, Motril, Aleve, and others.

    Following the acute stage of the condition, you will need physical therapy to rehabilitate the shoulder. This will include exercises to increase range of motion. Your doctor or physical therapist will give you an exercise regime to follow. You can do the exercises given below to help prevent loss of range of motion. Therapy may also include ultrasound or massage.

    Very occasionally, surgery is necessary. Subacromial decompression is a minimally invasive procedure that surgeons can perform in order to trim or remove inflamed tissues to enlarge the space needed by the rotator cuff tendons. You will wear a shoulder sling for a time after surgery, but you will probably begin gentle range of motion exercises almost immediately.

    Exercises:

    Pendulum:Standing, bend over at the waist and let your arm hang down at your side. You can hold onto a support with the other hand. Allow your arm to swing from side to side and back and forth, then in small circles. Keep the distances short. Repeat this exercise for 3-7 days then add a small weight (1-2 lbs). Gradually increase the range of motion.

    Passive stretches:
    These are best performed after the above pendulum exercise. Do 2 sets of 10-20 repetitions twice each day and do not stretch to the point of pain, only tension.

    Armpit stretch:
    Lift the arm of the affected side onto a surface that is about chest-high. Slowly bend your knees so that your armpit gradually opens. Increase the bend as the shoulder loosens.

    Wall walking:
    Standing and facing a wall that is about three-quarters of your arm’s length away, walk your fingers up the wall until your arm is at shoulder level. Do not use your shoulder muscles to achieve this - just your fingers.

    Prognosis:
    Shoulder bursitis usually responds well to treatment. If you are diligent about following medical advice, you should find that the bursitis has resolved after two to three months.

  • Shoulder Labral Tear

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    Shoulder Labral Tear

    A labral tear is an injury to the glenoid labrum of the shoulder joint. Three bones, the clavicle (collarbone), scapula (shoulder blade), and the humerus (arm bone), form the shoulder joint. The upper end of the humerus is large and rounded, and it sits in a shallow concavity of the scapula called the glenoid fossa. It is the shallowness that allows for such extensive mobility of the shoulder joint, but it makes the joint fundamentally unstable. There is therefore a rim of thick fibrous tissue around the edge of the glenoid fossa that deepens the socket and helps to keep the humerus in position. Several ligaments (bands of strong connective tissue) have their attachments on the glenoid labrum.

    There are particular types of labrum tear. These are:
    • SLAP (superior labrum from anterior to posterior) tear: this is a tear at the top of the labrum where the biceps tendon has its insertion onto the labrum. Athletes who use repetitive overhead throwing motions are prone to SLAP tears.
    • Bankart lesion: this tear happens during a shoulder dislocation and increases the vulnerability of the shoulder to future dislocations. Younger people (under 30) are more likely to suffer a Bankart lesion during a dislocation.
    • Posterior labral tear: in this injury, the rotator cuff of the shoulder and the labrum are compressed together in the posterior (back) shoulder.
    Causes:
    Glenoid labrum tears often happen in conjunction with other shoulder injuries, such as dislocations.

    Repetitive shoulder movements can result in injury to the labrum. Examples might include repeated overhead throwing motions, or lifting heavy weights above the head.

    Trauma is another cause of a labrum tear. A hard blow to the shoulder, falling onto an outstretched arm, a sudden force as when trying to lift something heavy, or grabbing at something overhead to prevent a fall, could provide enough force to tear the soft tissues of the labrum.

    Age will cause the labrum to become more brittle, increasing the risk of injury.

    Symptoms:
    • Pain, made worse with particular activities
    • Achy pain in the shoulder joint
    • Sensation of locking or catching of the shoulder joint with movement
    • Sense of the shoulder being unstable
    • Weakness in the shoulder
    • Loss of range of motion of the shoulder
    Diagnosis:
    Your doctor will ask you for your medical history, including any previous injuries to your shoulder. You will probably be asked about your normal level of activity and whether you participate in any sports. You will be asked for details about your current injury, any circumstances surrounding the onset of pain, and the type and severity of your symptoms.

    Diagnosis of a labral tear is difficult. Your shoulder will be physically examined, which will likely include the doctor moving your shoulder and arm to assess the passive range of motion, and asking you to move your arm and shoulder yourself, to assess active range of motion.

    X-rays will be taken to view the bony structures of the shoulder, and a CT (computed tomography) or MRI (magnetic resonance imaging) scan taken to look at the labrum itself, and surrounding tissues. A contrast dye may be injected before the scan, to show any tears more clearly.

    It may only be possible to make a definitive diagnosis using arthroscopic surgery, which involves inserting very slender instruments into the joint through tiny incisions around the shoulder. Confirmation of a diagnosis of a labrum tear would then occur at the same time as surgical repair.

    Treatment:
    Most labral tears are treated conservatively (non-surgically). Specific treatment depends on the type of labrum tear.

    SLAP tears do not heal as well as other labrum tears because the area involved has a poor blood supply. However, conservative treatment usually works. Treatment will include rest, anti-inflammatory medication and perhaps a cortisone injection into the joint.

    A Bankart lesion increases the risk of future shoulder dislocations so, although conservative treatment may relieve symptoms, surgery may be necessary to stabilize the joint. Without surgery, a Bankart lesion will take at least six months to heal. Because young athletes may be reluctant to wait for so long, and because the chance of a repeat dislocation is so high, many doctors will recommend immediate surgical repair of the lesion. Older patients are less likely to need surgery as, after age 30, the chance of a repeat dislocation diminishes rapidly.

    Depending on the type and severity of your injury, your doctor will probably prescribe anti-inflammatory medication and rest before considering surgery. Resting the shoulder may involve wearing a sling for a few weeks. You will certainly need to avoid any movements that make the pain worse. If conservative treatment fails, or your injury requires it, surgery will be performed. Surgery will be either open or arthroscopic, depending on your surgeon’s preference.

    During surgery, the labrum will be carefully examined, along with the biceps tendon. The stability of the joint depends on the location of the tear; if the biceps tendon is intact, the joint is stable and the surgeon will simply remove or trim the torn piece of labrum. If the biceps tendon is detached or torn, the labrum will need to be reattached and the shoulder stabilized with the use of wires or sutures, which may be absorbable.

    You will be instructed to use a sling for three to four weeks after surgery. You will also have to rehabilitate the shoulder through a graduated series of exercises designed to gently increase the range of motion of the shoulder. These will probably begin with pendulum exercises, where you bend at the waist and simply let your arm hang downwards then begin to make small circles with the arm, clockwise and anticlockwise. When you are no longer wearing the sling you will begin exercises to strengthen the biceps, which will have weakened through disuse, and to continue to increase flexibility in the shoulder. Your doctor or physical therapist will supervise your exercise program.

    It is extremely important to resume activities slowly and not rush rehabilitation as further injury to the labrum might occur. Follow medical advice carefully.

    Full recovery after surgery may take six months or longer.

  • Shoulder Separation

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    Shoulder Separation

    Definition:
    A shoulder separation is an injury to the ligaments that connect the clavicle (collarbone) to the highest part of the scapula (shoulder blade), the acromion. The connection of these two bones is known as the acromioclavicular joint hence a shoulder separation can also be called an acromioclavicular separation or an AC separation.

    Ligaments are strong bands of connective tissue that attach bones to bones, helping to stabilize joints. There are several ligaments attaching the clavicle to the scapula, both around the AC joint and also further along the clavicle. A severe injury to the shoulder can cause the ligament to tear, partly or completely, which can result in the two bones separating. Sometimes the injury includes a broken bone.

    Causes:
    The most likely causes of a shoulder separation are a fall onto the shoulder or a heavy blow to the top of the shoulder that forces the clavicle downwards and away from the scapula. This might typically happen in a sporting injury or a vehicle accident.

    Symptoms:
    • Depending on the severity of the injury, there may be a visible deformity on the top of the shoulder. The end of the clavicle, having been separated from the acromion, would form a lump under the skin.
    • Pain is usually present, with the desire to support the affected arm with the other hand.
    • Tenderness at the acromioclavicular joint site.
    • Possible swelling or bruising on the top of the shoulder.
    • Numbness or muscle weakness in the affected arm.
    • Decrease in mobility of the shoulder.
    Diagnosis:
    It is possible that a severe injury may only produce relatively mild symptoms, so it is important to seek medical advice if you suspect you may have a shoulder separation.

    Your doctor will ask about your medical history, particularly any previous injuries to your shoulder. You will also be asked about your general lifestyle and activities. Your shoulder will be physically examined, and X-rays will be taken in order to assess the condition of the acromioclavicular joint. Other diagnostic scans, such as MRI or ultrasound, that show the soft tissues in more detail than X-rays, may be performed at a later date.

    Treatment will depend on the grade of injury that is diagnosed. Types I and II shoulder separations usually respond to conservative (non-surgical) treatment. Type III injuries are a little more complicated in terms of which treatment is best; people whose occupations require heavy labor or overhead movements may be more appropriate candidates for surgery. Types IV, V, and VI are less common and may include damage to associated muscles. Surgery is the likely treatment for these injuries.

    Treatment:
    Immobilize the joint by placing the shoulder in a sling or shoulder brace. This is to prevent further damage to the joint caused by the weight of the arm pulling on the joint, and also to restrict movement. Once the acute stage of the injury is over, usually after a few days, it is helpful to begin moving the shoulder gently to minimize stiffness and decrease the risk of developing a frozen shoulder (adhesive capsulitis).

    Apply ice, crushed in a bag and wrapped in a towel, to the top of the shoulder. You can apply ice for as long as is comfortable, several times a day. It will reduce swelling and help to relieve pain.

    Over-the-counter NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Advil), naproxen (Aleve), or aspirin can be taken to help reduce swelling, or acetaminophen (Tylenol) for pain relief.

    Physical therapy to rehabilitate the joint will probably begin after a few days, when the initial swelling and pain has diminished. Your doctor or physical therapist will design a program specifically for you, based on your particular injury.

    Some of the most severe shoulder separations require surgical repair, as might injuries that fail to respond to conservative treatment, and deformities of the shoulder that cause irritation. Surgery to reattach ligaments can be very successful even if performed some time after the injury, so in many instances it is sensible to wait to see if other treatments resolve the problem. Surgery might also be performed to trim the end of the clavicle so that it no longer rubs against the acromion.

    Prognosis:
    Most people recover well from a shoulder separation and can return to normal activities within two to three months. Sometimes a deformity remains, but does not affect shoulder mobility. If pain persists, it is usually due to the ends of the bones in the acromioclavicular joint continuing to rub against each other, or the development of arthritis, or the joint cartilage between the bones has been injured.

    Exercises:
    When your doctor advises that it is safe to do so, you may begin some gentle rehabilitation exercises. These should be done on a daily basis to gradually increase the range of motion of your shoulder. Strengthening exercises will begin once you have been performing range of motion exercises for a few days. You will be prescribed specific exercises, but you can begin with the following:

    Pendulum:
    Bend forward at the waist and allow your injured arm to hang straight down towards the floor. Gently move your hand in small circles, both clockwise and anticlockwise. The momentum will cause your arm to move.
    Wand flexion:
    Standing, hold a stick in both hands with your palms facing down. Slowly, keeping your elbows straight, lift your arms above your head. Hold the stretch for 5 seconds then lower your arms. Repeat 10 times.
    Wand extension:
    Standing, hold a stick behind your back, using both hands. Slowly lift the stick away from your back. Hold the stretch for 5 seconds then lower. Repeat 10 times.
    Shoulder flexion:
    Stand with your arms at your sides; keeping your elbows straight, carefully raise your arms out to the side and as high as they will go without pain. Hold for 5 seconds. Repeat 10 times.
    Scapular range of motion:
    Standing, shrug your shoulders up. Hold for 5 seconds. Squeeze your shoulder blades back towards each other. Hold for 5 seconds. Drop your shoulder blades down as though putting them in a back pocket. Hold for 5 seconds. Repeat exercise 10 times.

  • Shoulder Subluxation

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    Shoulder Subluxation

    A shoulder subluxation is similar to a shoulder dislocation, the difference being that a subluxation is temporary and partial. It can be described as shoulder joint instability. A study of over 4,000 West Point cadets showed that shoulder subluxations are much more common than dislocations, and often happen in conjunction with other injuries such as Bankart lesions.

    The shoulder is a highly mobile joint, allowing the arm to move in almost any direction. The joint is formed by the connection of the humerus (the upper arm bone) and the scapula (shoulder blade). The articular end of the humerus is rounded and fits into a shallowly concave surface of the scapula called the glenoid fossa, forming a flexible ball-and-socket joint. Helping to stabilize the joint are ligaments and tendons that together form what is known as the rotator cuff.

    The flexibility of the joint and the shallowness of the glenoid fossa make the joint fundamentally unstable; the humerus can quite easily be pushed out of place as a result of a trauma. If the humerus then spontaneously returns to its correct position, the incident is treated as a subluxation. During such an injury, associated tissues such as shoulder muscles, ligaments, and tendons may be stretched or torn. There may also be nerve or blood vessel damage.

    Causes:
    Shoulder subluxations can occur as a result of a fall onto the shoulder, a heavy blow to the shoulder, or a severe twist of the arm. Sports that carry a high risk are boxing and football.

    Previous shoulder injuries may increase the risk of subluxation, particularly if those injuries have been dislocations that have stretched the ligaments. If the ligaments are especially loose, subluxations can occur during normal activities.

    Subluxations can also happen to people who naturally have loose ligaments; these people are sometimes called ‘double-jointed’ due to the excessive mobility of their joints.

    Symptoms:
    • Sensation of your shoulder joint having gone out of position and then back in
    • Pain, varying from mild pain upon performing daily activities, to severe pain during subluxation
    • Instability of the shoulder joint, ranging from mild to extreme
    • Weakness or numbness in the shoulder or arm
    Diagnosis:
    Your doctor will ask you questions about your medical history, paying particular attention to any previous injuries to your shoulder. Your doctor will want to know about the circumstances of this injury and the type and severity of any symptoms that you may be experiencing. You will also be asked about your lifestyle and regular activities. Your shoulder will be physically examined, including manipulation of the joint to assess instability and weakness. X-rays may be taken to rule out bone fractures.

    Shoulder subluxation can sometimes be misdiagnosed as bursitis or a rotator cuff tear. An MRI (magnetic resonance imaging) scan can be a useful diagnostic tool, although it does not always show subluxation. An experienced orthopedic surgeon should be able to make a correct diagnosis.

    Treatment:
    Initial treatment includes applying ice to the affected area to reduce swelling and thereby relieve pain. Ice should be placed in a bag, crushed, wrapped in a towel and applied for as long as is comfortable, several times a day.

    Over-the-counter pain medication such as acetaminophen (Tylenol) or NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Advil), naproxen (Aleve), or aspirin, will reduce inflammation and relieve pain.

    Rest the shoulder by wearing a sling for a few days, but do not completely immobilize it in order to avoid developing a frozen shoulder (adhesive capsulitis).

    After the acute phase of the injury has passed it is important that you do exercises to strengthen the muscles of the rotator cuff.

    Repeated subluxations may require surgical intervention to tighten up the ligaments. Your surgeon may use arthroscopic techniques to both make a definitive diagnosis and, at the same time, repair any damage. Arthroscopy is minimally invasive as it uses very narrow instruments inserted through tiny incisions made around the shoulder. Recovery is faster than with traditional ‘open’ surgery.

    Prognosis:
    Many people can make a good recovery using conservative (non-surgical) treatment as described above. Following surgery there would be a period of about 2-3 weeks when the shoulder would be supported by a sling or brace and you would be doing range of motion exercises, after which a program of strengthening exercises would begin. A full return to normal activities and sports should be achievable within six months.

    Exercises:
    Your health care provider or physical therapist will design an exercise program specifically for you, but, with medical approval, doing the following exercises will help you begin to rehabilitate your shoulder.
    Range of motion: Go carefully and gently, without forcing.
    Shoulder flexion:
    Standing with your arms straight by your sides. Keeping your elbow straight, lift your arm up as high as you can. Hold for 5 seconds. Repeat 10 times.
    Shoulder extension:
    Stand with your arms straight by your sides. Keeping your elbow straight, move one arm backwards as far as it will go, without forcing. Hold for 5 seconds. Repeat 10 times. Repeat exercise with the other arm.
    Shoulder abduction:
    Standing with your arms at your sides, slowly lift the arms out to the side and up. Hold for 5 seconds. Repeat 10 times.
    Isometric:
    External rotation:
    Stand in a doorway with the injured shoulder nearest the doorframe. Bend the elbow and press the back of the wrist against the doorframe. Hold for 5 seconds. Repeat 10 times for 1 set. Do 3 sets.
    Internal rotation:
    Standing just to the side of a doorway, bend the elbow of the injured arm and press the front of the wrist against the doorframe. Hold for 5 seconds. Repeat 10 times for 1 set. Do 3 sets.
    Adduction:
    Hold a pillow between the chest and arms. Squeeze the pillow and hold for 5 seconds. Repeat 10 times for 1 set. Do 3 sets.
    Extension:
    Stand with your back to a wall so that your bent elbows just touch the wall. Press your elbows back against the wall and hold for 5 seconds. Repeat 10 times for 1 set. Do 3 sets.


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Arm & Shoulder Pain

Common shoulder injuries can be caused by overworking the arm and shoulder muscles, overextending joints or the deterioration of bones and connective tissue with age. Because we use our upper extremities to perform most of our day-to-day activities, arm and shoulder problems can cause huge disruptions to our routines and our comfort. Here, MMAR Medical provides a comprehensive library of articles written by medical professionals to help patients and those in the sports medicine field to understand the causes of tricep, bicep and deltoid pain as well as how to prevent injuries.

Each article above addresses a specific arm or shoulder injury, its causes, diagnosis, rehabilitation techniques and recommendations of proper support or bracing options to speed up the healing process and increase the patient’s comfort during recovery. Contact us with further questions about your specific condition.

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