I dislocated my collarbone when I fell onto it about 16 years ago. I put it in a sling, but it never popped back in.  Just recently it is starting to give me some discomfort, and I have noticed that the right arm is much weaker than the left when holding my arms out in front of me for prolonged periods (during martial arts).

I have assumed over the years that it is too late to treat this simply as my body will have grown and developed to accommodate this. Is there any advice you can give as to a course of action, or is it simply something I will have to live with having left any treatment so long?

Regards,

Tim

Dear Tim,

Thank you very much for your kind email – I am however sorry to hear of your unfortunate shoulder injury. Most commonly a dislocated collar bone occurs when the AC joint is injured. This is also called a shoulder separation. An AC joint injury can be managed in several different ways depending on the severity. I have been reconstructing many of these arthroscopically, even in chronic cases, and you may be a candidate for this type of minimally-invasive surgery for your problem, especially since it sounds as if you are having a lot of disability with this injury. I usually fix type 5’s and some type 3’s in those who are chronically symptomatic (as are you) or in overhead athletes. However, as you can imagine, there can be many different factors to consider for shoulder injuries such as yours. Furthermore, as you might expect there can be several treatment options and risks with benefits with each type that I would be happy to discuss with you. You can go to the following websites for some additional online information:

shoulder1.com

drmillett.com

If you would like, I would be happy to review your x-rays and MRI, and afterwards, if possible, I could give you my opinion about what should be done surgically to either cure the problem or at least alleviate the symptoms. I can usually determine from the studies and a telephone conversation whether it would be worthwhile having you come for a visit/surgery.  It would be best if I could evaluate you in person as this gives me the greatest chance of effectively diagnosing and treating your problem. You can call to schedule an appointment to see me.

Thank you again for your email – I look forward to helping you with this problem.

Regards,
Dr. Millett

I injured my shoulder last summer and was diagnosed with a torn rotator cuff.  It was a very serious injury, and I had surgery and it appears that the surgery did not take.  I am seeking information on what my options are with a failed rotator cuff repair. I have read about revision rotator cuff surgery and I’m seeking further help.  What are my treatment options?

Thanks,

Carl M.

Dear Carl,

Rotator cuff surgeries for a rotator cuff injury do at times fail for a variety of different reasons.  It is important to seek the care of experienced specialist in a situation such as yours. It is also important to figure out why the tendon failed to heal. If the torn rotator cuff tendon is still repairable, as determined by an MRI, you may consider a revision rotator cuff surgery in which the tendon is reattached surgically. If however the tendon is of poor quality, you may need to consider other options. Sometimes we augment the repair with a collagen patch to reinforce the repair. The collagen patch serves to provide additional support for the repair and helps new cells to heal the damaged area of the tendon. In other cases of massive irreparable tears, one may need to consider a tendon transfer surgery. This is usually considered the last resort for repeated rotator cuff injuries or irreparable tears and can yield positive results. During a tendon transfer for rotator cuff repair, another healthy tendon and its muscle are moved from one location to another to substitute for the chronically torn rotator cuff tendons.  The tendon transfer for rotator cuff repair is completed principally to alleviate pain and secondarily so that lost function of the shoulder can be regained. There are a number of criteria that a patient must meet to be permitted to receive this surgery. Some of the criteria include good physical health, strong bones, strong muscles to transfer and an understanding and willingness to follow the strict rehabilitation protocol that is necessary.

For more information on revision rotator cuff surgery, please call my office or look at my website where additional resources can be found.

I am 72 years old and have severe osteoarthritis in both of my shoulders from years of heavy lifting, golfing, etc.  I’m considering a double shoulder replacement surgery and have spent quite a bit of time researching my options.  Can you tell me what my recovery time will be like once the joint replacement surgery is completed, how I will feel after, and how long the effects of the surgery will last?

Best,

Teresa

Hi Teresa,

I use an approach known as an anatomic total shoulder replacement surgery.  This shoulder replacement surgery is a joint replacement procedure most commonly performed on patients suffering from more advanced arthritic conditions — such as yourself. Most of my patients will feel dramatic improvement, sometimes occurring almost immediately postoperatively.  Most patients regain complete use of their arms with the ability to go back to all pre-surgery activities after about three to four months, although most patients find that they are able to lift their arms to about shoulder level within the first few weeks. Patients are allowed as well as encouraged to begin using their shoulders for light activities almost immediately.  In order for shoulder replacement surgery to be effective and successful, each patient should adhere to a strict rehabilitation program.  The program will consist of strengthening movies, range of motion activities and stretching.

In almost all cases, patients who have double shoulder replacement surgery end up pain-free and typically will completely regain their normal shoulder motion and function. Many patients have bilateral disease (both sides right and left), and I have performed a number of bilateral (double) shoulder replacement surgeries. Typically we do one side first (either the dominant arm or the more painful side) and then come back anywhere from six weeks to four months to do the other side. There is a great patient story on my website about a patient who had a “double shoulder replacement.” Feel free to read more about his experience:  Double Shoulder Replacement Surgery Patient.

More information on joint replacement procedures including the anatomic total shoulder replacement can be found on my website.

I have arthritis in both shoulders and experience chronic shoulder pain. I’ve had arthroscopic surgery and several other procedures to help with my shoulder conditions. I know that I am too young as of now for shoulder replacement surgery but I have heard of a technique called shoulder resurfacing as an alternative treatment for shoulder arthritis. Can you explain what this is?

Thanks,

Tommy R.

Dear Tommy,

While shoulder replacement surgery can be highly effective for patients with severe shoulder arthritis, it represents a procedure that leaves patients with little options once it is performed. Therefore, in young patients, I prefer to use other joint preserving techniques.

Shoulder resurfacing is a type of replacement that removes less bone from the humerus bone than a traditional total shoulder replacement surgery. It is useful for young patients whose arthritis is severe. We like to call this a “bone preserving shoulder replacement.”

Another option is a procedure, known as the CAM procedure (Comprehensive Arthroscopic Management) which uses a variety of arthroscopic surgical joint preserving techniques to remove loose cartilage and labral tissue and to smooth out and reshape the joint. The satisfaction rate for this surgery is high and most young athletes that have this surgery are able to return to their activities after recovery from this procedure.

I have personally developed this procedure for my younger patients where I feel shoulder replacement surgery is not yet a great option and where some form of a joint preserving technique is preferred.  Studies have shown significant benefits to patients with improvements in range of motion, alleviation of pain, and dramatic improvements in function.

Dear Dr. Millett,

Can please explain the difference between a dislocated shoulder and a separated shoulder? They sound like the same condition to me.

Sincerely,

Ben H.

Dear Ben,

I’m often asked what is the difference between a dislocated shoulder and separated shoulder. They are both common injuries, and they are very commonly confused. Both can be caused by trauma to the shoulder such as a hard fall or direct blow to the shoulder.

A dislocation of the shoulder involves the true shoulder or glenohumeral joint and occurs when the ball (humerus) comes out of the socket (glenoid). When this injury occurs, a reduction may be needed where the ball is put back into the socket. Sometimes, a patient can achieve this on his or her own; and other times, a trip to the ER will be necessary so that a medical professional can reduce the injury (put the joint back into place). A dislocated shoulder frequently leads to chronic shoulder instability.  Arthroscopic stabilization surgery can be performed as treatment for a dislocated shoulder to help repair and stabilize the shoulder once it dislocates.  Treatment for a dislocated shoulder will be determined once the extent of the injury has been analyzed using an MRI.

A shoulder separation involves the acromioclavicular or AC joint. It too is technically a dislocation but it involves the clavicle coming out of its attachment to the shoulder blade. When a shoulder becomes separated, the ligaments between the shoulder blade and the clavicle are torn. This always involves some type of trauma. This causes the shoulder to droop as the clavicle moves upwards.  An AC joint separation injury can often times be treated without surgery. In more severe cases or in those cases where non-surgical treatment has failed, surgery can be helpful to restore the continuity of the AC joint. I perform this procedure arthroscopically to repair the AC joint separation and this procedure yields a high success rate to reestablish the collarbone and re-position it back to its proper position.

For additional information on treatment for a dislocated shoulder, arthroscopic stabilization surgery or for further material on AC joint separations, please visit my website.

I have chronic shoulder instability and am interested in learning more about the Bankart Reconstruction surgery technique to treat this condition. Is this surgery effective for this injury?

Thanks,

John M.

Dear John,

Thank you for your question. Within the shoulder there are many ligaments and tendons that provide stability to the shoulder while at the same time allow the joint to be extremely mobile. When a person dislocates their shoulder to the front, the most common direction, the labrum and associated ligaments can be torn. When the anterior-inferior ligament in the shoulder is torn together with the labrum, it is called a Bankart Lesion. A Bankart Reconstruction Surgery or Bankart Repair is an operation which tightens and repairs the damaged labrum and re-tensions the ligaments. Anchors are used to attach the ligament and labrum back to the shoulder socket.   I often use the Bankart reconstruction surgery on patients with chronic shoulder instability.

In even more severe cases of chronic shoulder instability, I will on occasion use a transplanted tendon (from another part of the body or from a cadaver) to make new ligaments and cartilage, which then act to prevent dislocation and stabilize the chronically unstable shoulder.

I perform a Bankart-type capsulolabral reconstruction surgery on many patients with chronic instability.  It is almost always performed arthroscopically. The procedure is effective and successful greater than 95% of the time.  You can read more about the Bankart reconstruction surgery and about chronic shoulder instability on my website.

Dear Dr. Millett,

My daughter is a competitive swimmer and has been most of her life. She is 17 years old.  She has been experiencing ongoing shoulder pain and feelings of instability. She is attending college next year and will swim for her college team.  Her team physician has told her that she has symptoms associated with shoulder instability.  Can you please explain what what is shoulder instability and what the treatments are?

Katie S.

Dear Katie,

I often get the question “what is shoulder instability?” from patients. Shoulder instability occurs when the ligaments that support the ball and socket joint stretch out. Sometimes this manifests itself as pain or symptoms of the shoulder coming out of its socket. Other times, instability may cause a secondary impingement where rotator cuff tendons that run under the shoulder blade become irritated and painful. The tendons rub against the shoulder blade because of the excessive looseness in the shoulder. Shoulder instability in swimmers, and in your daughter’s scenario, is most likely instability and secondary impingement that has been caused by the overuse of the shoulder. Shoulder instability in swimmers is pretty common. Because she has been swimming for many years it is likely that the ligaments that hold the shoulder in place have become stretched and the muscles and tendons that stabilize the shoulder have become weak over time due to the repetitive nature of swimming.

The simplest treatment for this is avoiding the motion or activity that causes the pain. Of course this is not the option for your college athlete. A careful evaluation with a sports medicine or shoulder specialist is important. Treatments for this injury depend upon the severity of the injury.

Treatments include:

• Painkillers or Anti-Inflammatory Medications
• Physical Therapy
• Steroid Injections
• Arthroscopic Shoulder Surgery

Your best option is to seek an evaluation with a specialist who can discuss the situation, diagnosis, and best treatment for your daughter.  If arthroscopic shoulder surgery is the recommended course of treatment, there are new techniques available today for those suffering from shoulder instability.

]]> http://drmillett.com/ask/what-is-shoulder-instability-shoulder-instability-in-swimmers-arthroscopic-shoulder-surgery-vail-colorado/feed/ 0 http://drmillett.com/ask/can-you-provide-informaton-on-how-to-treat-a-torn-ucl-using-the-tommy-john-surgery/ http://drmillett.com/ask/can-you-provide-informaton-on-how-to-treat-a-torn-ucl-using-the-tommy-john-surgery/#comments Thu, 19 Jan 2012 19:01:07 +0000 admin http://drmillett.com/ask/?p=113 Dear Dr. Millett,

I need Ulnar Collateral Ligament Reconstruction Surgery (Tommy John Surgery). I was wondering if you could answer some questions I have on the topic of UCL surgery?  I’m curious to know how athletes get this injury and how is the UCL surgery performed?   What advancements have been made to the procedure since it was first developed and what is rehabilitation like?

Thank you.

Answer:

Many athletes will suffer ligament injuries that can be directly related to over-use.  A ligament is a moveable structure that holds bones together and helps to control the movement of joints. The ulnar collateral ligament (UCL) is located on the inside (medial side) of the elbow. Injuries such as a torn UCL tend to occur in throwing athletes where repetitive motion occurs. Less commonly it may occur with a single traumatic event. This injury is extremely uncommon in non-throwing athletes. Tommy John was a Hall of Fame professional baseball player who was the first professional baseball player to successfully recover from this injury and the subsequent surgery. He actually had more wins after the surgery, than before!  The surgery has been named after him:  Tommy John Surgery.

Obviously UCL tears and injuries are most common among baseball players, especially pitchers. But it is not uncommon for tennis players and other racquet sports participants to tear their UCL. At times we may see this injury in athletes who play contact sports but they frequently will not need surgical repair.

When non-surgical treatment fails, UCL tears may need to be reconstructed surgically with an ulnar collateral ligament reconstruction surgery. To do so we take a tendon from another part of the body, usually one of the hamstring tendons from the knee or a cadaver ligament, and we use this to rebuild the torn UCL. This particular procedure has an 85-90% success rate and has enabled many overhead athletes to get back to competition. Because we have a better understanding of the anatomy and have adapted better surgical procedures the surgery itself has evolved into a much more reliable procedure.

After surgery it can take up to a year to achieve the full benefits of surgery but most throwing athletes can resume competition at about 7 months. But during this year it is very important that the athlete seeks physical therapy and continues with this program until the new UCL is completely healed. It is advised that once stability is achieved through physical therapy, the athlete begins a throwing program to regain his power and endurance in the arm. Precision usually returns after 8 months.

I am impressed with your work on sports injury prevention. Using the suggestions from your articles and website, I have increased my pre-skiing stretches, especially after lunch.  Do you have any recommendations for the proper protocol for stretching “cold” muscles? Do you suggest I stretch them before skiing, or after an easy warm-up run?

Thanks!

Hi there,

I consulted with my head athletic trainer, Brandie Martin, who was the former Athletic Trainer for the US Women’s Ski Team.  Here are our suggestions:

Pre-Exercise stretching has not been shown to decrease injuries, however it has not been shown to increase injuries either.  I would suggest that Mr. Bredy does a 8-10 min warm-up of light aerobic exercise then begin sport-related dynamic stretches (core activation is always good too) before hitting the slopes. An added exercise maybe a quick bout of explosive dynamic plyos (squat jumps or fast-feet) to help activate his muscles before he skis.   Dynamic stretching before activity may increase performance while static stretches before activity may decrease performance (this was shown in a study measuring short sprint performance).

Colorado Orthopedic Shoulder Surgeon Discusses Epidemic of Osteoarthritis in Young Patients and Offers Insight on New Groundbreaking Treatment for Arthritis and Joint Pain

In the United States, youth sports dominate the lives of millions of young children and their families. With the pressure to start early, advance fast, train hard, and compete to win, sporting competition among our youth has been taken to a whole new level.

The U.S. Centers for Disease Control states that nearly 30 million children and adolescents participate in youth sports in the United States each year. According to the Sports Trauma Overuse and Prevention (STOP) campaign, sports injuries among our youth have reached epidemic heights and it is estimated that more than 3.5 million kids under the age of 14 receive medical treatment for sports injuries each year.

According to Dr. Peter Millett, an orthopedic surgeon specializing in shoulder and sports medicine in Vail, CO, “A vast majority of the youth sports injuries I treat each year are caused by overuse. Extensive training, beginning at very young ages, puts too much pressure on young joints that are still developing. This is why so many of our young athletes sustain injuries.  It’s important to understand that while each child develops differently, most do not stop growing until after puberty.  Until that time, the delicate tendons, ligaments, cartilage, muscles, and bones are vulnerable to injury.”

Once a child suffers an injury, particularly one that involves a joint, there is risk for future injury and the onset of premature degenerative changes.

Dr. Millett and the other orthopedic surgeons that make up the Steadman Clinic in Vail, are among an elite group of sports medicine specialists in the nation who are seeing an increase in the number of overuse injuries and acute injuries associated with sports trauma.

“Although I treat many traumatic injuries that are sustained in competition or recreational sports —for example fractured collarbones, dislocated shoulders, torn rotator cuffs that are caused from direct impact sports—more alarming, is the number of patients I am treating that have severe joint and cartilage damage from years of over-training and past injuries. I unfortunately have seen degenerative joint disease and the onset of arthritis as early as teenage years and now routinely perform surgery for osteoarthritis in young patients in their 30’s and 40’s,” said Dr. Millett.

Initial treatment for young patients who suffer damage to their joint will often be conservative with rest and rehabilitation. More advanced injuries may require arthroscopicsurgery to tighten shoulder ligaments or repair the labrum, which is a cartilage that can be torn from a traumatic injury or overuse. For young patients with significant cartilage damage, new joint preservation approaches are now available to help delay more radical techniques such as a full shoulder replacement.

“A particular interest of mine is shoulder arthritis in the active athlete,” states Dr. Millett. “Many times there are options other than joint replacement which preserve the shoulder and alleviate pain.  Some of the newer techniques can delay the need for shoulder replacement surgery. Joint replacement surgery, although very effective, is best saved for older patients or when all other available treatments have been exhausted.”

The CAM procedure is one such technique that has been used successfully on young patients.  CAM stands for Comprehensive Arthroscopic Management and it used for the treatment of advanced arthritis of the shoulder. Dr. Millett developed the CAM procedure as a treatment option for younger patients — predominantly athletes and active individuals — with advanced arthritis, as a means to delay full shoulder joint replacement surgery. Using a variety of minimally invasive arthroscopic surgery techniques and regenerative technologies, loose cartilage is removed from the shoulder joint and the bones are re-shaped to prevent compression on nerves, to alleviate pain, and to restore mobility. The CAM technique was designed in stages over the course of five years with a specific focus to alleviate pain along the back and side of the shoulder.  Microfracture is another technique that can be used in conjunction with the CAM procedure to regenerate cartilage helping to alleviate the pain and stiffness for arthritic shoulders.

Recently some newer, bone-preserving types of shoulder replacement have been used in young patients who have more end-stage types of shoulder arthritis as a way to preserve more native tissue and to save bone stock for future surgeries that might be needed. There are many different factors to consider for shoulder injuries that cause arthritis. Furthermore, as one might expect there can be several treatment options and risks with benefits with each type that should be discussed with your surgeon after an evaluation.

For young athletes and their parents, it is crucial to understand that degenerative conditions associated with injury and years of training may become a large burden later in life, once their sporting careers are over. Arthritis typically gets worse with age. It is crucial that all athletes understand how to protect themselves during sports and follow the recommended safety guidelines when it comes to stretching, therapy, wearing protective devices and guards.

But most importantly, says Dr. Millett, “Knowing when to take a break and when to rest seems to be one of the most overlooked points of all. There is no reason to paly hurt. The body has an amazing ability to heal itself. When injured, rest and appropriate orthopaedic care can help save the joints of many of our young athletes for years and years to come.”

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About the Writer/Expert:

Kristy M. Theis is a Dallas, TX freelance communications writer and the editor for eMedical Media. Dr. Peter J. Millett is an Orthopedic Shoulder Surgeon, Sports Medicine Specialist and a Partner at the Steadman Clinic in Vail, CO.