Shoulder Surgery and Arthroscopy in Maryland, Washington DC, and Virginia

The shoulder and the elbow are two of the
most widely used joints in the human body.
All of this wear and tear causes many injuries
to the shoulder and elbow. Some of the most
common problems are:

• Rotator Cuff Injuries

  The rotator cuff is actually made of four muscles that attach to the shoulder blade (scapula), and wrap around the front, back, and top of the shoulder. Together these muscles help guide the shoulder through many motions, and also lend stability to the joint. The ends of the rotator cuff muscles form tendons that attach to the arm bone (humerus).

  Rotator cuff injuries are seen both in the young and old. Usually in younger patients, there is either a traumatic injury or the patient is demanding unusual use of his shoulder, as seen in professional athletes. As people age, the muscle and tendon tissue of the rotator cuff loses some elasticity and becomes more susceptible to tearing and is often injured while performing everyday activities. Therefore, this is an injury that tends not to discriminate by age.

  The most common symptom of a rotator cuff injury is pain. It is often difficult for a patient to localize the pain to a specific area; rather, it is described as a generalized discomfort that is exacerbated with specific movements of the shoulder. Depending on the severity of the injury, there may also be a loss of range of motion.

  Rotator cuff tears do not heal well with time, and therefore, only minor tears with minimal disruption to the patient’s life are left alone. In these cases, physical therapy and cortisone injections may help to relieve pain and strengthen the muscles around the joint. However, in more significant tears, surgery is often necessary. The surgical procedure usually involves both the use of an arthroscope, and a short incision to get access to the arm bone (humerus). The procedure allows the surgeon to insert strong sutures to repair the tear in the rotator cuff and reattach the mechanism to the arm bone.

  Some period of immobilization of the shoulder joint is needed to protect the newly placed sutures from being disrupted. After one to two weeks, physical therapy begins. Initially, the therapy is gentle so as not to affect the repair. After four to six weeks, more active lifting with the arm begins. Several months after the operation, physical therapy will become more intense in an effort to strengthen the rotator cuff muscles. Complete recovery usually requires at least four to six months.

  Rotator Cuff Tears Animation

  Arthroscipic Rotator Cuff Repair Animation

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• Arthritis
  • Osteoarthritis and post-traumatic arthritis
    Osteoarthritis (OA), or degenerative joint disease (DJD), is a form of arthritis characterized by the loss of joint smoothness and range of motion without major joint inflammation. Post-traumatic arthritis is similar to osteoarthritis, but the cause is clearly evident (usually the result of a trauma to the joint sometime in the past).
    
    Osteoarthritis is the most common type of arthritis, affecting over 20 million people in the United States. It probably affects almost every person over age 60 to some degree, but symptoms are often mild.
    
    Signs of osteoarthritis include joint pain and aching, limited range of motion and instability, erosion of the joint's cartilage and formation of bone spurs. Other symptoms include stiffness and roughness on motion; these symptoms are worse after heavy use. OA pathological changes involve both the cartilage and the bones.
    
    If degenerative joint disease is related to abnormalities of cartilage surrounding joints (articular cartilage), it may involve many of the joints of the body. On the other hand, if the degenerative joint disease is caused by an injury, only one joint may be involved. The hips, knees, spine, and shoulders are most commonly involved. This condition may also affect some finger joints, the joint at the base of the thumb, and the joint at the base of the big toe.
    
    In osteoarthritis, the normally smooth cartilage surface softens and becomes pitted and frayed. As the cartilage breaks down, the joint may lose its normal shape. The bone ends thicken and form bony growths, or spurs, where the ligaments and capsule attach to the bone.
    
    Stiffness and joint deformity usually progress slowly without general body symptoms. By contrast, rheumatoid arthritis (RA) usually begins earlier, often developing more suddenly. RA usually affects the same joint on both sides of body (e.g. both knees), causing redness, warmth, and swelling of many joints. RA is often accompanied by a general feeling of sickness, fatigue, weight loss, and fever.
    
    In the hip, OA may produce pain around the groin or in the inner thigh. Some people feel referred pain to the buttocks, the knee or along the side of the thigh. Degenerative joint disease of the hip may cause a limp and may limit range of motion, for example making it difficult to spread the legs.
    
    Degenerative joint disease of the knees may produce pain and stiffness of the knee associated with a grating or catching sensation in the joint when it is moved. It may make it difficult to walk up and down stairs and lumps may be noted particularly along the medial (inner) side of the knee. If the pain prevents you from moving or exercising your knee, the large muscles around the knee area will become weaker.
    
    Degenerative joint disease of the fingers may produce bony lumpiness around the joints of the finger and perhaps pain and stiffness of these joints as well. In the fingers, the breakdown of joint tissue in the fingers causes bony growths (spurs) to form in these joints. If spurs occur in the end joints of the fingers, they are called Heberden's nodes. If they occur in the joints in the middle of the fingers they are called Bouchard's nodes.
    
    Degenerative joint disease of the feet most commonly affects the large joint at the base of the big toe. Stiffness, lumpiness and pain may be associated. Wearing tight shoes and high heels can make this pain worse.
    
    Degenerative joint disease of the spine may produce stiffness of the back and at times, symptoms of pressure on the spinal cord and nerves running through the spine. The latter are particularly important to notice and may include numbness or weakness of the arms or legs, difficulty with controlling the bowel or bladder, loss of balance and pain radiating out the arms or down the legs.
    
    "Wear and tear" is a widely accepted explanation of the cause of OA. It should be noted that OA is the result of an interlocking pathophysiologic malfunction of cartilage and bone metabolism. Interpreting "wear and tear" of the joints in OA from a biomechanic perspective allows patients to understand how OA differs from age-associated degeneration and overuse of the joints. There are ways to reduce the OA "wear and tear" effects which include weight control, muscle strengthening exercises, and increased proprioception accuracy (the ability to feel your joint's position in space).
    
    The effects of degenerative joint disease can often be controlled by a few basic measures, such as diet, exercise, medication, and surgery.
    
    If you have OA, your diet should optimize your body weight so that the joints do not bear large loads which would cause them to wear more quickly. Joints in a person with OA should be protected from rough use, particularly those involving sudden impacts. Canes or walkers may help protect the hip and knee and prevent limping. Physical therapy can help maintain joint ranges of motion, strength and stability. Your doctor may prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) which are also effective in relieving pain.
    
    Surgical treatment for OA may include removing joint spurs, realigning the joint, fusion of the joint, and joint replacement. In the past several years, these operations have become very effective, and many people have benefited from joint reconstruction or replacement.
    
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  • Rheumatoid arthritis
    Rheumatoid arthritis (RA) primarily affects the synovium, the membrane that lines and lubricates a joint. It is the most common form of inflammatory arthritis.
    
    There is no cure for rheumatoid arthritis at present. Until the cause of RA is known, it will not be possible to eliminate the disease entirely. The goals of current treatment methods, therefore, are to relieve pain, reduce inflammation, stop or slow down joint damage, and improve function and patient well-being.
    
    Initial symptoms of rheumatoid arthritis are generally pain and stiffness in the morning and few symptoms with activity. The pain and swelling will usually progress on to obvious joint swelling and the level of stiffness in the morning increases. Other symptoms include fatigue and difficulty sleeping due to joint stiffness.
    
    Rheumatoid arthritis can be distinguished from other forms of arthritis by the location and number of joints involved. The areas affected include the neck, shoulders, elbows, wrists, and hands, especially the joints at the base and middle of the fingers but not the joints at the end of the fingers. In the lower extremities, RA can affect the hips, knees, ankles, and the joints at the base of the toes. RA tends to spare the low back. The joints affected tend to be involved in a symmetrical pattern. That is, if knuckles on the right hand are inflamed, it is likely that knuckles on the left hand will be inflamed as well. This symmetry is not found as often in most other types of arthritis.
    
    Inflamed joints will be warm, swollen, tender, often red, and painful or difficult to move. These physical signs of arthritis are due to inflammation of the lining of joints and tendons in a layer of tissue that is called synovium. The cells of the immune system within the synovium appear active and capable of causing tissue damage. If this inflammation persists or does not respond well to treatment, destruction of nearby cartilage, bone, tendons, and ligaments can follow. This leads to deformity and disability that can be permanent.
    
    Anyone can get rheumatoid arthritis, including children and the elderly. However, the disease usually begins in the young to middle adult years. Among people with RA, women outnumber men by 3 to 1. In the United States, approximately one percent of the population, or 2.5 million people, have rheumatoid arthritis. It occurs in all ethnic groups and in all parts of the world.
    
    The goals of current RA treatment methods are to relieve pain, reduce inflammation, stop or slow down joint damage, and improve function and patient well-being. There is no single standard treatment that applies to all people with RA. The disease may be very different from person to person. Instead, a treatment program should be designed to best meet each person's needs, taking into account how severe the arthritis is, other medical problems, and individual lifestyle and preferences. Often the use of two or more medications at a time, each serving a distinct purpose, is necessary. Some of these medications affect the immune system, making careful monitoring a requirement for treatment.
    
    Treating rheumatoid arthritis usually involves a teamwork approach, using health professionals from different disciplines to help an individual deal with the disease. Treatment most often is directed and coordinated by an arthritis specialist, who is a physician with special training in arthritis and other diseases of the bones, muscles, and joints. Other health professionals, such as physical therapists, occupational therapists, nurses, psychologists, orthopaedic surgeons, and social workers, often play other roles in implementing the treatment plan.
    
    It often is difficult to be patient when suffering from rheumatoid arthritis. People with rheumatoid arthritis might be tempted to try unproven treatments. A treatment that promises "a quick cure" or "miraculous relief" can sound wonderful. But remember, these unproven treatments usually are expensive and will do nothing. The sensational successes advertised are usually illusions. They even may be harmful and often keep people from getting the medical care they really need. For example, magnet therapy has not been proven to work for rheumatoid arthritis. New or alternative treatments should be discussed with your doctor.
    
    Medical management may include the use of non-steroidal antiinflammatory medication, corticosteroids, injectable gold salts (Myochrysine, Solganal), methotrexate (Rheumatrex), hydroxychloroquine (Plaquinil) and antimalarial drugs, Sulfasalazine (Azulfidine), D-Penicillamine (Depend, Cuprimine), and various other immunosuppressive agents.
    
    Physical therapy treatments are helpful for most individuals with rheumatoid arthritis. Physical therapists can teach you how to exercise appropriately for your physical capabilities. They will give you valuable instruction on how best to use heat and cold treatments to reduce joint stiffness and swelling and make movement easier. At times, therapists may use special machines to apply deep heat or electrical stimulation to reduce pain or improve joint mobility.
    
    Therapists construct splints for the hand and wrist and teach people how to best protect and use their joints when they are affected by arthritis. They also show people how to better cope with day-to-day tasks at work and at home, despite limitations that may be caused by RA. Sometimes this includes the use of practical tools and items that help individuals perform their day-to-day activities. It is important to remember that people with RA can and should be able to do most of the normal or usual things everyone else can, except that it takes them a little bit longer to do it.
    
    For individuals with severe joint damage, surgery such as total joint replacement can mean the difference between being dependent on others and independent life at home or in the community. Such procedures are performed by orthopaedic surgeons with special training in joint replacement. The damaged parts of the joints are replaced with metal or plastic components. Some people with RA will benefit from replacement of other joints and from other types of surgery for hand and foot problems caused by the disease. Patients with early rheumatoid arthritis, however, should be placed on a program of medications and therapy before surgery is considered.
    
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• Frozen Shoulder

  Frozen shoulder, or adhesive capsulitis, is a painful condition which results in a severe loss of motion in the shoulder. It may follow an injury to the shoulder, but may also arise gradually with no warning or injury. The cause of this condition is unclear.

  The symptoms are primarily pain and a very reduced range of motion in the joint. The range of motion is the same whether you are trying to move the shoulder under your own power or if someone else is trying to raise the arm for you. There comes a point in each direction of movement where the motion simply stops as if there is something blocking the movement. The shoulder usually hurts when movement reaches the limit of the range of motion, and can be quite painful at night.

  Treatment of the frozen shoulder can be frustrating and slow. Most cases will eventually improve, but it may be a process that takes months. Initial treatment is directed at decreasing inflammation and increasing the range of motion of the shoulder with a stretching program. Anti-inflammatory medications may be prescribed. It is critical that a physical therapy program be started and continued to regain the loss of motion.

  An injection of cortisone and long-acting anesthetic, similar to Novocain, may bring the inflammation under better control and allow the stretching program to be more effective. In some cases, injecting a long-acting anesthetic along with the cortisone right before a stretching session with the physical therapist can allow the therapist to break up the adhesions while the shoulder is numb from the anesthetic.

  If progress is slow, your doctor may recommend a manipulation of the shoulder while you are under anesthesia. This procedure allows your doctor to stretch the shoulder joint capsule, and break up the scar tissue while you are asleep. In most cases, a manipulation of the shoulder will increase the motion in the shoulder joint faster than allowing nature to take its course. Alternatively, an arthroscope can be inserted into the joint to cut through adhesions. Open surgical release is rarely necessary.

  Frozen Shoulder Animation

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• Nerve Problems of the Upper Extremities
  • Carpal Tunnel Syndrome

    The carpal tunnel is a passageway in the wrist formed by the eight carpal (wrist) bones, which make up the floor and sides of the tunnel, and the transverse carpal ligament, a strong ligament stretching across the roof of the tunnel. Your orthopaedic surgeon will further explain this anatomy to you, in order that you may understand your condition.

    Inside the carpal tunnel are nine flexor tendons which flex (bend down) your fingers and thumb. Also running through the carpal tunnel is the median nerve, a cord about the size of a pencil containing thousands of nerve fibers supplying sensation (feeling) to your thumb, index and middle fingers, and half of the ring finger. The median nerve lies directly beneath the transverse carpal ligament and comes in contact with the ligament when bending or straightening the wrist or fingers. Carpal tunnel syndrome occurs when swelling in the tunnel compresses the median nerve.

    Tingling, numbness and pain in the thumb, index and middle fingers are the most common symptoms of carpal tunnel syndrome. These symptoms are usually experienced at night, but also accompany prolonged gripping. Patients may also experience clumsiness when handling objects or weakeness in grip.

    There are many non-surgical courses of treatment for carpal tunnel syndrome, such as splints or braces to immobilize and rest the wrist, activity modifications, oral anti-inflammatory medications, and steroid injections.

    If non-surgical treatment is not successful or if treatment is sought too late, surgery may be required. This surgery involves enlarging the carpal tunnel, which in turn will relieve the swelling and pressure on the nerve. This is an outpatient procedure done under local anesthesia. In severe cases, even surgery may not reverse the effects of carpal tunnel syndrome. Carpal tunnel surgery is followed by hand therapy which varies per person, but usually lasts from 1 to 3 months.

    Carpal Tunnel Syndrome Animation

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  • Cubital Tunnel Syndrome

    Cubitus is Latin for elbow. The cubital tunnel is an anatomic passageway between the bony prominence of the inside of the elbow (medial epicondyle) and the tip of the elbow (olecranon process). Through this passageway travels the ulnar nerve as it crosses behind the elbow. To keep the nerve from displacing with motion of the elbow, the tunnel is completed by a covering of tissue called fascia. There are several other tunnels that the ulnar nerve passes through while traveling down the arm. Cubital tunnel syndrome occurs when there is compression or injury of the ulnar nerve in the cubital tunnel or in surrounding smaller tunnels.

    The ulnar nerve provides sensation to the little finger and half of the ring finger. It also supplies several muscles in the forearm but most importantly it controls many of the small muscles in the hand responsible for coordinating finger motion and pinch. Patients with this condition commonly exhibit symptoms of intermittent numbness or tingling in the ring and little fingers of the affected extremity. These symptoms may occur with prolonged flexion of the elbow or resting against the elbow. There may be an associated aching discomfort along the inner forearm or elbow. If nerve damage persists, there is loss of sensation in the ring and little fingers. Eventually there is loss of pinch and grip strength.

    In early stages of cubital tunnel syndrome, symptoms may be alleviated by avoiding activities requiring prolonged or repetitive elbow flexion or resting against the elbow. To prevent elbow flexion, particularly at night, it may be necessary to use a long-arm splint. An elbow pad worn during the day can be beneficial in protecting the cubital tunnel from direct pressure. At times, an oral anti-inflammatory is helpful in alleviating symptoms. When cubital tunnel syndrome is severe or fails to improve with conservative management, surgery may be indicated.

    Cubital Tunnel Syndrome Animation

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  • Thoracic Outlet Syndrome

    Thoracic outlet syndrome is a repetitive stress disorder that involves the shoulder and upper arm. The thoracic outlet is a triangular area through which nerves and blood vessels pass from the neck to the arm. The area is bordered by the collar bone, the first rib, and the anterior and middle scalene muscles. Thoracic outlet syndrome occurs when the nerves and blood vessels between the neck and shoulder are compressed. Activities such as pulling your shoulders back and down, sleeping with your arms above your head, carrying items such as a backpack or suitcase, or work that requires frequent overhead lifting may increase the risk of this syndrome.

    Symptoms are similar to carpal tunnel syndrome: numbness in the fingers and hand, tingling in the arm as if it is "asleep", and pain that begins in the base of the neck and radiates into the arm or hand. Your orthopaedic surgeon must differentiate between the two conditions. Often with thoracic outlet syndrome, numbness and tingling may be in other parts of the upper extremity depending on which nerves are involved.

    The mainstay of treatment is physical therapy. The goals are to modify postural habits, relieve muscle tension, improve alignment and increase nerve gliding. Rest, adjustments to how you perform daily activities, oral anti-inflammatory medications and steroid injections may be recommended. If non-surgical treatment is not successful or treatment is sought too late, surgery may be required. The two procedures available are release of the scalene muscles or excision of the first rib. Both procedures provide improvement in approximately 80% of properly selected patients, but over time 10% of the patients develop recurrent symptoms. The procedure is performed as an inpatient and generally requires several months for full recovery.

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• Shoulder and Elbow Trauma
  (Fractures, Dislocations)

  Injuries to the shoulder and elbow may occur in any age group: children, adolescents, adults, and the elderly. Like any injury involving a joint, the ramifications can be quite disabling. Both the shoulder and elbow react to trauma in ways that are difficult to manage. The extremes of stiffness and instability may commonly result, depending on the injury.

  Given the demands that we place on our upper extremities, it is crucial that the shoulder and elbow retain as much function as possible following an injury. Although the hand may not have been involved, it can be made essentially useless if the shoulder or elbow fail to function properly. For this reason, it is important to seek medical attention as soon as possible after an injury to these joints to avoid unnecessary complications.

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• Stiff, Painful Elbows

  The elbow is an extremely temperamental joint. Under various circumstances, the elbow often becomes stiff and painful. Trauma, even mild trauma, is the most common reason for this problematic phenomenon. Even immobilizing the elbow for a short time in a cast or sling may cause significant stiffness. In special instances, bone can actually form around the elbow, and fuse it solid.

  An elbow without motion renders the entire upper extremity useless. Specially trained physicians and therapists must work together with the patient in order to relieve pain and regain motion. Many hours of special equipment, exercises, stretching, and occasionally surgery are required to achieve those rehabilitative goals.

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Greater Metropolitan Orthopaedics provides a
comprehensive approach to the care and treatment
of shoulders and elbows. If left untreated, any of
these ailments can prevent you from enjoying life
to the fullest.