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Collateral Ligament Injuries

Ligaments are tough bands of tissue that connect the ends of bones together. There are two collateral ligaments, one on either side of the knee, that limit the side to side motion of the knee. The medial collateral ligament (MCL) is located on the inside of the knee, and connects the femur to the tibia. The lateral collateral ligament (LCL) is located on the outside of the knee, and connects the femur to the fibula.

Causes of Collateral Ligament Injuries

Collateral ligament injuries usually occur when the knee is forced sideways. MCL tears are often caused when an impact pushes the knee inwards, while LCL tears are often caused when an impact pushes the knee outwards. LCL tears occur less frequently than other knee injuries.

Symptoms

Symptoms for a collateral ligament injury are similar to symptoms of other knee injuries, so it’s important for a physician to exam your knee to determine the problem.  Symptoms for a MCL or LCL injuries include:

  • A popping sound at the time of injury
  • Pain and/or tenderness along the sides of the knee. MCL pain is on the inside of the knee; LCL pain is on the outside of the knee.
  • Swelling in and around the knee joint
  • Instability, or feeling that your knee is going to “giving way”

Treatment

Injuries to the MCL rarely require surgery. Isolated injuries to the LCL can also be managed conservatively with bracing and physical therapy. Initial treatment for an MCL or LCL injuries should include rest, ice, compression, and elevation. Bracing can help protect the injured ligaments from unnecessary stress. Physical therapy can help reduce pain and swelling, and increase mobility and stability. If damage to the LCL occurs alongside damage to other structures in the knee, surgery may be required.

Surgical Intervention

If collateral ligaments are torn in such a way that it cannot heal or is associated with other ligament injuries, your physician may suggest surgery to repair the damage. Surgery to repair Surgery to repair collateral ligaments depends on the severity of the tear. If the ligament is torn where it attaches to bone, the surgeon will reattach the ligament. If the tear happened in the ligament, the surgeon will sew the torn ends together. If the damaged ligament cannot be repaired, the surgeon may reconstruct the ligament using a graft taken from a tendon in your quadriceps or hamstrings.

Recovery

Recovery time for MCL and LCL injuries differ depending on the severity of the injury. A minor tear to a collateral ligament can take up to 10 days to improve. A more severe tear can take up to eight weeks to heal. Once you have regained strength, stability, range of motion, and can walk without a limp, your physician may allow you to begin a gradual progression back to normal activities.

Total Shoulder Joint Replacement Arthroplasty

The shoulder is made up of three bones: the upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle).  The shoulder is a ball-and-socket joint where the ball (or head) of the humerus fits into the socket of the scapula.  The socket is called a glenoid.  The parts of the bones that come in contact with each other are covered with cartilage that protects the bones and allow them to move easily.  There is also a smooth tissue membrane that covers all of the other areas inside the shoulder that makes fluid that lubricates the cartilage and eliminates friction in the shoulder.  In total shoulder joint replacement arthroplasty, the damaged parts of the shoulder are removed and replaced with a prosthetic.  This involves the replacement of both the ball and socket.

Common Causes of Total Shoulder Replacement

There are many conditions that can cause the shoulder to be painful and become disabled, and lead to needing total shoulder joint replacement surgery:

  • Post-traumatic Arthritis: Fractures of the bones that make up the shoulder or tears of the shoulder tendons or ligaments may damage the articular cartilage over time. This causes shoulder pain and limits shoulder function.
  • Avascular Necrosis (Osteonecrosis): Painful condition that occurs when the blood supply to the bone is disrupted. Since bone cells die without a blood supply, osteonecrosis can ultimately cause destruction of the shoulder joint and lead to arthritis.
  • Rheumatoid Arthritis: This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness.
  • Osteoarthritis (Degenerative Joint Disease): This is an age-related, wear and tear, type of arthritis that usually occurs in people 50 years of age and older; however, it may occur in younger people, too. The cartilage that cushions the bones of the shoulder softens and wears away. The bones then rub against one another and cause the shoulder joint to become stiff and painful.
  • Rotator Cuff Tear Arthropathy: A patient with a large rotator cuff tear for a considerable amount of time may develop this arthropathy.  Changes in the shoulder joint due to the rotator cuff tear may lead to arthritis and destruction of the joint cartilage.
  • Severe Fractures: A severe fracture of the shoulder can be difficult for a surgeon to put pieces of bone back together.  Also the blood supply to the fractured bones can be interrupted.

Symptoms

People who benefit from shoulder replacement surgery often have:

  • Severe shoulder pain that affects everyday activities, such as reaching into a cabinet, getting dressed, bathing, using the restroom, etc.
  • Moderate to severe pain while resting, preventing a good night’s rest
  • Loss of motion and strength
  • Failure to improve with conservative treatments such as physical therapy, medications, and injections

Diagnosis

If it is determined that total shoulder joint replacement surgery is needed, further evaluations like physical examinations and diagnostic tests may be necessary to determine the extent of the damage as well as planning the surgery. 

Surgical Intervention

Total shoulder replacement surgery replaces damaged parts of the shoulder with artificial components. There are different types of shoulder replacement. Your surgeon will evaluate your situation and recommend a treatment option that is best for you.

  • Total Shoulder Replacement involves replacing the arthritic joint surfaces where a plastic “cup” is placed into the shoulder socket (glenoid) and a metal “ball” is attached to the upper arm bone (humerus). Patients with bone-on-bone osteoarthritis and an intact rotator cuff are generally good candidates for traditional total shoulder replacement.
  • Stemmed Hemiarthroplasty is a partial shoulder replacement that involves only replacing the “ball” of the upper arm (humerus). Hemiarthroplasty is recommended if:
    • The humeral head is severely fractured but the socket is normal
    • If arthritis only affects the head of the humerus
    • For shoulders with severely weakened bone in the glenoid (socket)
    • For severely torn rotator cuff tendons accompanied with arthritis
  • Reverse Total Shoulder Replacement switches the location of the socket and metal ball, where the metal ball is placed into the shoulder socket and the plastic cup is attached to the upper arm bone. Reverse total shoulder replacement is used for people with completely torn rotator cuffs accompanied by severe arm weakness, had a previous shoulder replacement that failed, or have severe arthritis accompanied by a torn rotator cuff.

Post-Operative Recovery

After surgery, your arm will be in a sling for two to four weeks to protect your shoulder. A physical therapy program will begin soon after surgery to help regain shoulder strength and improve range of motion and flexibility in the shoulder joint. Follow the therapy program and home exercises as prescribed by your physician. You may need to do the exercises two to three times a day for a month or more.Some common restrictions following surgery include:

  • You will not be able to drive for two to four weeks after surgery.
  • Don’t use your arm to push yourself up in bed or from a chair.
  • Don’t overdo it – reduced pain in the shoulder after surgery can result in a false security of healing. Early overuse of the shoulder may result is severe limitations of motion long term.
  • Don’t lift anything heavier than a glass of water for the first two to four weeks.
  • Don’t lift your arm straight out to the side or place it behind your back for the first six weeks after surgery.

Reverse Total Shoulder Surgery

Conventional shoulder replacement mimics the normal anatomy of the shoulder, where a plastic “cup” is placed into the shoulder socket (glenoid) and a metal “ball” is attached to the upper arm bone (humerus). A reverse total shoulder replacement switches the location of the socket and metal ball, where the metal ball is placed into the shoulder socket and the plastic cup is attached to the upper arm bone.

Symptoms

The main purpose for a reverse total shoulder is to restore pain-free motion and function to the shoulder, and is used as an alternative surgery option for patients with:

  • A completely torn rotator cuff that cannot be repaired, because a reverse total shoulder replacement relies on the deltoid muscles instead of the rotator cuff to power and move the joint.
  • A previous shoulder replacement that was unsuccessful.
  • Severe arthritis accompanied by a torn rotator cuff.
  • Inability to lift your arm away from your body or over your head.
  • Vascular damage such as vascular necrosis or osteonecrosis.

Diagnosis

Your physician will assess any degenerative changes to the shoulder joint by conducting a physical exam. During the physical exam, your physician will perform arm and shoulder movements to check your muscle strength, joint motion, and joint stability. X-rays help determine the condition of the shoulder bones and articular cartilage. Advanced imaging tests, such as a CT scan or MRI, will show images of soft tissue (muscles, ligaments, tendons) within the shoulder joint. 

Post-Op Recovery

Following your procedure, you can expect to stay in the hospital for one to two days. You will wear an arm sling for support, and will have restrictions on shoulder movement for about three weeks. Physical therapy will play an important role in helping you regain motion, strength, stability, and coordination to the shoulder joint. Recovery from reverse total shoulder replacement is different for each patient. It usually takes several weeks to recover completely from surgery.

Shoulder Arthroscopy

Surgeons have been performing shoulder arthroscopies since the 1970s. It has made diagnosis, treatment, and recovery from surgery easier and faster than ever thought possible. Arthroscopy is a procedure that orthopedic surgeons use to inspect, diagnose, and repair problems inside a joint. During shoulder arthroscopy, the surgeon inserts a small camera into your shoulder joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments. Because the camera and surgical instruments are small in size, only very small incisions are needed instead of a larger one that is needed for open surgery. Therefore, this results in less pain and shortens recovery time for patients. 

Common causes of Shoulder Arthroscopy

Problems that can lead to a shoulder arthroscopy include acute injuries, overuse injuries, and wear and tear on the joint.  The arthroscopy is only recommended when it is expected to relieve the painful symptoms that can lead to damage of the labrum, rotator cuff, articular cartilage, and other soft tissues around the shoulder joint. Common arthroscopic procedures include:

  • Rotator cuff repair
  • Bone spur removal
  • Labrum repair
  • Repair of ligaments
  • Removal of inflamed tissue or loose cartilage
  • Repair for recurrent shoulder dislocation

Surgical Intervention

If the patient is generally healthy, arthroscopy shoulder surgery will be performed as an outpatient procedure and can usually take less than one hour. However, the length of surgery will ultimately depend on what the surgeon finds and the extent of the repairs needed.  The procedure is usually performed using nerve blocks to numb the shoulder and arm.  Yet, many surgeons also used sedation or light general anesthesia due to patients being uncomfortable staying in one position for the length of the surgery.During the procedure, a small incision is made and the tiny camera (arthroscope) is inserted into the shoulder so the doctor can see any damage on the inside of the shoulder.  Once the surgeon identifies the extent of the damage, tiny instruments are inserted through other small incisions in order to repair the damaged shoulder.  When the repair has been made, the surgeon will close the incisions usually with either stitches or steri-strips (small Band-Aids).

Post-Operative Recovery

Recover from shoulder arthroscopy is often faster than open surgery, yet it may still take weeks for the shoulder joint to completely recover.  Some pain and discomfort is likely for at least a week, and the doctor may prescribe medicine to help relieve it as much as possible.  Sleep position for the first several days will be very important in keeping the shoulder comfortable and stable.  Also, some type of sling will likely be needed to protect your shoulder during recovery.  Rehabilitation is also very important during recovery of shoulder arthroscopy.  An exercise program developed by your doctor or physical therapist will help regain strength and motion.  Because every patient’s health differs from the other, recovery times will differ as well.  Also, minor repairs will usually have much faster recovery than a more extensive arthroscopy.  Most patients do not have complications from shoulder arthroscopy, but as with any surgery, there are some risks that the surgeon will discuss with the patient prior to the operation.  These risks are usually minor and treatable and include infection, excess bleeding, blood clots, and nerve or blood vessel damage. Although it can be a slow process, following the surgeon's guidelines and rehabilitation plan is vital to a successful recovery.

Rotator Cuff Tear

The rotator cuff is a group of four muscles and their tendons that combine to from a “cuff” around the head of the humerus (the upper end of the arm). These four muscles—supraspinatus, infraspinatus, subscapularis, and teres minor—originate from the scapula (shoulder blade). The rotator cuff stabilizes the humeral head within the joint socket while coordinating the motion of the arm by initiating both lifting and rotation of the arm at the shoulder.

Causes of a Rotator Cuff Tear

There are two main causes of rotator cuff tears:  acute injuries and degeneration.

  • Falling down on an outstretched arm or lifting something too heavy with a jerking motion.
  • Degeneration refers to chronic wear and tear on the tendons in the shoulder joint that occurs in people over 40.
  • Repetitive motion and stress from sports, work-related activities, or routine chores can cause overuse tears.
  • As a person ages, calcium deposits or bone spurs due to arthritis can irritate or pinch the rotator cuff.

Symptoms and Diagnosis

Symptoms of a rotator cuff tear may include:

  • Pain and muscle spasms in the upper arm and shoulder, particularly when resting or lying down.
  • Shoulder weakness when lifting or rotating the arm.
  • Shoulder pain when movement involves lifting, pulling, or reaching behind the back or overhead.
  • Crackling sensation when moving your shoulder in certain positions.

Rotator cuff tears are initially diagnosed based on a physical examination where the patient complains of pain and limited motion in the shoulder and/or weakness and muscle deterioration. Imaging tests help confirm the diagnosis. 

Imaging Tests

X-rays, MRI scans, or ultrasounds can all be used to help diagnose whether a tear to the rotator cuff exists.  MRI scans can be useful in confirming the diagnosis by displaying the soft tissue around the shoulder and rotator cuff. Early diagnosis and treatment of a rotator cuff tear may help improve overall treatment results.

Treatment Options

The goals of treatment are to improve overall shoulder function and quality of life by relieving pain, improving range of motion, and restoring strength to the involved shoulder. Many rotator cuff tears can be treated non-surgically. Anti-inflammatory medication, steroid injections, and physical therapy may all be of benefit in treating symptoms of a cuff tear. Even though a full-thickness tear cannot heal without surgery, satisfactory function can often be achieved with non-surgical treatments.

Surgical Intervention

Surgery is recommended if pain or weakness in the shoulder that does not improve after six months of non-surgical treatments. Frequently, patients who require surgery will report pain at night and difficulty using the arm for lifting and reaching. Surgery is also indicated in active individuals who use the arm for overhead work or sports. The type of repair performed is based on the findings at surgery. A partial tear may require only a trimming or smoothing procedure called a debridement. A full-thickness tear with the tendon torn from its insertion on the humerus is repaired directly to bone. Three techniques are used for rotator cuff repair:

  • open repair (through a traditional incision)
  • mini-open repair (partially assisted by a camera view, with a smaller incision)
  • arthroscopic (performed with only a small camera inserted through multiple small puncture wounds)

Post-Operative Recovery

Rehabilitation is important in both the non-surgical and surgical treatments of a rotator cuff tear. Recovery is usually six months or longer depending on the extent of the tear. When a tear occurs, there is a great loss of motion of the shoulder. An exercise or physical therapy program is necessary to regain strength and improve function in the shoulder. Even though surgery repairs the defect in the tendon, the muscles around the arm are still weak. A disciplined rehabilitation regimen is necessary for the procedure to succeed and may take several months.

Shoulder Impingement

Impingement refers to mechanical compression and/or wear of the rotator cuff tendons. The rotator cuff is actually a series of four muscles connecting the scapula (shoulder blade) to the humeral head (upper part of the shoulder joint). The rotator cuff is important in maintaining the humeral head within the glenoid (socket) during normal shoulder function and also contributes to shoulder strength during activity. Normally, the rotator cuff glides smoothly between the undersurface of the acromion, the bone at the point of the shoulder, and the humeral head. Any process which compromises this normal gliding function may lead to mechanical shoulder impingement. 

Causes of Shoulder Impingement

Shoulder impingement is a frequent source of pain in adults. Common causes of shoulder impingement include:

  • Weakening and degeneration within the tendon due to aging.
  • The formation of bone spurs and/or inflammatory tissue within the space above the rotator cuff.
  • Overuse injuries caused by repetitive movement and stress on the joint. Athletes and other workers who use repetitive overhead movement (i.e. swimmers, baseball players, tennis players, painters, and construction workers) are more susceptible of developing this condition.
  • Acute trauma from a fall or impact to the shoulder joint.

Symptoms and Diagnosis

Patients with impingement most commonly complain of:

  • Pain in the shoulder, which is worse with overhead activity and sometimes is severe enough to cause awakening in the night
  • Difficulty reaching up behind the back
  • Weakness of shoulder muscles

The diagnosis of shoulder impingement can usually be made with a careful history and physical exam. Manipulation of the shoulder in a specific way by your physician will usually reproduce the symptoms and confirm the diagnosis.

Imaging Tests

X-rays are also helpful in evaluating the presence of bone spurs and/or the narrowing of the subacromial space. MRIs are usually not necessary to diagnose shoulder impingement but may be used to rule out more serious diagnoses.

Treatment Options

The first step in treating shoulder impingement is eliminating any identifiable cause or contributing factor. This may mean temporarily avoiding activities with repetitive overhead movements. A non-steroidal anti-inflammatory medication may also be helpful. The primary source of treatment involves exercises to restore normal flexibility and strength to the shoulder, including strengthening both the rotator cuff muscles and the muscles responsible for normal movement of the shoulder blade. On occasion, an injection of cortisone may prove to be helpful in treating this condition.

Surgical Intervention

In most cases, surgery is not necessary for treatment of shoulder impingement.  However if symptoms continue after trying proper nonsurgical treatment options, surgery could be beneficial.  Typically, the surgery would involve removing the tissue that is causing irritation to the shoulder.  This is done by either open or arthroscopic procedures with the outcome being favorable in more than 90% of the cases.

Post-Operative Recovery

An exercise or physical therapy program usually begins the week after surgery, and will continue for eight to ten weeks. Most patients can return to work one to two weeks after surgery, depending on their job requirements. Full recovery for most patients is achieved within three to five months following surgery.  

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Of Note

The material on this website is for informational purposes only and is not a substitute for medical advice or treatment for any medical conditions. You should promptly seek professional medical care if you have any concern about your health, and you should always consult your physician before starting a fitness regimen. No representation is made about the quality of the podiatric services to be performed or the expertise of the podiatrist performing such services.

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