http://www.sciencedaily.com/releases/2010/03/100306223835.htm

Shoulder Function Not Fully Restored After Rotator Cuff Surgery, Study Finds

(snip...) "We found that the motion pattern of the repaired shoulder is significantly different than the patient's opposite shoulder," says Dr. Bey. "These differences in shoulder motion seem to persist over time in some patients."

According to the American Academy of Orthopaedic Surgeons, rotator cuff tears are a common cause of pain and disability among adults, especially among those over age 40. The rotator cuff is comprised of four muscles and several tendons that create a covering around the top of the upper arm bone. The rotator cuff holds the bone in and enables the arm to rotate.

(herein lies the rub)

The rotator cuff can be torn from a single injury but most tears result from overuse of the muscles and tendons over years. Those at especially high risk are those who engage in repetitive overhead motions. Common treatments include anti-inflammatory medication, steroid injections , physical therapy and surgery." (more...)

Need to cite this story in your essay, paper, or report? Use one of the following formats:
APA

MLA Henry Ford Health System (2010, March 9). Shoulder function not fully restored after rotator cuff surgery, study finds. ScienceDaily.

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Interesting. Now, what I would ask first is, how many of the patients had steroid injections before surgery? As these injections rot out the ligaments and tendons of the *shoulders. Don't EVER permit the use of steroid injections into your shoulders. Preferable is Hyaluronic Acid - which does the job without injuring the shoulder mechanism or soft tissue of the shoulder.

Interesting.

My rotator cuff is a constant nuisance. I 'suppose' I'll HAVE to do summat about it at some time, but will put it off - really do NOT want ANY surgery here in France. The rheumy (whom I've decided to dump anyways) suggested that I have cortisone injections...shock, horror! Told him why, he'd 'not known of the studies'. Oh well. Should know, his business TO know, considering his position out there. But no. Closed mind, NO scientific inquisitiveness, nor did he even want to know. Sad. Can't get along with that kind of attitude in my medical team - which at the moment is sadly lacking even one person I'd consider of note or worth!! Ah me!

Molly C (France)
Keeping on Keeping on (as one does...you bet chum!)

Hi Molly,

Thanks for the info about steroid shots in the shoulder. I was in terrible pain for quite some time in my shoulder, and got one steroid shot. The pain went away and did not return.

If I ever need another shot I will make sure that the doctor uses Hyaluronic Acid instead. The last thing I need is my ligaments and tendons to rot!

It's always something!!!!!!

Laurie

tore my rotator cuff pretty badly several years ago. a little at first, but then free style swimming stroke when i didn't think it was too bad and felt this terrible pain, couldn't lift my arm up at all, impingement of the tendon, so inflamed couldn't lay on it without great pain (had to prop it up off the bed with a folded hand towel). the physiatrist showed me this one simple exercise, said it would never heal on its own (after months of it not healing on its own). took several months, but she was right, by doing the exercise every day, it seems to be good as new now......fast forward to this past fall, other side, rotator cuff, same impingement, after the upper in general had been such a mess, rotator cuff not quite as bad, and lower tendons this time, but again, did the same exercise, and after a few months, it is much better. think unless its a full blown rupturue, the rotator cuff exercises just might do the trick, maybe not for everyone, but maybe for others. i did have to be really careful with the exercise, started out with no weight at all, just raising my arm up, about 5 degrees up from my body, starting with only 1 or 2 repetitions, but i kept with it every day, and within a few months could raise it up 90 degrees with a 3 lb weight. have always been taught by PTs and physiatrists to do one more repetition past the first twinge of pain, and no more. the old adage no pain, no gain, they don't believe that. now that i've seen results by listening to them, i'm of the same mind. as i said, may not work for everyone, but thought it worth mentioning.

Ok now I am a little worried.
I did my rotator cuff late last year and have had 2 cortisone injections in it. It was still playing up pretty bad when I was diagnosed with AS 2 weeks ago and then my doc went arrrr thats why your shoulder isnt healing. I dont realy understand what he meant but anyway little scared to hear the rot thing.

My mum also did her rotator cuff some years ago now and has had numerous injections and 2 surgeries on her shoulder and still having trouble with it. She is actualy waiting on a workers compensation payout for the injury and the doctors now want her to have surgery on her neck. Something to do with the shoulder has no affected her neck.

Thanks for sharing. Makes for interesting if not a little scary reading.

Laurie : - You've only had the oe shot, and so long as it went into the asbsoltely 'right' place, then you'll be OK. Very diff to get the 'right' sdpot, even by the most experienced orthopod! Need to use ultrasond. But, anyways, you've only had the one shot.

Hyaluronic acid is far more expensive than cortisone, but, yes, ask for the Hyaluronic - though be prepsared for him to baulk, or even, not know what you are talking about! Bring the info with you. Osternil is the name of the product.

Aussiegirl : Don't be scared, but don't have any more cortisone shots into yr shoulders, please. As for your mom. Hmmmmmm. Well, she will need a really good orthopod.

Now gals. Will post again the info on cortisone shots into the shoulder and what they can do. Just need a space to pick up the links for you. OK?

Don't be scared, but do be careful of those shoulders.

Take care -

Sue, yes, one ca indeed re-set the shoulder from a rotator cuff tear - so long as the tear isn't massive. (Mine is at critical point two years ago and is now jipping me every day. Think it has started to be in a right mess.)

However. Now, to the exercise you posted. More explanation please.

Which way does one raise one's arm? Out to the side, or straight upwards to the front...? Which?


Also, hand turned inwards, or outwards?

This is important. Outwards puts a bigger strain on the shoulder, that is, hand turned up, and taken out to the side. Also puts more strain on the shoulder IF turned outwards and hand taken straight upwards to the front.

Now, palm downwards and out to the side is more stress on the shoulder than palm downwards and taken 'straight' upwards to the front.

In fact, you can try this and feel the differences as you move around the relevant points of the compass, palm upwards verses palm downwards. You can 'feel' the different stress levels in the shoulder as the tendons and ligaments come into play.

Sue. Please clarify. Important. And thanks for input.

hi molly,

the exercise i was given was to start with arms at side, palms against body, and to raise arms 90 degrees out to side, palms down (with light 2-3 lb weights, up to 20 repetitions). i modified the exercise to fit my needs. i started with no weight. raised arms in that direction just a few inches / few degrees just a few times until i just started to feel a "twinge". as time went on, increased repetitions til i could do 20 to that height. then raised a little higher, just until i felt the "twinge". then worked up to 20 repetitions. kept going higher, then more repetitions, etc, until i was up to 90 degrees out to side, palm down. then repeated the whole process over again with 1 lb, then 2 lb, then 3 lb weight. then started doing different angles, instead of straight out to side, or straight out front, did those plus everything in between, even turning hand different angles to get different feels. it was actually somewhere in between there that i felt the most, that was the most difficult. just kept working until i could do all those angles with no more pain. don't remember if it was 3, 4, 5, 6 months, just know it was a long time, very patient, just adding a repetition or two each day, a few degrees, each time. that was back in the early 2000s when i hurt my right rotator cuff pretty badly. this time in the fall, it was a different part of the rotator cuff, so the angle that was the most difficult was a bit different, and the impingement was a little different too, but my approach was the same. didn't even need to go to PT this time, knew what to do based on what i had learned the first time. hope that helps and is detailed enough but not so much so that one gets bogged down in the description. to be honest, its one of the few tendons i feel i know how to strengthen properly after tearing. that first physiatrist taught me well. she had originally been trained and worked as a PT before she went back to med school to become an MD. she was great, was able to help me with both the "doctoring" and the practical PT avice as well. but then i had to move to a different state. i still miss her.

That's good Sue. Needed the explanation for others, as just 'my' knowing was not going to help any! It was your input and therefore your part of the thread, so, needed your clarification. Good clarification, and clear about working around the compass - my term. Different angles, your term.

Thanks. Yep. Palm downwards is 'softer' on the shoulder.

Small warning. Initially, don't bring arm 'across front' of body as that puts quite a strain on the shoulder tendons. (Could do with Cindy in on this one. 'Smile'.)

Can also work with therabands to strengthen. I used to do mine with the aid of the stair bannister. My left shoulder with the replacement is now quite strong, but the right shoudler with the rotator cuff problem is not at all strong, and of course, not yet ready for thera bands...

ah yes, do the therabands too, especially like the rowing exercises with the therabands for the rhomboids. wall pushups good too. just everything carefully.

and if i'm thinking about this correctly when you say "don't bring arm across front of body", is that where you bend the elbow, raise the arm up 90 degrees, and then bring arm in front of body? that's when i feel the impingement when things are bad and then yes, avoid that, cause it hurts. tendon inflamed, rubbing inside its shaft. is that what you mean? or something else?

and yes, "working around the compass" good term for it.

Oops. Was forgetting to add - and therefore will make a new post on this aspect, as it is *Important.

NEVER work 'through' a pain level. You can do further damage to the shoulder. IF it hurts, stop, immediately.

Look at 'what' you are doing, analyse the exercise. You may be at the wrong angle (point of compas); trying to go with palm 'upwards'; may be using too much weight too soon (IF you have progressed to using weight aids 'to' the exercise).

Please be CAREFUL.

Now will go check out the info on steroid injections and whatever else I find of interest to add to this rotator cuff thread. Lot of information available, but don't want to swamp y'all...!!

Arm straight out Sue. IF you bend the arm, not nearly so much leverage. Straight out in front, across the body - using different point/s of the compass?

See IF I can find illustrations for this'un.

Another point. Warning: don't bring arm out to the back of you, whether arm is bent or straight. This will do a lot of damage to an already damaged rotator cuff! And steer well clear of overhead stuff. Even taking items off high shelves; stand on a kitchen stool or summat. But ensure that the stool is one of those safety ones, with a bar in front, to grab and steady. (Don't want you guys falling forwards/backwards off stools!)

Rotator Cuff - lot of information here. This is the best site bar none, for shoulder information.

Rotator Cuff Tears :-http://www.shoulderdoc.co.uk/article.asp?section=22

Now,, you will read that corisone injections are mentioned, but, will post on the Hyaluronic Acid (Osternil) aspect wehn I have picked it up from THIS site itself...Prof Funk, BTW is a renowned internation expert on shoulders. And he is an amazing teacher.

Will use this response to add *relevant sections as I pick them up from the site. OK?

Shoulder Anatomy :-
http://www.shoulderdoc.co.uk/article.asp?section=3&article=1

"The shoulder is one of the most sophisticated and complicated joints of the body:

"It has the greatest range of motion of any joint in the body allowing complete global movement allowing you to position the hand anywhere in space.
The coordinated activity of numerous muscles working together in set patterns is required to produce this motion
It is made up of FOUR joints and FIVE linked bone groups which are related and work together.
To allow so much movement the joints need to be 'free' to move, therefore the shoulder should be unstable; However a series of complex ligaments and muscle keep it in joint." (more...)

Shoulder Tendons :-
http://www.shoulderdoc.co.uk/article.asp?article=1180&section=857

Partial thickness cuff tears :-
http://www.shoulderdoc.co.uk/article.asp?article=1368&section=22

Latest news :- (this is very informative and worth picking out salaient areas of interest.)http://www.shoulderdoc.co.uk/latest.asp?region=products&section=82

Shoulder Injections - important. You'll see why it is crucial for the person doing the procedure to use ultrasound or imaging to assist in doing the shoulder injection. It should NEVER be done without such aids - as can cause damage...! (coming up, more on this 'Shoulder Injections' aspect.)

Intra-articular injection of the acromioclavicular joint
(snip...) "Intra-articular punctures and injections are performed routinely on patients with injuries to and chronic diseases of joints, to release an effusion or haemarthrosis, or to inject drugs. The purpose of this study was to investigate the accuracy of placement of the needle during this procedure." (and) "Correct positioning of the needle in the joint should be facilitated by fluoroscopy, thereby guaranteeing an intra-articular injection."

Corticosteroids Reduce the Tensile Strength of Isolated Collagen Fascicles
http://www.shoulderdoc.co.uk/article.asp?article=969
(snipped...) "Clinical Relevance: Corticosteroids may weaken specific regions of the injected tendon and leave it more prone to rupture. This weakening effect is manifested in the individual collagen fascicles that constitute the tendon."

Hyaluronans in the Shoulder
http://www.shoulderdoc.co.uk/article.asp?article=82
HA does not have the know detrimental effects on tendons that corticosteroids have (14) (See Shoulder Injections ) and therefore is an attractive alternative to corticosteroids around the sensitive rotator cuff.

Shibata et al [8] prospectively compared HA and steroid injections in patients with rotator cuff tears. There was no difference with respect to the pain relief experienced, range of motion and surgical requirements between the two groups. However, biopsies from the rotator cuff stumps were examined from patients who underwent surgery and showed that the collagen fibres from those injected with HA pre-operatively were significantly denser than those treated with steroid. HA injected patients were more responsive to rotator cuff repair with better outcomes. There was also a link between the number of steroid injections and the outcome of surgery. Repeated steroid injections may cause severe local destruction. They concluded that although local steroid injection is often used for pain, since it has a good analgesic effect, repeated injections are associated with a softer residual cuff, and poor surgical results may be due to the giving way of this soft tissue (7)." (more...)
(snip...) "Our clinical experience after one year is that (HA)it is a useful alternative to corticosteroids and provides similar pain relief, without the concern of complications such as rotator cuff damage and fat necrosis."

Here is the biggie :-

Shoulder Injections
http://www.shoulderdoc.co.uk/article.asp?section=56&article=101

(snip...) "there is little overall evidence to guide treatment and subacromial corticosteroid injections for rotator cuff disease may be beneficial, although their effect may be small and not well-maintained"

(snip...) "Adverse Effects of Corticosteroid Injections

The accuracy of injecting corticosteroid into the subacromial bursa is at best 70% in the hands of an experienced shoulder surgeon [6,7]. Thus in 30% of cases corticosteroid is being injected into the surrounding tissues including the rotator cuff tendon and muscle.

Nelson et al. reviewed the use of corticosteroid injections in primary care [11]. They noted the local complications of corticosteroid injection include tendon and ligament weakening, bacterial infections of joints and related structures, and subcutaneous tissue atrophy. Systemic complications were rare but included hyperglycemia and adrenal axis suppression.

A number of studies have expressed concerns that steroids injected into the tendons and muscles can significantly weaken the collagen fibres and precipitate rotator cuff ruptures when injected for subacromial impingement[2-5,16]. Corticosteroids damage the ultrastructure of collagen molecules, reduce collagen density [8], as well as inhibiting the reparative properties of tendon by inhibiting tendon cell migration [9] and synovial fibroblast proliferation [10].

Due to the clinical complications of steroid injections into tendons, Fredberg in 1997 stated that the injection of corticosteroid inside the tendon has a deleterious effect on the tendon tissue and should be unanimously condemned [12].

Corticosteroids injected into the subcutaneous tissues can cause lipodystrophy and soft tissue infections. This is more common following repeated injections and in immunocompromised and rheumatoid patients [3,8,14].

Due to the nature of rheumatoid arthritis and the disease process effects on tendons, repeated corticosteroid injections compound the tissue damaging effects and make any surgical repair of these tissues more difficult and more likely to fail [8,13,14].

Hyaluronans
Subacromial injection is an important part of the management of impingement syndrome, therefore are there safer substances to use instead of steroids?

Hyaluronan (HA) injections have been proven to be as effective as corticosteroids for the treatment of impingement syndrome and rotator cuff disease [8,15], without the complications associated with corticosteroids.

At present, we are prospectively comparing a Hyaluronan (Ostenil) with corticosteroid (Depomedrone) for impingement syndrome and selected cases of arthritis (unfit for surgery).

Our early experience is that Ostenil is as effective as corticosteroids with regard to pain relief and range of motion. Click here for more.
Also See:
- Hyaluronans - Basic Science
- Hyaluronans in the Shoulder

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There is MORE information available on the shoulderdoc.co.uk website. (In fact, enough information of TRUE *excellence, to keep even a top orthopaedic surgeon going for a year, let alone *ESSENTIAL information for the rheumatologist and GP - and for the patient who needs to be very well informed before letting anyone loose on their shoulder!)

Molly, good article and discussion, especially since there are so many AS'ers with shoulder problems. Yes cortisone injections can be a tough call unless you know you have a OS that is a specialist in shoulder injuries and AS. Any injury that involves the connective tissues is going to be hard to heal in patients with AS due to the direct imflamation to those tissues normally but especially after an injury. If there are Hyloronic acid is best for those with joint deterioration from Osteoarthritis. If patients with connective tissue injuries want temorary relief they should consult their OS about the possibility of Marcaine injections to decrease the pain so they can get range of motion back. Shoulders are a big problem with AS patients and simple stretching and strengthening should be done on a daily basis and avoid repetative movements that will cause imflamation.

Cindy

Yea Cindy - Thank you for that. I feel that ALL ASers should have this printed out and kept to the forefront of their folders...

Yes, Professor Funk speaks of the Marcaine injections, and also in using Marcaine in conjunction 'with' the HA. Facinating. (He sure is filled with consternation at the damage those corisone shots do, and to the free use of such shots by rheumatologists and doctors, and that is excluding orthopods use of cortisone shots in the shoulders...! )

Again, my thanks for joining the thread with your expert physio input.

Take care - Go well -

Molly C (France)
Keeping on Keeping on

wow, this thread is just what I needed. My shoulder injury just will not heal. I'm going to absorb all this info and re-think my strategy. thanks!!!

I've been avoiding cortisone shots in my shoulders for these very reasons. Haven't had one yet but there've been times when I've been tempted.

I have had several, over a period of 20 years. In both shoulders. My shoulders are one of my biggest pain problems. This is not good news for me, as the cortisone injections really helped.
Donna

AS and steroid injections not a good mix. I've had so many injections in both shoulders over the years, I'm a prime example of what not to do. I have torn rotator cuff and Labial tears in both shoulders and right biceps tendon ruptured and the left biceps is about 50% torn. I really works against people with AS. Steroids weaken the very ligaments and tendons that the AS imflames, only makes sence when you think about it.
Cindy

I wonder what the effect of anabolic steroids would be on someone with AS? You always hear these professional athletes that get busted for using roids saying they were just trying to recovery from an injury, not gain a competitive edge.