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Shoulder Arthroscopy

Common Shoulder Arthroscopy Procedures for Shoulder Impingement    

Post-Surgical Rehabilitation following Should Arthroscopy

Shoulder Arthroscopy is a surgical procedure used to address conditions and injuries such as shoulder impingement.

This procedure reduces tissue damage, only requires small incisions, and may speed up healing time.  After your shoulder arthroscopy, you may be put in an immobilizer or sling and be restricted in some movements.  After working with a physical therapist, you should be able to resume normal activities.

The shoulder is a very complex piece of machinery.  Its elegant design gives the shoulder joint great range of motion, but not much stability.  As long as all the parts are in good working order, the shoulder can move freely and painlessly.

Shoulder Impingement

Many people refer to any pain in the shoulder as bursitis.  The term bursitis really only means that the part of the shoulder called the bursa is inflamed.  Tendinitis is when a tendon gets inflamed.  This can be another source of pain in the shoulder.  Many different problems can cause inflammation of the bursa or tendons.  Impingement syndrome is one of those problems.  Impingement syndrome occurs when the rotator cuff tendons rub against the roof of the shoulder, the acromion.

Why do I have problems with shoulder impingement?

Usually, there is enough room between the acromion and the rotator cuff so that the tendons slide easily underneath the acromion as the arm is raised.  But each time you raise your arm, there is a bit of rubbing or pinching on the tendons and the bursa.  This rubbing or pinching action is call impingement.

Impingement occurs to some degree in everyone's shoulder.  Day-to-day activities that involve using the arm above shoulder level cause some impingement.  Usually it doesn't lead to any prolonged pain.  But continuously working with the arms raised overhead, repeated throwing activities, or other repetitive actions of the shoulder can cause impingement to become a problem.  Impingement becomes a problem when it causes irritation or damage to the rotator cuff tendons.

Raising the arm tends to force the humerus against the edge of the acromion.  With overuse, this can cause irritation and swelling of the bursa.  If any other conditions decreases the amount of space between the acromion and the rotator cuff tendons, the impingement may get worse.

Bone spurs can reduce the space available for the bursa and tendons to move under the acromion.  Bone spurs are bony points.  They are commonly caused by wear and tear of the joint between the collarbone and the scapula, called the acromioclavicular (AC) joint.  The AC joint is directly above the bursa and rotator cuff tendons.

In some people, the space is too small because the acromion is oddly sized.  In these people, the acromion tilts too far down, reducing the space between it and the rotator cuff.

if you are still having problems after trying non-surgical treatments, your doctor may recommend surgery. 

Common Shoulder Arthroscopy Procedures for Shoulder Impingement

Subacromial Decompression

The goal of surgery is to increase the space between the acromion and the rotator cuff tendons.  Taking pressure off the tissues under the acromion is called subacromial decompression.  The surgeon must first remove any bone spurs under the acromion that are rubbing on the rotator cuff tendons and bursa.  Usually the surgeon also removes a small part of the acromion to give the tendons even more space.  In patients who have a downward tilt of the acromion, more of the bone may need to be removed.  Surgically cutting and shaping the acromion is call acromioplasty. It gives the surgeon another step to get pressure off (decompress) the tissues between the humerus and the acromion.

Resection Arthroplasty

Impingement may not be the only problem in an aging or overused shoulder.  It is very common to also see degeneration from arthritis in the AC joint.  If there is reason to believe that the AC joint is arthritic, the end of the clavicle may be removed during impingement surgery.  This procedure is call resection arthroplasty.

The most common procedure for AC joint osteoarthritis is resection arthroplasty.  A resection arthroplasty involves removing a small portion of the end of the clavicle.  This leaves a space between the acromion (the piece of the scapula that meets your shoulder) and the cut end of the clavicle, where the joint used to be.  Your surgeon will take care not to remove too much of the end of the clavicle to prevent any damage to the ligament holding the joint together.  Usually only a small portion is removed, less than one centimeter.  As your body heals, the joint is replaced by scar tissue.  Remember, the AC joint doesn't move much, but it does need to be flexible.  The scar tissue allows movement but stops the bone ends from rubbing together.

The procedure can be done in two ways.   Today, it is more common to do this procedure using the arthroscope.  An arthroscope is a slender tool with a tiny TV camera on the end.  It lets the surgeon work in the joint through a very small incision.  This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery time.

Arthroscopic Procedure

Today, acrommioplasty is usually done using an arthroscope.

An arthroscope is a special type instrument designed to look into a joint, or other space, inside the body.  The arthroscope itself is a slender metal tube smaller than a pencil.  Inside the metal tube are special strands of glass called fiber optics.  These small strands form a lens that allows one to look into the tube on one end and see what is on the other side - inside the space.  This is similar to a microscope or telescope.  In the early days of arthroscopy, the surgeon actually looked into one end of the tube.  Today, the arthroscope is attached to a small TV camera.  The surgeon can watch the TV screen while the arthroscope is moved around in the joint.  Using the ability to see inside the joint, the surgeon can then place other instruments into the joint and perform surgery while watching what is happening on the screen.

The arthroscope lets the surgeon work in the joint through a very small incision.  This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery.  Once your surgeon is done with the arthroscope, you may be able to go home the same day.

To perform the acromioplasty using the arthroscope, several small incisions are made to insert the arthroschope and special instruments needed to complete the procedure.  These incisions are small, usually about one-quarter inch long.  It may be necessary to make three or four incisions around the shoulder to allow the arthroscope to be moved to different locations to see different areas of the shoulder.

A small plastic, or metal, tube is inserted into the shoulder and connected with sterile plastic tubing to a special pump.  An other small tube allows the fluid to be removed from the joint.   This pump continuously fills the shoulder joint with sterile saline (salt water) fluid.  This constant flow of fluid through the joint inflates the joint and washes any blood and debris from the joint as the surgery is performed.

There are many small instruments that have been specially designed to perform surgery in the joint.  Some of these instruments are used to remove torn and degenerative tissue.  Some of these instruments nibble away bits of tissue and them vacuum them up from out of the joint.  Others are designed to burr away bone tissue and vacuum it out of the joint.  These instruments are used to remove any bone spurs that are rubbing on the tendons of the shoulder and smooth the under surface of the acromion and AC joint.

Post-Surgical Rehabilitation following Shoulder Arthroscopy.

Rehabilitation after shoulder surgery can be a slow process. You will probably need to attend physical therapy sessions for several weeks, and you should expect full recovery to take several months.  Getting the shoulder moving as soon as possible is important.  However, this must be balanced with the need to protect the healing muscles and tissues.

Your surgeon may have you wear a sling to support and protect the shoulder for a few days after surgery.  Ice and electrical stimulation treatments may be used during your first few therapy sessions to help control pain and swelling from the surgery.  Your therapist may also use massage and other types of hands-on treatment to ease muscle spasm and pain.

Therapy can progress quickly after a simple arthroscopic procedure.  Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening.   You just need to be careful to avoid doing too much, too quickly.

Therapy goes slower after open surgery in which the shoulder muscles have been cut.  Therapists will usually wait up to two weeks before starting range-of-motion exercises.  Exercises begin with passive movement. During passive exercises, your shoulder joint is moved but your muscles stay relaxed.  Your therapist gently moves your joint and gradually stretches your arm.  You may be taught how to do passive exercise at home.

Active therapy starts four to six weeks after surgery.  You use your own muscle power in active range-of-motion exercise.  You may begin with light isometric strengthening exercises.  These exercises work the muscles without straining the healing tissues.

At about six weeks you start doing more active strengthening.  Exercises focus on improving the strength and control of the rotator cuff muscles and the muscles around the shoulder blade.  Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket.  This helps your shoulder move smoothly during all your activities.

Some of the exercises you'll do are designed to get your shoulder working in ways that are similar to your work tasks and sport activities.  Your therapist will help you find ways to do your tasks that don't put too much stress on your shoulder.   Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Knee Arthroscopy

A knee arthroscopy is a surgical procedure performed by using a small scope that is inserted into the knee joint to repair injuries to the articular cartilage and/ or meniscus.

Knee Arthroscope of Articular Cartilage Injuries          Knee Artthroscope of Mensicus Injuries

Articular cartilage problems in the knee joint are common.  Injured areas, called lesions, often show up as tear or pot holes in the surface of the cartilage.  If a tear goes all the way through the cartilage, surgeons call it a full-thickness lesions. When this happens, surgery is usually recommended.  However, these operations are challenging.  Repair and rehabilitation are difficult.  Your surgeon will consider many factors when determining the procedure that's best for you.

Articular cartilage is a smooth, slippery material that covers the ends of the bones that make up the knee joint.  The articular cartilage allows the surfaces to slide against one another without damage to either surface.

The meniscus is a commonly injured structure in the knee.  The injury can occur in any age group.  In younger people, the meniscus is fairly tough and rubbery, and tears usually occur as a result of a forceful twisting injury.  The meniscus grows weaker with age, and meniscal tears can occur in aging adults as the result of fairly minor injuries, even from the up-and-down motion of squatting.

What is a meniscus, and what does it do?

There are two menisci between the shinbone (tibia) and the thighbone (femur) in the knee joint. (menisci is plural for meniscus.)

The C-shape medial meniscus is on the inside part of the knee, closest to your other knee.  Medial means closer to the middle of the body.)  The U-shaped lateral meniscus is on the outer half of the knee joint. (Lateral means further out from the center of the body.)

These two menisci act like shock absorbers in the knee.   Forming a gasket between the shinbone and the thighbone, they help spread out the forces that are transmitted across the joint.  Walking puts up to two times your body weight on the joint.   Running puts about eight times your body weight on the knee.  As the knee bends, the back part of the menisci takes most of the pressure.

By spreading out the forces on the knee joint, the menisci protect the articular cartilage from getting too much pressure on one small area on the surface of the joint.  Without the menisci, the forces on the knee joint are concentrated onto a small area, leading to damage and degeneration of the articular cartilage, a condition called osteoarthritis.

Surgeons use an arthroscope (mentioned earlier) during surgery for an injured meniscus.  Small incisions are made in the knee to allow the insertion of the camera into the joint.

Knee Arthroscopy of Articular Cartilage Injuries

Arthroscopic Debridement

Surgeons use an arthroscope, a tiny camera inserted into the knee during surgery, to see into the joint and clean up the joint by trimming rough edges of cartilage and removing loose fragments.  Sometimes this procedure is referred to as Chondroplasty.  It is only intended to be a short-term solution, but it is often successful in relieving symptoms for a few years.  This procedure  is usually used when the lesion is too large for a grafting type procedure or the patient is older and an artificial knee is planned for the future.

Abrasion Arthroplasty

When osteoarthrities affects a joint, the articular cartilage can wear away, leaving bone rubbing on bone.  This causes the bone to become hard and polished.  During arthroscopy the surgeon can use a special instrument known as a burr to perform an abrasion arthroplasty.  In this procedure, the surgeon carefully scrapes off the hard, polished bone tissue from the surface of the joint.  The scraping action causes a healing response in the bone.  In time new blood vessels enter the area and fill in with scar tissue (fibro cartilage) that is like articular cartilage. Fibro cartilage is weaker than normal articular cartilage.  Because this is not true articular cartilage, it does not function as well for weight bearing as articular cartilage.  The fibro cartilage that forms may not be strong enough to remove all the symptoms of pain in the knee.  This usually is a temporary solution.  Symptoms may return after this surgery.

Micro fracture

Surgeons use a blunt awl ( a tool for making small holes) to poke a few tiny holes in the bone under the cartilage.  Like abrasion arthroplasty, this procedure is used to get the layer of bone under the cartilage to produce a healing response.  The fresh blood supply starts the healing response and trigger the body to start forming new cartilage (mainly fibro cartilage) inside the lesion.

Post-Surgical Rehabilitation

Depending on the type of surgery, some surgeons have their patients use a continuous passive motion (CPM) machine to help the knee begin to move and to alleviate joint stiffness.  This machine is used after many different types of surgery involving joints and is usually started immediately after surgery.  The machine straps to the leg and continuously bends and straightens the joint.  This continuous motion has been shown to reduce stiffness, reduce pain, and help the joint surface heal better with less scarring.

Many surgeons will have their patients take part in formal physical therapy after knee surgery for articular cartilage injuries.  The first few physical therapy treatments are designed to help control the pain and swelling from the surgery.  Physical therapist will also work with patient to make sure they are only putting a safe amount of weight on the affected leg.

With the exception of those who undergo a simple debridement, patients will be instructed to avoid putting too much weight on their foot when standing or walking for up to six weeks.  This gives the area time to heal.  People treated with an allograft are often restricted in their weight bearing for up to four months.

Patients are strongly advised to follow the recommendations about how much weight is safe.  They may require a walker or pair of crutches for up to six weeks to avoid putting too much pressure on the joint when they are up and about.

Your physical therapist will choose exercises to help improve knee motion and to get the muscles toned and active again.  At first, emphasis is placed on exercising the knee in positions and movements that don't strain the healing part of the cartilage.  As the program evolves, more challenging exercises are chosen to safely advance the knee's strength and function.

Ideally, patients will be able to resume their previous lifestyle activities.  Some patients may be encouraged to modify their activity choices, especially if an allograft procedure was used.

The physical therapist's goal is to help you keep your pain under control, ensure safe weight bearing, and improve your strength and range of motion.  When you are well under way, regular visits to the therapist's office will end.  Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Knee arthroscopy of Meniscus Injuries.

Partial Meniscectomy

The procedure to take out the damage portion of the meniscus is called partial miniscectomy.  The surgeon makes a small incision.  This opening is needed to insert surgical instruments into the knee joint.  The instruments are used to remove the torn portion of the meniscus, while the arthroscope is used to see what is happening.

Surgeon would rather not take out the entire meniscus.  This is because the meniscus helps absorb shock and adds stability to the knee.  Removal of the meniscus increases the risk of future knee arthritis.  Only if the entire meniscus is damage beyond repair is the entire meniscus removed.

Meniscal Repair

Whenever possible, surgeons prefer to repair a torn meniscus, rather than remove even a small piece.  Young people who have recently torn their meniscus are generally good candidates for the repair.  Older patients with degenerative tears are not.

To repair the torn meniscus, the surgeon inserts the arthroscope and views the torn meniscus.  Some surgeons use sutures to sew the torn edges together.  Others use a special fasteners called suture anchors, to anchor the torn edges together.

Surgeons are beginning to experiment with different ways to replace a damaged meniscus.  One way is by transplanting tissue, called an allograft, from another person's body   Further investigation is needed to see how well these patients do over a longer period time.

Post Surgical Rehabilitation

Rehabilitation proceeds cautiously after surgery on the meniscus, and treatment will vary depending on whether you had a part of the meniscus taken out or your surgeon repaired or replaced the meniscus.

Patients are strongly advised to follow the recommendations about how much weight can be borne while standing or walking.  After a partial menisectomy, your surgeon may instruct you to place a comfortable amount of weight on your operated leg using a walking aid.  After a meniscal repair, however, patients may be instructed to keep their knee straight in a lock knee brace and to put only minimal or no weight on their foot when standing or walking for up to six weeks.

Patients usually need only a few physical therapy visits after menisectomy.  Additional treatment may be scheduled if there are problems with swelling, pain, or weakness.  Rehabilitation is slower after a meniscal repair or allograft procedure.  At first, expect to see the physical therapist two to three times a week.  If your surgery and rehabilitation go as planned, you may only need to do a home program and see your therapist every few weeks over a six-to-eight week period.

 

 

Total Shoulder Replacement

The most common causes for a shoulder replacement are degeneration, or osteoarthritis, rheumatoid arthritis, and fracture(s) of the bones of the shoulder.  Once your shoulder replacement is performed, physical therapy will help you regain motion, strength, and function of your shoulder.  You should be able to return to most of your previous activities that your shoulder pain had prevented you to do before your surgery.

The first few outpatient physical therapy treatments will focus on controlling pain and swelling.  Ice and electrical stimulation treatments may help.  Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.  Continue to use your shoulder sling as prescribed.

As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the shoulder's strength and function.

Finally, a select group of exercises can be used to simulate day-to-day activities, like grooming your hair or getting dressed.  Specific exercises may also be chosen to simulate work or hobby demands.

When your shoulder range of motion and strength have improved enough, you'll be able to gradually get back to normal activities.  Ideally, you'll be able to do almost everything you did before.  However, you may need to avoid heavy or repeated shoulder actions.

You may be involved in a progressive rehabilitation program for two to four months after surgery to ensure the best results from your artificial joint.  In the first six weeks after surgery, you should expect to see your therapist two to three times a week.  At that time, if everything is still going as planned, you may be able to advance to a home program.  Then you will only check in with your therapist every few weeks.

Total Hip Replacement

Osteoarthritis, rheumatoid arthritis, and traumatic injury are all main reasons for opting for a hip replacement.  The goal of a hip replacement is to reduce pain, restore function and mobility, and let you return to most of your previous activities that your hip prevented your from doing.

Shortly after surgery, your physical therapist will see you in your hospital room.  You'll practice getting out of bed and walking using your walker ore a pair of crutches.  Exercises are used to improving muscles tone and strength in the hip and thigh muscles are to help prevent the formation of blood clots.

During your recovery, you should follow your surgeon's instructions about how much weight you can put down while standing or walking.  After you return home from the hospital, your surgeon may have you work with a physical therapist for up to six in-home visits.

These visits are to ensure you are safe in and about the home and getting in and out of a car.  Your therapist will make recommendations about your safety, review special hip precautions and make sure you are placing a safe amount of weight on your foot when standing or walking.  Home therapy visits end when you are safe to get out of the house.

A few additional visits in outpatient physical therapy at Northern Michigan Sports Medicine Center may be needed for patients who still have problems walking or who need to get back to physically heavy work or activities.

Our goal is to help you maximize hip strength, restore a normal walking pattern, and do your activities without risking further injury to your hip.  When you are well under way, regular visits to Northern Michigan Sports Medicine Center will end.  We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Total Knee Replacement

The main reason for replacing any arthritic joint with an artificial joint is to stop the bones from rubbing against each other. The goal is to help people return to many of their activities with less pain and with greater freedom of movement.
 
After going home from the hospital, some patients may be seen for a short period of home therapy before beginning outpatient physical therapy. Outpatient treatments are designed to improve knee range of motion and strength and to safely progress your ability to walk and do daily activities. Northern Michigan Sports Medicine Center utilizes aquatic therapy to help you progress quickly and with less pain.
 
Our goal is to help you keep your pain under control, maximize knee mobility, and improve muscle strength and control. When you are well under way, regular visits to Northern Michigan Sports Medicine Center will end. Our therapists will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

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