June 4, 2003

Note to our users: This interactive feature is in no way a substitute for the examination and advice of a physician. You are responsible for all actions you take after reading material on this site. Always seek the advice of a doctor for concerns about your health or a specific condition.

Knee1: Dr. Sklar is a partner at New England Orthopedic Surgeons, where he specializes in sports medicine and knee arthroscopy.

Shoulder1: Welcome to today's discussion with Dr. Dan Guttmann of Taos, New Mexico.

Shoulder1: Dr. Guttmann is an Associate Director of the Taos Orthopaedic Institute, and currently is Chief of Upper Extremity Surgery and the Hip Arthritis Service.

Shoulder1: Users, we welcome your questions!

Shoulder1: Dr. Guttmann, why don't we begin with having you tell us how you got started in orthopaedics.

Dr. Guttmann: I used to follow my dad around on rounds while I was in high school and then in medical school after rotating on orthopaedics, I knew it was for me.

faberm62@aol.com: Could many shots of cortisone aid in the breakdown of cartilage in my shoulder? I was injected about 5 times over 2 years with cortisone for pain and went back to work. I jackhammered roads 90% of the time I was on cortisone. After my first surgery, I was told I lost quite a lot of my cartilage. I think the cortisone masked the pain and allowed me to perform my job but did a lot of damage. Is that right?

Dr. Guttmann: Cortisone injections can be potentially damaging to the soft tissue and rotator cuff if given too frequently. Most shoulder injections do not go into the joint, and therefore should not affect the cartilage.

bfinkel: A month ago I had repairs done for a torn rotator cuff in my right shoulder. After the repairs (about a month later), I am diagnosed with a rotator cuff repair again in my right shoulder, though the doctors "assure" me this isn't the same tear even though this is again my right shoulder. Is this possible?

Dr. Guttmann: That would be unusual, however the integrity of a repair depends on the surgical technique, the implants and the quality of the tissue and bone. It is possible to retear a repair or have a new tear, but that would be very rare so early in rehab unless you had an accident.

mthrtresa@aol.com: My daughter broke her clavicle on her left side. We went to the ortho doc today and he said there was nothing he could do about it. My daughter is 13 and goes to middle school. I am concerned about the healing process. Especially since she will be walking around school (where the kids tend to run and grab you) and her clavicle will not heal because of lack of protection. Is there anything made that she can wear to protect her from being injured again? Thanks.

Dr. Guttmann: She should protect the clavicle with either a sling or figure 8 brace for 2 weeks. The vast majority of fractures heal without surgery, especially in children.

bsabes12@uni.edu: I had surgery on my shoulder nearly six months ago. I am a baseball pitcher and I threw a lot. My doctor tried everything from PT to injections before surgery. Nothing showed up on my two MRIs or my two arthrograms. The MRI/Arthro combined showed a little inflammation; I took an injection but it didn't help. He finally scoped my shoulder and fixed my labrum, which was frayed, took out my bursa, and said I had some scuffing on my glenoid. I did all of the rehab and really worked hard so I could play again. Now it's been six months, and some days are better than others. I can throw, but not like I want and I have some pain on the outer part of my shoulder. My neck and deltoid muscle also are stiff. I was wondering if scar tissue from the surgery could be affecting this and if I should see my doctor again and have him go in and clean it up.

Dr. Guttmann: Labral tears and secondary rotator cuff problems are classic in baseball pitchers. Often the MRIs are normal because it is a dynamic problem. Scoping the shoulder allows the doctor to diagnose the problem better. There are also subtle findings during arthroscopy that may lead to a formal repair of the labrum and/or treatment of the capsular laxity. Six months may be too soon to know for sure especially if you are a competitive thrower.

jhewlett: I play some baseball pitching (amateur) and as a right-handed pitcher, I tend to put all my backpacks/weights/carry-ons on my left just to be safe. Recently I wondered if I am not unnecessarily straining my left shoulder even though my coach tells me this is good practice.

Dr. Guttmann: You should probably wear the backpack on both shoulders. An overhead athlete derives much of his/her strength from the lower extremities and back and these should be appropriately strengthened as well.

maree.martin@ecu.edu.au: I have had a subacromial decompression & distal clavicle on my right shoulder 6-7 months ago. My injury was caused playing squash 16 months ago. I thought I was healing well until a month ago when I noticed a lump on the top of my shoulder, which feels like a knuckle. I have pain in my shoulder and feel I am back where I started. Can you advise as to what this lump may be?

Dr. Guttmann: This may be related to the clavicle excision. Sometimes the clavicle can be made unstable.

argom3@mmcable.com: I find that when I sleep on either side, after awhile my left arm goes numb. What could be causing this?

Dr. Guttmann: Either neck problems, pressure on your brachial plexus, possible carpal tunnel or peripheral nerve compression could be causing this.

hroth: Can one shoulder develop muscularly differently than the other one? I lift weights and do other standard fitness exercises. I have no shoulder pain or any noticeable problems but I think one of my shoulders is getting bigger than the other?

Dr. Guttmann: It is very common to have increased size in dominant extremity; try working the other extremity more.

jgiles: I had shoulder surgery maybe five years ago. At that time I was informed that I would never again get complete recovery of the flexibility in my shoulder. Has the technology changed in the past five years considerably? Should I have myself checked to see if any kind of "upgrade" work is possible?

Dr. Guttmann: It depends on what problem you had and what was done. The technology and minimally invasive techniques have progressed rapidly and there is a good chance you could have improved flexibility after an evaluation by a shoulder specialist.

Teresa: I saw my ortho today; he wanted to know if I had pain in my shoulder if I were to turn my head the same way, towards my sore shoulder. I didn't ask him what that could be, do you have any idea what he may have been looking for? (I also have alot of upper back pain with the shoulder.)

Dr. Guttmann: He could possibly be checking for thoracic outlet syndrome and/or cervical spine problems.

g6steph@comteck.com: I had surgery for an impingement on my left shoulder. I had physical therapy and work simulation. I am still having severe pain and there is a "catching" as I bring it down. I have received a second opinion in which the doctor did more x-ray's and an MRI with the dye. The only thing they told me was there was tendonitis and some swelling around the clavicle bone. I was told that was normal. My shoulder injury was 6 months ago and now they are talking as if it is a permanent restriction for me. Is there anything they could have missed? And is swelling around the clavicle 6 months later normal?

Dr. Guttmann: Swelling around the clavicle may be normal; it depends if you have pain over the acromioclavicular joint with crossing your arm across you body. Surgery for impingement is sometimes unpredictable, and the operative findings would help figure out what could still be problematic.

ckozer1@aol.com: How long does it normally take to recover external rotation after open surgery for traumatic instability?

Dr. Guttmann: That is a great question! It depends on what technique was used, sunscap split versus subscap release. It can take 3-4 months.

gjshelton@prodigy.net: In 1998, at the age of 23, I had arthroscopic surgery to repair a bankart(labral) tear. One question I never asked during the time surrounding my surgery is how effective is the repair (durability of sutures and anchors) over an individual's lifespan? Does the tear heal over time or do the sutures and anchors continue to keep the shoulder stable?

Dr. Guttmann: Great question; it depends on whether anchors were metal or bioabsorbable and also whether suture was absorbable or not. Open repairs have a success rate in the literature of approx 85-90%. The repair should biologically heal in 6-8 weeks. Instability repairs also depend on capsular tightening.

swmdncsal1@aol.com: I had surgery for impingement over a year ago and all the old symptoms are coming back. I have a constant pulling in the back of my shoulder 24/7 and teach aerobics work out with weights and still do rotator cuff exercises. It is a real effort to finish the classes; we use a combination of weights and bands - any ideas or helpful hints?

Dr. Guttmann: Posterior shoulder pain often stems from a tight posterior capsule. There are specific stretches you can do to stretch that aspect of your capsule and it may help. Seems like strength is not the problem.

coronado@northrim.net: In July of 2001 I had a bone spur removed-initially the surgery seemed like a success other than some pretty severe numbness in my arm, which has since quit. Now my shoulder is becoming worse, the pain is back and it is constant. It is to the point that it never lets up; I am in constant pain. What I was wondering if a bone spur can grow back, what else might be wrong and what can I do to get some relief from this?

Dr. Guttmann: Bone spurs may grow back there also may be a problem with the rotator cuff and/or the ac joint. Sometimes selective shoulder injections, subacromial and/ or ac joint may help pinpoint the problem.

jomo36@hotmail.com: I am a college catcher. I had capsular shrinkage done to my shoulder along with debridement of the rotator cuff. It has been almost 6 months since surgery and I have been throwing for about 5 weeks now. I am continuously trying to strengthen my shoulder but I am afraid I could re-stretch my shoulder out if I do too much too fast. My trainers here have never worked with someone who had this procedure so I wonder if they really know what they are doing and often feel like I am doing everything on my own. I guess I am asking for any advice on this procedure as far as recovery and when I should expect to be throwing with full power again, if ever. Also, what are the best exercises to do, and are there any that I shouldn't be doing?

Dr. Guttmann: Thermal shrinkage is somewhat controversial. At 6 months, however, you should be able to do whatever you want. Start out by achieving full range of motion, then strengthen your rotator cuff and start a gradual throwing program.

surthrese@yahoo.com: I've been told that I have a type 3 injury consisting of a complete AC dislocation with complete tears of the costoclavicular and AC ligaments. I have been looking at the pros and cons of surgery or no surgery. I have been looking at the Internet and there are mixed theories. A fixation with smooth Kirschner wires or threaded seem to be the best if I wanted surgery, but I don't know. Any advice?

Dr. Guttmann: Surgery and non-operative treatment both have been shown to help patients with type 3 ac joint dislocations. I would not recommend any fixation with wires, rather modified "weaver-dunn" reconstruction using heavy sutures and ligament transfer.

pfriedman: Is it a good idea to ice a shoulder after a heavy workout? I've only had pain maybe once or twice in my lifetime, and I did this for my pain those two times. I'm probably going to transition into a more rigorous regimen soon and was wondering if this practice should be frowned upon.

Dr. Guttmann: Icing is very effective before and after workouts.

Shoulder1: We're just about out of time. Dr. Guttmann, do you have any closing thoughts on shoulder care for our users?

Dr. Guttmann: Thank you all for the opportunity to share some thoughts, ideas regarding the shoulder. The shoulder is complex always humbling.

Shoulder1: Thank you, Dr. Guttmann, for your insightful responses today. Users, thank you for joining us. Stay tuned for future discussions!