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FirstHealth of the Carolinas
The shoulder By Dick Broom

The shoulder is an incredibly complex mechanism that, because of its design, has the greatest range of motion of any joint in the body. It also can withstand tremendous stress and exert great power.

The three bones that form the shoulder are the collarbone, shoulder blade and upper arm bone.

The shoulder is a ball-and-socket joint. A ball at the end of the upper arm bone fits into a socket in the shoulder blade. The socket is much shallower than the socket in the hip joint, which allows the arm to move farther in every direction.

The shallow socket means the bone-tobone connection in the shoulder is less stable. But this instability is offset by tendons and ligaments, which are strong, fibrous bands that hold the bones together. Four tendons that attach major muscles to the shoulder bones form what is called the rotator cuff, a protective covering that wraps around the entire joint.

The surfaces of the ball and socket are covered with cartilage, a smooth, firm tissue that allows bones to move smoothly against each other with a minimum of friction. Tiny sacs called bursa, located inside the rotator cuff, excrete a lubricating fluid that also helps the joint move freely.

The four tendons that form a cuff around the shoulder joint are incredibly tough. They have to be.

They are subjected to a lot of pressure and pulling as they connect the rotator cuff muscles to the shoulder blade and the upper arm bone. Sometimes they are squeezed between the two.

“They live in a very harsh environment,” says orthopaedic surgeon Glen Subin, M.D., of the Mid-South Orthopaedic Clinic in Pinehurst.

Glen Subin, M.D.
David Fedder, M.D.

Sometimes the environment is too harsh and, over the years, one or more of the tendons will start to fray. It is similar to what happens with your shoelaces, Dr. Subin says.

“The laces become frayed over time, and then one day you’re tying your shoes and one of the laces snaps,” he says. Rotator cuff tendons seldom actually snap, but they do develop painful tears.

The process that leads to a torn rotator cuff tendon often starts with inflammation, tendonitis, which can be caused by overuse, says David Fedder, M.D., an orthopaedic surgeon with Pinehurst Surgical.

“With chronic overhead repetitive use such as swimming or painting a ceiling, a tendon can get jammed between the bones in the shoulder, and that causes inflammation and swelling,” Dr. Fedder says. “But the tendon doesn’t have room to swell, because it’s in such a tight space. So it hurts.”

An inflamed or frayed tendon doesn’t always lead to surgery.

“There are stages in the process at which it is reversible,” Dr. Fedder says. “You get the inflammation down (sometimes with steroid injections), you have therapy to work the muscles and stop the pinching, and your problem is likely to go away.”

Once a rotator cuff tendon is damaged, it can take a long time to heal and become strong again.

“You need blood to bring in the cells that repair the tissue, and the blood supply isn’t very good in that location,” Dr. Subin says.

Bursitis, inflammation of a bursa, is another common shoulder problem. It is often caused by the bursa being jammed between two bones, which is the same thing that causes rotator cuff tendonitis.

Orthopaedic surgeons frequently see people with dislocated shoulders. If you take a hard fall on your arm or outstretched hand, the ball at the top of the arm bone can pop out of its socket. It is quite painful, but relatively easy to repair.

Gentle traction on the arm allows the ball to be put back in place. Whether it ever pops out again depends a lot on your age.

“The younger a person is, the more likely it is that the shoulder will dislocate again,” Dr. Fedder says.

If it happens a second time, chances are even greater that it will happen a third time, and so on, because each dislocation causes the shoulder to become looser, Dr. Fedder explains.

However, if you are 50 when your shoulder pops out, it probably isn’t going to happen again.

“As we get older, our shoulders—like the rest of our joints—become stiffer and less supple,” Dr. Subin says.

Most shoulder problems are the result of physical activity that causes the joint to be pounded, twisted, jammed, stretched or simply worn out. So most people probably could avoid hurting their shoulders if they didn’t swim, play golf or tennis or participate in other strenuous activities.

But, as Dr. Subin says, “They wouldn’t have as much fun, either.”

Peter Franklin finished a round of golf after suffering an injury that he later learned was a torn rotator cuff. Since having surgery to repair the injury, he is on the golf course about three times a week.

Peter Franklin
“There was no question about what I did or when I did it,” Peter Franklin says about tearing the rotator cuff in his shoulder while playing golf. “It was on the second shot of the first day of a member-guest tournament.”

Although he was in a lot of pain, he finished the round of golf before going to the Emergency Department at FirstHealth Moore Regional Hospital.

“I asked the doctor to give me a shot so I could play the next day, and he just laughed,” Franklin recalls. That was about six years ago.

Franklin knew he probably should get the rotator cuff fixed, but he kept putting if off. “I had heard horror stories about recovery taking six months, and I figured that at my age, I didn’t have six months to give,” he says.

But three years ago, when he was 77, there was leakage around the tear in his shoulder and an abscess developed. David Fedder, M.D., an orthopaedic surgeon with Pinehurst Surgical, told him he really needed to have the rotator cuff repaired.

Dr. Fedder performs orthopaedic procedures at FirstHealth Moore Regional Hospital.

“Within 10 days after the operation, I was able to raise my arm without any pain,” Franklin says. “I was chipping within a month and playing full rounds of golf within two months. And I take a lot of (golf) shots!”

Now, he typically plays at least three times a week.

“I may ache everywhere else,” he says, “but I have absolutely no pain in my shoulder.”

Joy Moser
Joy Moser hurt her shoulder when she ran into a wall during a racquetball game more than 20 years ago. At the time, she was living in the Atlanta area, where she was a public school teacher.

Over the years, she went to see several doctors about her shoulder. “They would say it was bursitis or something else, and they tried various treatments,” Moser says. “Finally, I went to a doctor who said she thought it was a torn rotator cuff, but I just didn’t want to have surgery.”

Ten years ago, Moser remarried and moved to Laurinburg, but it wasn’t until 2004 that she finally decided to have her shoulder fixed.

“It hurt every night, and I wasn’t sleeping well,” she says. “I had to sleep in different positions with something under my shoulder, because I was so uncomfortable.”

Moser went to see Glen Subin, M.D., of the Mid-South Orthopaedic Clinic in Pinehurst, who performs orthopaedic procedures at FirstHealth Moore Regional Hospital. He discovered that Moser actually had four separate tears in her rotator cuff tendons that needed to be repaired.

“I was a little concerned, because we had very good hospitals in Atlanta, and this one was relatively small,” Moser says. “I considered going to Raleigh for the surgery, but I’m so glad I decided to have it here.

“It was a perfect experience. I can’t imagine it could have gone any better. I never had any trouble with my shoulder at all. Of course, I also had a wonderful physical therapist and I was very good about doing my exercises.”

Moser, who is 62, says she has only one regret about her rotator cuff surgery.

“I wish I hadn’t waited so long to have it,” she says.